Anesth Analg 2007;104:991
© 2007 International Anesthesia Research Society
doi: 10.1213/01.ane.0000258800.86589.57
LETTER TO THE EDITOR
Section Editor:
Lawrence Saidman
Continuous Peripheral Nerve Catheters in Patients Receiving Low Molecular Weight Heparin
Lisa L. Bleckner, MD, and
Chester C. Buckenmaier, III, MD
Department of Anesthesiology; Army Regional Anesthesia and Pain Management Initiative; Walter Reed Army Medical Center; Regional Anesthesia and Pain Management; Washington, DC; chester.buckenmaier{at}na.amedd.army.mil
To the Editor:
Recently, Bickler et al. (1) described bleeding complications with femoral and sciatic nerve catheters in three patients receiving low molecular weight heparin. Our group works with a large patient population of wounded soldiers returning from Iraq and Afghanistan with traumatic extremity injuries, many in need of continuous peripheral nerve catheters for pain management. However, all of these soldiers are receiving prophylactic enoxaparin (Sanofi-Aventis) for prevention of deep venous thrombosis. Because of the paucity of published data concerning peripheral nerve catheters and anticoagulation, we opted to liberally interpret the American Society of Regional Anesthesia and Pain Medicine (ASRA) Consensus Conference on Neuraxial Anesthesia and Anticoagulation guidelines published in 2003 (2). These guidelines, as suggested by the Conference, "may be more restrictive than necessary" for peripheral nerve catheters.
We (3) have recently reported our experience with our first 187 patients (more than 3000 catheter days) in whom indwelling peripheral catheters had been inserted while they were receiving Lovenox. The guidelines used at our institution for placement and removal of peripheral nerve catheters in patients receiving deep venous thrombosis prophylaxis are provided in this article. We note that the results in our study population of young, healthy, traumatically injured or amputated soldiers may not necessarily translate to a nontraumatically injured, potentially older patient populations with existing comorbidities. However, it is our hope that this may be a starting point to understanding and using continuous peripheral nerve catheters in patients who are receiving prophylactic doses of low molecular weight heparin.
We agree with Bickler et al. that more data are needed to determine if the same guidelines should be used for both neuraxial and peripheral nerve catheters in patients receiving this anticoagulation. Our initial experience with our revised guidelines seems to suggest that continuous peripheral nerve catheters can be used safely with low molecular weight heparin under specific conditions, although our patient population is still too small to make a definitive judgment. We plan to continue our efforts in investigating this question and applaud Bickler et al. for contributing these case reports which will only help to revise the next ASRA Consensus guidelines.
REFERENCES
- Bickler P, Brandes J, Lee M, et al. Bleeding complications from femoral and sciatic nerve catheters in patients receiving low molecular weight heparin. Anesth Analg 2006;103:1036–7.[Abstract/Free Full Text]
- Horlocker TT, Wedel DJ, Benzon H, et al. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA consensus conference on neuraxial anesthesia and anticoagulation). Reg Anesth Pain Med 2003;28:172–97.[Web of Science][Medline]
- Buckenmaier CC III, Shields CH, Auton AA, et al. Continuous peripheral nerve block in combat casualties receiving low-molecular weight heparin. Br J Anaesth 2006;97:874–7.[Abstract/Free Full Text]
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