ANESTHESIA Hadzic's Peripheral Nerve Blocks Hadzic parte 03
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38. Brodner G, Buerkle H, Van Aken H, et al. Postoperative analgesia after knee surgery: a
comparison of three different concentrations of ropivacaine for continuous femoral nerve blockade.
Anesth Analg. 2007;105:256-262.
39. Allen HW, Liu SS, Ware PD, Nairn CS, Owens BD. Peripheral nerve blocks improve analgesia
after total knee replacement surgery. Anesth Analg. 1998;87:93-97.
40. Ng HP, Cheong KF, Lim A, Lim J, Puhaindran ME. Intraoperative single-shot “3-in-1” femoral
nerve block with ropivacaine 0.25%, ropivacaine 0.5% or bupivacaine 0.25% provides comparable
48-hr analgesia after unilateral total knee replacement. Can J Anaesth. 2001;48:1102-1108.
41. Good RP, Snedden MH, Schieber FC, Polachek A. Effects of a preoperative femoral nerve block
on pain management and rehabilitation after total knee arthroplasty. Am J Orthop. 2007;36:554-557.
42. Iskandar H, Benard A, Ruel-Raymond J, Cochard G, Manaud B. Femoral block provides superior
analgesia compared with intra-articular ropivacaine after anterior cruciate ligament reconstruction.
Reg Anesth Pain Med. 2003;28:29-32.
43. Mutty CE, Jensen EJ, Manka MA Jr, Anders MJ, Bone LB. Femoral nerve block for diaphyseal
and distal femoral fractures in the emergency department. Surgical technique. J Bone Joint Surg Am.
2008;90 Suppl:218-226.
44. Fowler SJ, Symons J, Sabato S, Myles PS. Epidural analgesia compared with peripheral nerve
blockade after major knee surgery: a systematic review and meta-analysis of randomized trials. Br J
Anaesth. 2008;100:154-164.
45. Luhmann SJ, Schootman M, Schoenecker PL, Gordon JE, Schrock C. Use of femoral nerve blocks
in adolescents undergoing patellar realignment surgery. Am J Orthop. 2008;37:39-43.
46. Noiseux N, Prieto I, Bracco D, Basile F, Hemmerling T. Coronary artery bypass grafting in the
awake patient combining high thoracic epidural and femoral nerve block: first series of 15 patients.
Br J Anaesth. 2008;100:184-189.
47. Hemmerling TM, Noiseux N, Basile F, Noel MF, Prieto I. Awake cardiac surgery using a novel
anesthetic technique. Can J Anaesth. 2005;52:1088-1092.
48. Stewart B, Tudur Smith C, Teebay L, Cunliffe M, Low B. Emergency department use of a
continuous femoral nerve block for pain relief for fractured femur in children. Emerg Med J.
2007;24:113-114.
49. Barker R, Schiferer A, Gore C, et al. Femoral nerve blockade administered preclinically for pain
relief in severe knee trauma is more feasible and effective than intravenous metamizole: a randomized
controlled trial. J Trauma. 2008;64:1535-1538.
50. Viscomi CM, Reese J, Rathmell JP. Medial and lateral antebrachial cutaneous nerve blocks: an
easily learned regional anesthetic for forearm arteriovenous fistula surgery. Reg Anesth. 1996;21:2-5.
51. Cook JL, Cook J. The lateral femoral cutaneous nerve block. Dermatol Surg. 2000;26:81-83.
52. Wardrop PJ, Nishikawa H. Lateral cutaneous nerve of the thigh blockade as primary anaesthesia
for harvesting skin grafts. Br J Plast Surg. 1995;48:597-600.
53. Maccani RM, Wedel DJ, Melton A, Gronert GA. Femoral and lateral femoral cutaneous nerve
block for muscle biopsies in children. Paediatr Anaesth. 1995;5:223-227.
54. Hotta K, Sata N, Suzuki H, Takeuchi M, Seo N. Ultrasound-guided combined femoral nerve and
lateral femoral cutaneous nerve blocks for femur neck fracture surgery—case report [in Japanese].
Masui. 2008;57:892-894.
55. Tumber PS, Bhatia A, Chan VW. Ultrasound-guided lateral femoral cutaneous nerve block for
meralgia paresthetica. Anesth Analg. 2008;106:1021-1022.
