Heparin and Epidurals--A Baaaad Combination

[VivaLasViejas, ASN, RN]

Well, my hospital certainly stepped in it this time: We had an 82 YO total knee replacement patient come to our floor the other day, and like most TKRs by this one surgeon , he arrived on the unit with an epidural.

No problem, everybody thought; we deal with this type of pain management all the time. But something no one thought of as a potential problem---giving Fragmin SQ---was nearly disastrous! The order got past 2 doctors, several nurses, AND the pharmacist, and it was only when the pt. developed a very large epidural hematoma that anyone noticed the fine print at the bottom of the pre-printed epidural anesthesia orders: "Do not initiate anticoagulant therapy without notifying anesthesia department".

Turns out that heparin in any form is apt to cause bleeding at the epidural insertion site (as well as anyplace else), which is why they don't start the pts on it until the epidural has been discontinued, but no one had ever really paid attention to that.

The pt. had to go back to surgery for a decompression laminectomy to evacuate the hematoma, and of course he was lucky not to end up paralyzed; he has a great attitude about all of this, and told a nurse the other night he wants to write to the president and tell him how caring and competent (!) the staff and doctors are. But the defecation has really collided hard with the oscillating ventilatory system, and I must admit I'm glad I wasn't involved in *this* mess.....talk about a lawsuit waiting to happen.

Anyway, the patient is OK now and doing great, but I think we all learned something from this, whether we were involved or not, and I'm sharing it with you because I'm sure I'm not the only nurse who didn't know that heparin and epidurals don't mix. But then, I KNOW I'm not the only nurse who, having 5 or more patients on a busy shift, doesn't always scrutinize every single order, trusting the MDs to communicate with one another and the pharmacists to catch things like this before they make it to the bedside. We're only human, and when a nurse is confronted with several sets of new orders to take off an hour before shift change, it's a wonder MORE things like this don't happen!

Scary, isn't it, to realize that YOUR mobility, or even your life, could depend on an overwhelmed nurse who hasn't had a break since hitting the floor this morning, an MD who's done eight procedures since 0600, and a pharmacist who's processed five gazillion orders in the past 12 hours?

:eek:

[P_RN, ADN, RN]

Ive heard about that and similar problems with LMW and heparinoids in San Francisco (I think) causing paralysis. This came out maybe 5-6 years ago.

[bluesky, BSN, RN]

Originally posted

the defecation has really collided hard with the oscillating ventilatory system [/b]

:roll :roll :roll :roll

[Spidey's mom, ADN, BSN, RN]

That is a standard order we always follow here. We don't start the Lovenox until after the epidural is out. It isn't fine print either.

That order needs to be fixed. And some inservicing needs to be done.

steph

[Chttynurs]

Unfortunately the same mistake has happened where I work--and while I didn't do it, I think I WOULD have made the same mistake had the patient been mine. The anasthesiologist caught the mistake after only one dose had been given, thank goodness. The order on our pre-printed epidural order sheet is miniscule also, which is why I would have missed it. Wish it were in bold letters. We can't give ANY anticoagulation! I'm working somewhere else per diem now, and their epidural order sheet doesn't mention it ANYWHERE!! I brought it to the attention of the education nurse, she said she'd look into it.

Glad everythink worked out for that patient!! :)

[VivaLasViejas, ASN, RN]

Me too!

I'm ashamed to even admit I didn't know about this potentially disastrous combination before all this hit the fan.....if I'd been caring for him, I'd have been part of the problem. Thank God we don't ALL have to make mistakes like that to learn from them, and I'm sure there will be some major inservicing as well as a change in the pre-printed forms!