Twitter-Enhanced Problem-Based Learning Discussion (PBLD): The Epidural Consent and Coagulation ConundrumBy Vivian Ip, MBChB MRCP FRCA May 9, 2019
On May 9, 2019, we posed this case:
A 23 year-old gentleman recently underwent a double lung transplant for a diagnosis cystic fibrosis and severe obstructive lung disease. He was admitted postoperatively into the intensive care (ICU) at 5 am, still intubated and requiring mechanical ventilation, and you are called at 9 am by the cardiothoracic intensive care team that is requesting the insertion of a thoracic epidural to facilitate extubation. Routine coagulation studies are as follows:
INR 1.2 (normal 0.8-1.2)
aPTT 45 (normal 27-39)
Plt 200 (normal 140-450)
The patient is currently sedated with a propofol infusion. Further evaluation reveals that the patient was not consented preoperatively for epidural placement.
- Would you insert an epidural catheter in this patient?
- How would you obtain procedural consent in this patient?
- If you could not consent for an epidural, what would be your alternative?
On May 16, 2019, our case continues:
Assume no epidural has yet been placed. The patient is now extubated and awake and describes significant pain, he finds coughing difficult and he is unable to take deep breaths. You are asked again to review his analgesic options. Unfortunately, subcutaneous heparin was last administered 15 minutes ago.
- Would you now insert an epidural catheter?
- If epidural analgesia is administered (opioid and local anesthetic) and hypotension develops, how would you manage the situation in this patient?
We will present the full report of this case scenario with the Twitter Poll results in our August 2019 edition of ASRA News.