56. Hurdle MF, Weingarten TN, Crisostomo RA, Psimos C, Smith J. Ultrasound-guided blockade of
the lateral femoral cutaneous nerve: technical description and review of 10 cases. Arch Phys Med
Rehabil. 2007;88:1362-1364.
57. Hirabayashi Y, Hotta K, Suzuki H, Igarashi T, Saitoh K, Seo N. Combined block of femoral,
sciatic, obturator nerves and lateral cutaneous nerve block with ropivacaine for leg amputation above
the knee [in Japanese]. Masui. 2002;51:1013-1035.
58. Vloka JD, Hadžić A, Mulcare R, Lesser JB, Koorn R, Thys DM. Combined popliteal and posterior
cutaneous nerve of the thigh blocks for short saphenous vein stripping in outpatients: an alternative to
spinal anesthesia. J Clin Anesth. 1997;9:618-622.
59. Akkaya T, Ersan O, Ozkan D, et al. Saphenous nerve block is an effective regional technique for
post-meniscectomy pain. Knee Surg Sports Traumatol Arthrosc. 2008;16:855-858.
60. Singelyn FJ. Single-injection applications for foot and ankle surgery. Best Pract Res Clin
Anaesthesiol. 2002;16:247-254.
61. van der Wal M, Lang SA, Yip RW. Transsartorial approach for saphenous nerve block. Can J
Anaesth. 1993;40:542-546.
62. Reilley TE, Gerhardt MA. Anesthesia for foot and ankle surgery. Clin Podiatr Med Surg.
2002;19:125-147, vii.
63. Sarrafian SK, Ibrahim IN, Breihan JH. Ankle-foot peripheral nerve block for mid and forefoot
surgery. Foot Ankle. 1983;4:86-90.
64. Rudkin GE, Rudkin AK, Dracopoulos GC. Bilateral ankle blocks: a prospective audit. ANZ J
Surg. 2005;75:39-42.
65. Rudkin GE, Rudkin AK, Dracopoulos GC. Ankle block success rate: a prospective analysis of
1,000 patients. Can J Anaesth. 2005;52:209-210.
66. Reuben SS, Steinberg RB, Maciolek H, Manikantan P. An evaluation of the analgesic efficacy of
intravenous regional anesthesia with lidocaine and ketorolac using a forearm versus upper arm
tourniquet. Anesth Analg. 2002;95:457-460.
67. Johnson CN. Intravenous regional anesthesia: new approaches to an old technique. CRNA.
2000;11:57-61.
68. Estebe JP. Locoregional intravenous anesthesia [in French]. Ann Fr Anesth Reanim. 1999;18:663-
673.
69. Bernateck M, Rolke R, Birklein F, Treede RD, Fink M, Karst M. Successful intravenous regional
block with low-dose tumor necrosis factor-alpha antibody infliximab for treatment of complex
regional pain syndrome 1. Anesth Analg. 2007;105:1148-1151.
70. Toda K, Muneshige H, Asou T. Intravenous regional block with lidocaine for treatment of complex
regional pain syndrome. Clin J Pain. 2006;22:222-224.
71. Lake AP. Intravenous regional sympathetic block: past, present and future? Pain Res Manag.
2004;9:35-37.
72. Bolte RG, Stevens PM, Scott SM, Schunk JE. Mini-dose Bier block intravenous regional
anesthesia in the emergency department treatment of pediatric upper-extremity injuries. J Pediatr
Orthop. 1994;14:534-537.
73. Barnes CL, Blasier RD, Dodge BM. Intravenous regional anesthesia: a safe and cost-effective
outpatient anesthetic for upper extremity fracture treatment in children. J Pediatr Orthop.
1991;11:717-720.
174. McCarty EC, Mencio GA, Green NE. Anesthesia and analgesia for the ambulatory management of
fractures in children. J Am Acad Orthop Surg. 1999;7:81-91.
175. Blaheta HJ, Vollert B, Zuder D, Rassner G. Intravenous regional anesthesia (Bier’s block) for
botulinum toxin therapy of palmar hyperhidrosis is safe and effective. Dermatol Surg. 2002;28:666-
671.
176. Blaheta HJ, Deusch H, Rassner G, Vollert B. Intravenous regional anesthesia (Bier’s block) is
superior to a peripheral nerve block for painless treatment of plantar hyperhidrosis with botulinum
toxin. J Am Acad Dermatol. 2003;48:302-304.
177. Handoll HH, Madhok R, Dodds C. Anaesthesia for treating distal radial fracture in adults.
Cochrane Database Syst Rev. 2002:CD003320.
