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Department of Anesthesia and Perioperative Care; University of California at San Francisco; San Francisco, CA; bicklerp{at}anesthesia.ucsf.edu
In Response:
We agree with Ben-David et al. (1) that the case report we cited is not a good choice to illustrate that bleeding complications can occur with these catheter techniques. There are, however, several reports of significant bleeding with lumbar plexus catheters in anticoagulated patients including those by Weller et al. (2) and Klein et al. (3). In addition, a psoas hematoma can develop even in a patient who has never had a nerve catheter (4). Of course, this is also the case with an epidural catheter and a spinal hematoma.
In the three cases we presented in our report (5), there was, indeed, a relationship between catheter removal and an increase in hematoma size and bleeding. Although some bleeding was noted before catheter removal, in each patient the bleeding worsened significantly after catheter removal. Also, none of the patients had known clotting abnormalities nor were they taking medications affecting hemostasis before surgery. In no case was needle or catheter insertion unusually traumatic. The bleeding was clearly not related to the surgical intervention.
The letter from Bleckner and Buckenmaier calls attention to their experience with parallel use of enoxaparin and peripheral nerve infusion catheters, and their recent publication (6) documenting lack of bleeding complications in 187 such patients. In their study, the mean time from enoxaparin dose to catheter removal was 16.3 h, with a range of 0.1–174 h. Although no catheter-related bleeding was seen in any of these patients, it is not clear if larger enoxaparin doses administered in close proximity to catheter removal might have produced bleeding problems. As noted in our case report, bleeding after catheter removal was associated with a 40-mg dose of enoxaparin given just a few hours before.
Even though significant neurologic sequelae may be rare after peripheral nerve catheter placement, it seems prudent to follow the same guidelines relating to anticoagulant use with peripheral nerve catheters as with epidural catheters. Withholding enoxaparin for a few hours on the morning of the peripheral nerve catheter removal seems like a small price to pay to avoid the type of complications our three patients experienced. Larger case series, or even clinical trials, are still needed to test this suggestion.
REFERENCES
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