Pain Management

Acute Pain Management

Uncomplicated Removal of Epidural Catheters in 4365 Patients with International Normalized Ratio Greater Than 1.4 During Initiation of Warfarin Therapy

Liu SS, Buvanendran A, Viscusi ER, et al (Hosp for Special Surgery and the Weill College of Medicine at Cornell Univ, NY; Rush Univ Med Ctr, Chicago, IL; Thomas Jefferson Univ, Philadelphia, PA) Reg Anesth Pain Med 36:231-235, 2011^§

Abstract

Background and Objectives

Current guidelines from the American Society of Regional Anesthesia state that an international normalized ratio (INR) of 1.4 is the upper limit of warfarin anticoagulation for safe removal of an epidural catheter. However, these guidelines are based primarily on expert consensus, and there is controversy regarding this recommendation as being “too conservative.”

Methods

Prospective (3211) and retrospective (1154) patients undergoing total joint replacement followed by daily warfarin thromboprophylaxis were enrolled in this observational study. All nonsteroidal anti-inflammatory drugs and anticoagulants were held before surgery, and all patients had normal coagulation test results before surgery. Patients were followed twice a day by the acute pain service, no other anticoagulants except nonsteroidal anti-inflammatory drugs were administered, and epidural analgesia was discontinued per institutional protocol. Only patients with INR greater than 1.4 at the time of removal of epidural catheter were included. Neurologic checks were performed for 24 hrs after removal.

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