178. Reuben SS, Sklar J. Intravenous regional anesthesia with clonidine in the management of complex
regional pain syndrome of the knee. J Clin Anesth. 2002;14:87-91.
179. Mohr B. Safety and effectiveness of intravenous regional anesthesia (Bier block) for outpatient
management of forearm trauma. CJEM. 2006;8:247-250.
7
Continuous Peripheral Nerve Blocks in Outpatients
Brian M. Ilfeld, Elizabeth M. Renehan and F. Kayser Enneking
Introduction
Single-injection nerve blocks provide up to 16 hours of postoperative analgesia.
Portable infusion pumps allow outpatients to receive continuous nerve blocks.
More than 40% of ambulatory patients experience moderate to severe postoperative pain at home
following orthopedic procedures.1
Up to 16 hours of analgesia may be provided by single-injection
peripheral nerve blocks with long-acting local anesthetics. However, following block resolution,
ambulatory patients must usually rely on oral opioids to control pain. Unfortunately, opioids are
associated with undesirable side effects, such as pruritus, nausea and vomiting, sedation, and
constipation. To improve postoperative analgesia following ambulatory surgery, there has been an
increasing interest in providing “perineural local anesthetic infusions,” also called, “continuous
peripheral nerve blocks,” to outpatients. This technique involves the percutaneous insertion of a
catheter directly adjacent to the peripheral nerve(s) supplying the surgical site. Local anesthetic is
then infused via the catheter providing potent, site-specific analgesia. Outpatients may theoretically
experience the same level of analgesia previously afforded only to those remaining hospitalized by
combining the perineural catheter with a portable infusion pump.
In 1946, Ansbro first described continuous regional blockade using a cork to stabilize a needle
placed adjacent to the brachial plexus divisions to provide a “continuous” supraclavicular block.2
However, for decades patients were required to remain hospitalized because the available pumps
used to infuse local anesthetic were large, heavy, and technically sophisticated. It was not until 52
years later that Rawal described outpatient perineural infusion using a percutaneous catheter and a
small lightweight, portable infusion pump.3
Advantages and Evidence
Significant decreases in postoperative pain and opioid side effects are possible.
Earlier home discharge is possible for a select subset of hospitalized patients.
Following Rawal’s article, case reports or series of ambulatory perineural infusion were
described via catheters in various anatomic locations, including paravertebral,4
interscalene,5–7
intersternocleidomastoid,8
infraclavicular,6
axillary,9
psoas compartment,9,10 femoral,9,11 fascia
iliaca,5
sciatic/Labat,9,10 sciatic/popliteal,6,12 and tibial nerve.6
Ambulatory continuous peripheral
nerve blocks in pediatric patients have also been reported in patients as young as 8 years of age.13
However, Klein et al provided the first prospective evidence quantifying infusion benefits in 2000.14
This randomized, double-masked, placebo-controlled investigation by Klein et al involved
subjects undergoing open rotator cuff repair who received an interscalene block and perineural
catheter preoperatively, and they were randomized to receive either perineural ropivacaine 0.2% or
normal saline postoperatively (10 mL/h). Patients receiving perineural placebo averaged a 3 on a
visual analog pain scale of 0 to 10, compared with a 1 for subjects receiving ropivacaine. Although a
portable pump was used, patients remained hospitalized during local anesthetic infusion <24 hours,
and catheters were removed by investigators prior to home discharge. Patients had access to
intravenous morphine via patient-controlled opioid analgesia because the investigators “felt
compelled to provide more than oral analgesics,” since patients remained hospitalized.14 As a result,
patients receiving normal saline theoretically received a greater degree of analgesia than that
available to ambulatory patients who must rely on oral instead of intravenous opioids. Consequently,
although these data suggested perineural infusion may improve postoperative analgesia following
hospital discharge, the extent of improvement for patients actually at home remained unknown.
