Catheters and anticoagulation?

So had a patient this weekend that left me wondering. Gentleman in his 70s, AF and PPM on dabigatran, last dose 24 hours ago. Normal bloods. Fallen and had some posterolateral rib fractures, and wasn’t managing with oral meds / oramorph and had some early signs of a chest infection. Couldn’t deep breathe or cough either.
Wanted to offer him a block but unsure which one or even if it was a good idea! What do you all think? What about the dabigatran? And should he get a single shot or a catheter ? If we put in a catheter, do we stop or continue the dabigatran?

16 thoughts on “Catheters and anticoagulation?

  1. Good article here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4540140/#!po=36.9318

    Sites:
    Gadsden J, Kwofie K, Shastri U. Continuous intercostal versus paravertebral blockade for multiple fractured ribs. J Trauma Acute Care Surg. 2012;73(1):293–294

    The advocate use of paravertebral catheter even in presence of coagulopathy and feel that compliance of the paravertebral space is insufficient to cause spinal cord compromise.

    Maybe not the case in my hands… Food for thought!

  2. If creatinine clearance >80 ml/min, wait 48 hrs after the last dose of dabigatran to perform a block. CrCl 50 – 80 ml/min – 72 hrs. CrCl 30 – 50 ml/min – 96 hrs. Catheters aren’t recommended.
    For anticoagulation, bridge the patient with LMWH.

    1. So is there no block we can offer in an anticiagulated patient? We do fascia iliaca blocks (suprainguinal) and put catheters in antocoagulated hip fracture patients all the time. Is there a fundamental difference between a fascia iliaca and a paravertebral? Also, can you think of any blocks for rib fractures that can be classified similarly to fascia iliaca?
      And considering his anticoagulation is for AF, do we really need to bridge him? What happens in pre assessment when we get patients anticoagulated for AF ?

  3. The guidelines specify epidural catheters but not other peripheral block catheters, so paravertebrals should still be alright, but I would be tempted to muscular plane block and put a catheter in. At worse you might just leave a muscular haematoma. We cannot do PECS 1, 2 or SAP as the fractures are posterior so Erector Spinae Plane Block would be my choice. This is article from chronic pain but has given good pictures about sensory loss after the block https://fhs.mcmaster.ca/anesthesiaresearch/…/ESPblockAnovelthoracicwallblock.pdf

    More people are trying it now for rib fractures and I am sure one of the GORAs must have tried it in RVI already.
    https://academic.oup.com/bja/article-abstract/118/3/474/2999653/Erector-spinae-plane-block-for-pain-relief-in-rib?redirectedFrom=PDF

    1. so yes, the guidelines from AAGBI only talk about neuraxial catheters (the advice for which is that dabigatran should be stoped for 48 hours if normal renal function, and then the patient shoulnt be on it on catheter removal). for paravertebrals i think its a grey area – its not neuraxial but its pretty close! Donna has referenced a paper above on that topic.
      Yes – i have done a single shot Serratus plane block for some lateral fractures, which were quite low if i remember right. The block did help, but it didnt last long!

    2. Idaracizumab (Praxbind)? NHS cost seems to be about £2400. I wonder how many level 3 ventilated bed days we need to save to make it worthwhile….

    3. Idaracizumab (Praxbind) to facilitate RA in imminent respiratory failure? NHS cost seems to be about £2400. I wonder how many level 3 ventilated bed days we need to save to make it worthwhile….

  4. If the benefits outweighs the risks then paravertebral catheter can be sited. There is good evidence from literature review that paravetebral catheter is safe even in fully anticoagulated pateients. This is one of the advantage of paravertebral over epidural catheter. I have personally done 4 PVB catheters in fully anticoagulated patients- 2 on therpeutic LMWH, 1 on rivoraxiban and 1 on clopidogrel with no complications.

  5. I agree with Varma (and not because i have to). The balance of risk is as follows;
    1. Risk of not doing a block- 70yr old with multiple rib fractures has probably got at least a 10% mortality. There is some evidence that regional anaesthesia can reduce his mortality (mostly for epidural and a little for PVB).
    2. Risk of doing a block- epidural is potentially catastrophic so out for me. So how about paravertebral block? Complications with US are exceptionally low- Anesth Analg 2016;122:1186–91.British Journal of Anaesthesia; 105 (6): 842-52. I am not aware of any reported case of catastrophic bleeding in relation to PVB. Even if we hit a blood vessel is it likely to cause any more bleeding than a fractured rib?
    What about nerve damage? In this context we are worried about two things, bleeding in a confined space but i think this would only happen if epidural injection or cathter migration. This is very unlikely with US and coiled catheter. The other concern is direct nerve puncture and bleeding from vasonervosum in the confined space of the nerve sheath. I dont think this has ever been reported and even if it did then the consequence of a neuropraxia of one thoracic nerve is unlikely to be serious.
    In terms of ESB or Seratus plane, they are pretty much an evidence free zone at present. Their main benefit is that pleural puncture would seem less likely and they are both less deep so needle visualisation would be easier. You could also be less likely to thread a catheter into the epidural space. Hoever if the analgesia is no good then you are exposing the patient to an unnecessary risk.
    Single shot vs catheter? Difficult one- ultimately needs a catheter. Is coagulation likely to improve? if not then i would insert catheter at time. Anticoagulation for af is a relatively soft indication but also the bleeding risk is pretty small.

    What would i have done? probably a paravertebral catheter
    Was it wrong to do a single shot SPB? no not at all
    Consider the risks, discuss it with the patient and do what you feel comfortable doing

    1. The last sentence is the most important, not sure if a hypoxaemic man in pain truly has competence to make the decision though but we should try our best!

  6. Nice discussion. I try and take a pragmatic view in these patients that coagulopathy is a relative C/I, and mortality is significant, not to mention consequences of respiratory failure, intubation and prolonged ITU stay. And the key is early analgesia using RA rather than resp depression with opioids. If anticoagulant is recent, personally I would go as low risk as poss – so in this case I would prob go single shot erector spinae 1st line and judge efficacy, escalating to PVB 2nd line. This should buy time and allow physiotherapy and avoid intubation. For most DCOAs buying a further 12-24hrs should reduce haematoma risk for then slipping a catheter into whichever block site was most effective.
    Whichever strategy taken could be justified by a risk-benefit analysis; however offering nothing except opioids on the basis of a bleeding risk of uncertain consequence is not going to produce the best outcome, experience or use of resources and may cause / exacerbate patient deterioration.

    1. Hi James, thanks for your response.
      I wanted to ask what your experience of ESP and SPB for rib fractures has been? As Jono Womack pointed out, its all evidence light at present and we dont do much of this at our centre. Do you have a pathway for fractures that involves non PVB blocks? Anecdotally or with numbers, do you think they actually work for this indication?
      Thanks
      Billy Qureshi (admin)

  7. An interesting discussion. I agree with much of what has been said above; we need to do something.
    I’ve put a few serratus plane catheters (deep to the muscle) in anticoagulated patients, with excellent results. If the fractures are too posterior (i.e. not covered by serratus muscle), then I would be more inclined towards PVB. ESP is an appealing lower risk option as James suggests, although I am yet to be convinced by its efficacy.
    I would do a pre-scan to see how technically difficult PVB would be in this individual patient (before having that informed shared-decision-making discussion, naturally).
    Oh, for some real evidence!

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