warfarin and Pain--Postoperative

To determine the coagulation status of patients receiving postoperative warfarin and epidural analgesia using thromboelastography (TEG(R)).Prospective, observational, clinical study.Orthopedic postoperative division at a university hospital.52 ASA physical status II and III patients undergoing knee arthroplasty and receiving prophylactic warfarin and epidural analgesia.Patients' preoperative and postoperative coagulation status was determined by TEG(R). Daily TEG(R) parameters were obtained until the epidural catheter was removed. TEG(R) parameters include reaction time (R-time or time until the first significant levels of detectable clot formation), K-time (clot firmness), maximum amplitude (MA-clot strength), alpha angle (clot development), and coagulation index (overall coagulation). In addition, daily international normalized ratios (INRs) were obtained as per our routine practice. On the day of catheter removal reaction time was significantly increased compared with preoperative values (p < 0.0001), but it remained within normal ranges. There was no change in the coagulation index. However, INR was abnormal and significantly increased (INR = 1.48+/-0.3; p < 0.0001), compared with preoperative values, on the day when the epidural catheter was removed. When the epidural catheters are removed, overall coagulation status, as measured by TEG(R), and despite an elevated INR (mean INR <1.5), remained within normal limits in patients receiving low-dose warfarin prophylaxis.

Topics: Aged; Analgesia, Epidural; Anticoagulants; Arthroplasty, Replacement, Knee; Blood Coagulation; Device Removal; Humans; International Normalized Ratio; Pain, Postoperative; Postoperative Complications; Prospective Studies; Thrombelastography; Thrombosis; Warfarin

The objective of this study was to compare the use of a resorbable oxycellulose dressing with a fibrin adhesive for the prevention of postextraction hemorrhage in patients taking anticoagulants.. A control group of 26 patients with a preoperative international normalized ratio (INR) in the range of 2.0 to 4.2 had extractions performed with the use of local anesthesia and the socket(s) dressed with a resorbable oxycellulose dressing and sutured with a resorbable suture. The study group with a comparable INR range of 2.1 to 4.1 was treated in a similar manner, except the sockets were dressed with a fibrin adhesive.. No discernible difference in the postoperative outcome with regard to hemorrhage was noted. Postoperative pain was reported more frequently in the group that used a resorbable oxycellulose dressing. Only 1 patient had significant postoperative bleeding.. This study shows that in patients receiving warfarin whose INR is within the therapeutic range, the fibrin adhesive is as effective as the resorbable oxycellulose dressing in preventing postextraction hemorrhage.

Topics: Absorbable Implants; Adult; Aged; Aged, 80 and over; Anesthesia, Dental; Anesthesia, Local; Anticoagulants; Bandages; Cellulose, Oxidized; Female; Fibrin Tissue Adhesive; Follow-Up Studies; Hemostatics; Humans; International Normalized Ratio; Male; Middle Aged; Oral Hemorrhage; Pain Measurement; Pain, Postoperative; Suture Techniques; Sutures; Tooth Extraction; Tooth Socket; Treatment Outcome; Warfarin

There is a paucity of data regarding the coagulation status when discontinuing perineural catheters in patients receiving anticoagulant after operation. This retrospective study was designed to establish international normalized ratio (INR) and prothrombin time (PT) at the time of removal of lumbar plexus perineural catheters in patients receiving warfarin after total hip replacement.. Patients who received a continuous lumbar plexus nerve block for postoperative analgesia and received warfarin after total hip surgery between August 2002 and June 2007 were included in this retrospective study. PT and INRs were recorded before surgery and every day after operation along with any post-surgical nerve injury and bleeding related to the removal of the perineural catheter.. Six hundred and seventy patients met the inclusion criteria. Almost all lumbar plexus catheters (89%) were removed on postoperative day 2. At the time of the perineural catheter removal, 36.2% of patients had an INR >1.4 (range: 1.5-3.9). One case of local bleeding was recorded at the time of the catheter removal with an INR of 3.0. This was managed with a direct pressure at the site.. Although in this retrospective analysis, we demonstrated that lumbar plexus catheters were removed with an INR > or =1.5, additional data are required to confirm the safety of such an approach.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Hip; Blood Coagulation; Catheterization, Peripheral; Device Removal; Female; Humans; International Normalized Ratio; Lumbosacral Plexus; Male; Middle Aged; Nerve Block; Pain, Postoperative; Postoperative Care; Prothrombin Time; Retrospective Studies; Warfarin

Topics: Adrenergic beta-Agonists; Adrenergic beta-Antagonists; Analgesia, Obstetrical; Analgesics, Opioid; Anesthesiology; Anesthetics, General; Anticoagulants; Asthma; Drug-Related Side Effects and Adverse Reactions; Genetic Variation; Humans; Malignant Hyperthermia; Myocardial Infarction; Neuromuscular Depolarizing Agents; Pain, Postoperative; Perioperative Care; Pharmacogenetics; Practice Patterns, Physicians'; Succinylcholine; Warfarin

Topics: Analgesics; Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Cyclooxygenase Inhibitors; Drug Synergism; Heparin, Low-Molecular-Weight; Humans; Ketorolac Tromethamine; Knee Prosthesis; Pain, Postoperative; Platelet Aggregation Inhibitors; Postoperative Hemorrhage; Tolmetin; Tromethamine; Warfarin

Topics: Analgesics; Anti-Inflammatory Agents, Non-Steroidal; Cyclooxygenase Inhibitors; Drug Synergism; Heparin, Low-Molecular-Weight; Humans; Indomethacin; Ketorolac Tromethamine; Knee Prosthesis; Pain, Postoperative; Platelet Aggregation Inhibitors; Postoperative Hemorrhage; Tolmetin; Tromethamine; Warfarin

A 31-yr-old parturient with myotonic dystrophy and asthma presented for elective Caesarean section. The patient was receiving warfarin having had two previous episodes of thromboembolism. Anticoagulation was subsequently provided by heparin in the weeks prior to delivery. The combination of the patient's medical conditions and the continuing need for anticoagulation presented a considerable anaesthetic problem in planning anaesthesia and analgesia for both elective and emergency delivery. Heparin was discontinued on the day prior to surgery and restarted immediately after surgery. During surgery flowtron anti-embolitic boots were used. Warfarin therapy was recommenced on the seventh postoperative day. Anaesthesia for Caesarean section was provided using a combined spinal epidural technique using a separate needle, separate interspace method. Postoperative pain was relieved by using a continuous epidural infusion, transcutaneous nerve stimulation and diclofenac. No new neurological problems arose despite the use of epidural analgesia in the presence of heparin anticoagulation. This method of providing anaesthesia and postoperative analgesia without the use of opioids in an anticoagulated, asthmatic, myotonic parturient has not been described elsewhere.

Topics: Adult; Analgesia, Epidural; Analgesia, Obstetrical; Anesthesia, Epidural; Anesthesia, Obstetrical; Anesthesia, Spinal; Asthma; Cesarean Section; Diclofenac; Elective Surgical Procedures; Female; Gravity Suits; Heparin; Humans; Myotonic Dystrophy; Pain, Postoperative; Pregnancy; Transcutaneous Electric Nerve Stimulation; Warfarin

Topics: Dyspnea; Hemoptysis; Humans; Leg; Male; Middle Aged; Pain, Postoperative; Postoperative Care; Postoperative Complications; Pulmonary Embolism; Thorax; Thrombophlebitis; Warfarin