Data involving perineural infusion in outpatients were subsequently provided in four randomized
double-masked, placebo-controlled studies.15–18 Patients receiving perineural local anesthetic
achieved both clinically and statistically significant lower resting and breakthrough pain scores
compared with those using exclusively oral opioids for analgesia (Figure 7-1). In addition, they
required dramatically fewer oral analgesics to achieve their improved level of analgesia (Figure 7-
1). Preoperatively, subjects scheduled for moderately painful procedures had a perineural catheter
placed: an infraclavicular catheter for hand/forearm procedures,15 a popliteal catheter for foot/ankle
surgeries,16,18 or an interscalene catheter for shoulder procedures.17 Postoperatively, patients
received either perineural local anesthetic or normal saline and were followed at home for up to 60
hours. All patients were instructed to use a bolus from their infusion pump for breakthrough pain and
oral analgesics if this maneuver failed. In patients with an interscalene catheter following shoulder
surgery, the local anesthetic infusion provided analgesia so complete that 80% of patients receiving
ropivacaine required one or fewer opioid tablets per day during their infusion, and they reported
average resting pain <1.5 on a scale of 0–10.17 This compares with all patients receiving placebo
requiring four or more opioid tablets per day, beginning the evening of surgery, and reporting average
resting pain scores between 3 and 4. For breakthrough pain, the differences between treatment groups
were even more pronounced in all of these four placebo-controlled studies (Figure 7-1).
FIGURE 7-1. Effects of interscalene and sciatic/popliteal perineural infusion of either ropivacaine
or placebo on average pain at rest (panels A and D), worst pain overall (panels B and E), and opiate
use (panels C and F) following moderately painful shoulder or lower extremity surgery (scale: 0–10).
Each opiate tablet consisted of oxycodone, 5 mg. Note: The infusion was discontinued after
postoperative day 2 as indicated by the horizontal lines. Data are expressed as median (horizontal
bar) with 25th–75th (box) and 10th–90th (whiskers) percentiles for patients randomly assigned to
receive either 0.2% ropivacaine or 0.9% saline placebo. For tightly clustered data (e.g., panel A,
postoperative days 0 and 1, ropivacaine group), the median approximated the 10th and 25th percentile
values. In this case, the median is zero and only the 75th and 90th percentiles are clearly noted; p <
0.05: *, compared with saline for a given postoperative day. Reproduced with permission.16,17
Additional benefits related to improved analgesia were experienced by patients who received
perineural local anesthetic. Of patients receiving perineural ropivacaine, 0 to 30% reported insomnia
due to pain, compared with 60 to 70% of patients receiving placebo.15–17 Additionally, awakenings
from sleep because of pain averaged 0.0 to 0.2 times on the first postoperative night, compared with
2.0 to 2.3 times for patients using only oral opioids.15–17 Using fewer opioid tablets was associated
with a lower rate of nausea, vomiting, pruritus, and sedation.15–18 Satisfaction with postoperative
analgesia was both clinically and statistically higher for patients receiving local anesthetic.15–18
Finally, patients with popliteal local anesthetic infusion rated their “quality of recovery” (0–100; 100
= highest) an average of 96 compared with 83 for patients receiving placebo.18 Whether these
demonstrated benefits result in an improvement in patients’ health-related quality-of-life remains
unexamined.19 Also uninvestigated to date is the relative superiority of one location over another for
similar procedures (e.g., axillary vs. infraclavicular for hand surgery).
The possible advantages of using outpatient perineural infusion to allow earlier discharge of
patients who require potent analgesia has only recently been explored. Individual benefits of a shorter
hospitalization may include a decrease in nosocomial infection,20,21 harmful medical errors,22,23 and
increases in health-related quality-of-life.19 Societal benefits include a potentially enormous cost
savings.24–26 Using ambulatory perineural infusion, patients have been discharged home directly from
the recovery room following total elbow (unpublished data, Ilfeld et al, 2004) and shoulder
replacement,27 and on the first postoperative day following total hip (unpublished data, Ilfeld et al,
2004) and knee replacement.28 Additional data are required to define the appropriate subset of
patients and assess the benefits and incidence of complications associated with this practice.
Patient Selection
Outpatient infusion is often limited to patients expected to have moderate pain.
Appropriate patient selection is crucial for safe outpatient infusion.
Many investigators have limited the use of ambulatory infusion to patients who are expected to have
moderate or severe postoperative pain >24 hours that is not easily managed with oral opioids. This
practice is in an attempt to balance the potential benefits of this technique with the potential risks,29,30
financial cost, and patient inconvenience of carrying an infusion pump and up to 600 mL of local
anesthetic.27 However, outpatient infusion may be used following mildly painful procedures—defined
here as usually well-managed with oral opioids—to decrease opioid requirements and opioid-related
side effects.3,31 Appropriate patient selection is crucial for safe outpatient infusion because not all
patients desire, or are capable of accepting, the extra responsibility that comes with the catheter and
pump system. Because some degree of postoperative cognitive dysfunction is common following
surgery,32 patients are often required to have a “caretaker” during infusion.15–17
,
33–36 Whether a
caretaker is necessary for one night or for the entire duration of infusion remains unresolved.37 If
removal of the catheter is expected to occur at home, then a caretaker willing to perform this
procedure must be available at the infusion conclusion if the patient is unwilling or unable to do this
themselves (e.g., psoas compartment catheter).
