Should Lovenox (enoxaparin) be administered or held in a patient with a high bleeding risk and a history of recent spinal fusion surgery, specifically a T8-T12 fusion on post-operative day 3?

From the Guidelines

I would hold the lovenox dose scheduled for 2100. The patient has a documented "NO ANTICOAG DT BLEEDING RISK" order which indicates they should not receive anticoagulation due to bleeding risk. Additionally, this is only day 3 post-operative from a thoracic spine fusion (T8-T12), which is a procedure with significant bleeding risk, especially in the early post-operative period. According to the guidelines for Enoxaparin use 1, the risks of bleeding must be weighed against the benefits of prophylaxis in determining the timing of initiation of DVT pharmacologic prophylaxis in combination with mechanical prophylaxis. Administering lovenox (a low molecular weight heparin anticoagulant) could increase the risk of post-operative bleeding complications, including epidural hematoma, which could lead to spinal cord compression and neurological deficits. This risk typically outweighs the benefit of VTE prophylaxis in the immediate post-operative period for spinal surgery.

• Key considerations include:
  • The patient's high risk of bleeding due to recent spinal surgery
  • The presence of a "NO ANTICOAG DT BLEEDING RISK" order
  • The potential for increased risk of bleeding complications with lovenox administration
  • The need to weigh the risks and benefits of anticoagulation in this patient I would document the hold decision and notify the provider about the conflicting orders to clarify the anticoagulation plan moving forward, considering the guidelines for Enoxaparin use and the patient's individual risk factors 1.

From the Research

Administration of Lovenox

• The patient has a Lovenox order for 2100 and a NO ANTICOAG DT BLEEDING RISK flag.
• Considering the patient is on postoperative day 3 after a T8-T12 fusion, the risk of bleeding and epidural hematoma must be weighed against the risk of venous thromboembolism (VTE) 2.
• Studies have shown that the use of low molecular weight heparin (LMWH) such as enoxaparin can increase the risk of hemorrhage, including spinal epidural hematoma 3, 4.

Risk of Bleeding and Epidural Hematoma

• The risk of bleeding and epidural hematoma is a significant concern in patients undergoing spine surgery, particularly in those receiving anticoagulation therapy 4, 5.
• The patient's NO ANTICOAG DT BLEEDING RISK flag suggests that the risk of bleeding is a concern, and caution should be exercised when administering anticoagulants.

Decision to Hold or Administer Lovenox

• Given the patient's recent spine surgery and the risk of bleeding and epidural hematoma, it may be prudent to hold the Lovenox administration until the risk of bleeding has decreased 2, 5.
• However, the decision to hold or administer Lovenox should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.