In medically unsupervised outpatients, complications may take longer to identify or be more
difficult to manage than for hospitalized patients. Therefore, hepatic or renal insufficiency have been
relative contraindications to outpatient infusion in an effort to avoid local anesthetic toxicity.38 For
infusions that may effect the phrenic nerve and ipsilateral diaphragm function (e.g., interscalene or
cervical paravertebral catheters), patients with heart or lung disease are often excluded because
continuous interscalene local anesthetic infusions have been shown to cause frequent ipsilateral
diaphragm paralysis.39 Conservative application of this technique is warranted until additional
investigation of hospitalized medically supervised patients documents its safety,40,41 although the
effect on overall pulmonary function may be minimal for relatively healthy patients.42
Selection of Insertion Technique
The optimal equipment and insertion techniques have yet to be determined.
A “test dose” of local anesthetic and epinephrine via the catheter is mandatory.
Securing the catheter adequately is of paramount concern.
In a substantial number of cases—as high as 40% in some reports43—inaccurate catheter placement
may occur.17,44,45 This issue is of critical importance for outpatients because catheter replacement is
not an option after leaving the medical facility. Many techniques and types of equipment have been
described for catheter insertion. Using one common technique, the initial local anesthetic bolus is
given via the needle, followed by catheter placement. However, using this method, it is possible to
provide a successful surgical block but inaccurate catheter placement.17 For ambulatory patients, the
inadequate perineural infusion often will not be detected until after surgical block resolution
following home discharge.17 Using another technique, investigators have first inserted the catheter and
then administered a bolus of local anesthetic via the catheter, with a reported failure rate of 1 to
8%.46,47
In an attempt to further improve catheter-placement success rates, “stimulating” catheters have
been developed that deliver current to the catheter tip.48 This design provides feedback on the
positional relationship of the catheter tip to the target nerve prior to local anesthetic dosing.33,34 To
date, there are no studies comparing stimulating and nonstimulating catheters. However, there is
limited evidence that passing current via the catheter may improve the accuracy of catheter
placement.49 The optimal placement techniques and equipment for ambulatory perineural infusion
have yet to be determined and require further investigation.50 A local anesthetic and epinephrine “test
dose” should be injected via the catheter in an effort to identify intrathecal,51 epidural,52 or
intravascular53 placement before infusion initiation, regardless of the equipment/technique used.
Local Anesthetic and Adjuvant Selection
Most outpatient infusions reported involved ropivacaine or bupivacaine.
No adjuvant added to local anesthetic has been demonstrated to be of benefit.
Although perineural infusions of levobupivacaine54 and shorter-acting agents have been reported,55–57
most publications have involved ropivacaine 0.2% or bupivacaine 0.125 to 0.25%. Currently, there is
insufficient information to determine if there is an optimal local anesthetic (or concentration) for
ambulatory infusions.31,54,58 The optimal concentration and infusion rate for a particular catheter site
in relationship to the degree of motor block has not been established either.
Patient-Controlled Regional Analgesia
Providing patients the ability to self-administer bolus doses maximizes benefits
The optimal basal rate, bolus volume, and lockout time have not been determined
Commonly used: basal 4–8 mL/h, bolus 2–5 mL, and lockout time 20–60 minutes
Available inpatient and outpatient data suggest that following procedures producing moderate to
severe pain, providing patients with the ability to self-administer local anesthetic doses (patientcontrolled regional analgesia) increases perioperative benefits and/or decreases local anesthetic
consumption.33,34,36,59–61 However, no information is available to base recommendations on the
optimal basal rate, bolus volume, or lockout period, other than for interscalene catheters.33 Until
recommendations based on prospectively collected data are published, practitioners should be aware
that investigators have reported successful analgesia using the following with long-acting local
anesthetics: basal rate of 4 to 8 mL/h, bolus volume of 2 to 5 mL, and lockout duration of 20 to 60
minutes. Practitioners should be aware that the maximum safe doses for the long-acting local
anesthetics remain unknown. However, multiple investigations involving patients free of renal or
hepatic disease have reported blood concentrations within acceptable limits following up to 5 days of
perineural infusion with similar dosing schedules.38,62–64 Extrapolating from data involving patients
receiving epidural bupivacaine infusion, a maximum infusion rate of 0.5 mg/kg per hour of
bupivacaine may be considered.38
Following ambulatory shoulder surgery with an interscalene catheter, infusion duration may be
increased and similar baseline analgesia may be provided by decreasing the basal rate from 8 to 4
mL/h when patients supplement their block with large bolus doses (6 mL).33 However, patients
experience an increase in breakthrough pain incidence and intensity, sleep disturbances, and a
decrease in satisfaction with their analgesia. Therefore, if ambulatory patients do not return for
additional local anesthetic, practitioners are left with the dilemma of superior analgesia for a shorter
duration versus a lesser degree of analgesia for a longer period of time. Of note, the infusion duration
may be increased by progressively decreasing the basal infusion rate with a reprogrammable infusion
pump, thus theoretically maximizing postoperative analgesia.7
The publications that investigated the optimal dosing regimen for outpatients involved surgical
procedures producing moderate postoperative pain. For procedures inducing mild postoperative pain,
it is possible—even probable—that adequate analgesia would be adequately treated with a bolusonly dosing regimen.31 There is also the possibility that stimulating catheters may be placed, on
average, closer to the target nerve/plexus compared with nonstimulating devices.49 If so, then the
optimal dosing regimens, basal rates, and bolus doses may vary among different catheter types.
Unfortunately, there are currently insufficient published data to draw any conclusions.
Equipment
There is no one perfect infusion pump for all applications.
A multitude of factors must be taken into account when choosing a pump.
Multiple small portable infusion pumps are currently available (Table 7-1; Figures 7-2 and 7-3),
each with benefits and limitations (Table 7-2). Many factors must be taken into account when
determining the optimal device for a given clinical situation. The provided list of infusion devices
includes those for which performance data are available from independent sources and is not meant to
be an exhaustive list of available units.
TABLE 7-1 Infusion Pump Distributors
FIGURE 7-2. Examples of portable disposable basal- and bolus-capable infusion pumps. (A) Pain
Care 3200, (B) Pain Pump II, (C) On-Q C-Bloc with OnDemand, (D) Accufuser Plus XL, (E) ambIT
PCA, (F) AutoMed 3200. Distributor information and pump attributes are included in the appendix
and Table 7-2. Note that the ambIT PCA is produced as a disposable model as well as a more
expensive reusable unit and therefore appears in both Figures 7-2 and 7-3.
FIGURE 7-3. Examples of portable reusable basal- and bolus-capable infusion pumps. (A) 6060
MT, (B) Ipump PMS, (C) CADD-Legacy PCA, (D) ambIT PCA, (E) BlockIt, (F) AutoMed 3400.
Distributor information and pump attributes are included in the appendix and Table 7-2. Note that the
ambIT PCA is produced as a disposable model as well as a more expensive reusable unit, and
therefore appears in both Figures 7-2 and 7-3.
TABLE 7-2 Infusion Pump Attributes
Bolus-Dose Capability
Various pumps allow for both patient-controlled local anesthetic boluses and a basal infusion (Table
7–2); others allow for only one of these.65–69 Bolus-dose capability (also termed patient-controlled
regional analgesia, or PCRA) offers two significant benefits over continuous infusions alone. First,
higher doses of oral opiates are often required for breakthrough pain without patient-controlled bolus
doses.34,68 Second, for outpatients using a limited local anesthetic reservoir, PCRA allows a provider
to minimize the basal rate and, in turn, allows maximum infusion duration and minimal motor block7
yet also permits bolus dosing for breakthrough pain34 and physical therapy.27,33,36,70 Compared with
continuous infusions alone, equivalent or superior analgesia with a lower rate of local anesthetic
consumption may be provided by using patient-controlled local anesthetic.34,59–61
Disposability and Cost
Reusable electronic infusion pumps are generally more expensive than the available singleuse/disposable models (Table 7–2). However, reusable pumps that use relatively inexpensive
disposable “cassettes” for each new patient (usually about US$10) may be more cost effective for
practitioners who use these devices repeatedly (Table 7–2). But a reusable unit requires the patient to
return the infusion pump by either the mail service or revisiting the surgical center.33,34,36
Patient Instructions
A prescription for oral opioids should be filled by patients following discharge.
Oral and written instructions, including health care provider contact numbers, should be provided.
Following a single-injection nerve block for ambulatory surgery, discharge with an insensate
extremity results in minimal complications.71 However, whether or not patients should weight-bear
with a continuous peripheral nerve block remains unexamined. Therefore, conservative management
may be optimal, and some investigators have recommended that patients avoid using their surgical
limb for weightbearing.8,16,36 A prescription for oral analgesics should be provided to all patients,
and the importance of filling the prescription immediately after leaving the surgical center should be
emphasized. If patients wait to fill the prescription until after they have determined if oral analgesics
are required, a period of inadequate analgesia may result.
Most investigators educate both the patient and his or her caretaker at the same time before
discharge because most patients have some degree of postoperative cognitive dysfunction. Both
verbal and written instructions should be provided, along with contact numbers for health care
providers who are available throughout the infusion duration.6,15,31,72 In addition to standard
outpatient instructions, topics reviewed often include expectations regarding surgical block
resolution, infusion pump instructions, breakthrough pain treatment, catheter site care, limb protection,
and the plan for catheter removal. Forewarning that pain in the operative limb is anticipated
following surgical block resolution and fluid leakage at the catheter site is common—and what to do
if these are experienced—often proves helpful. Signs and symptoms of possible catheter- and local
anesthetic-related complications include, but are not limited to, pulmonary compromise,40,41 nerve
injury,73 site infection,74 and local anesthetic toxicity.53 Although there are case reports of initially
misplaced catheters, migration following a documented correct placement has not been described but
remains a theoretical risk.51–53
,
75,76 Possible complications of an unidentified initially misplaced
catheter or of a catheter migration include intravascular or interpleural catheterization resulting in
local anesthetic toxicity, intramuscular catheterization resulting in myonecrosis, and
epidural/intrathecal catheterization when using interscalene, intersternocleidomastoid, paravertebral,
or psoas compartment catheters. As is standard of care for inpatients, health care providers may want
to consider documenting each patient contact (Figure 7-4).
FIGURE 7-4. An example of a progress note that may be used to record telephone contacts with
ambulatory patients. Reproduced with permission.79
Catheter removal may be achieved with various techniques: Patients may be discharged with
written instructions,12 a health care provider may perform this procedure,77 or patients’ caretakers (or
occasionally the patients themselves) may remove the catheters with instructions given by a provider
over the telephone.15–17
,
33,34,36 Although one technique has not been demonstrated to be superior to the
others, one survey revealed that with instructions given by phone, 98% of patients felt comfortable
removing their catheter at home.78 Of note, only 4% would have preferred to return for a health care
provider to remove the catheter, and 43% responded they would have felt comfortable with
exclusively written instructions.78 Nonsterile gloves may be provided for patients having their
catheters removed at home.15–17
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. Grant SA, Nielsen KC, Greengrass RA, Steele SM, Klein SM. Continuous peripheral nerve block for
ambulatory surgery. Reg Anesth Pain Med. 2001;26:209-214.
0. Klein SM, Greengrass RA, Grant SA, Higgins LD, Nielsen KC, Steele SM. Ambulatory surgery for
multi-ligament knee reconstruction with continuous dual catheter peripheral nerve blockade. Can J
Anaesth. 2001;48:375-378.
1. Chelly JE, Gebhard R, Coupe K, Greger J, Khan A. Local anesthetic delivered via a femoral
catheter by patient-controlled analgesia pump for pain relief after an anterior cruciate ligament
outpatient procedure. Am J Anesthesiol. 2001;28:192-194.
2. Klein SM, Greengrass RA, Gleason DH, Nunley JA, Steele SM. Major ambulatory surgery with
continuous regional anesthesia and a disposable infusion pump. Anesthesiology. 1999;91:563-565.
3. Ilfeld BM, Smith DW, Enneking FK. Continuous regional analgesia following ambulatory pediatric
orthopedic surgery. Am J Orthop. 2004;33:405-408.
4. Klein SM, Grant SA, Greengrass RA, et al. Interscalene brachial plexus block with a continuous
catheter insertion system and a disposable infusion pump. Anesth Analg. 2000;91:1473-1478.
5. Ilfeld BM, Morey TE, Enneking FK. Continuous infraclavicular brachial plexus block for
postoperative pain control at home: a randomized, double-blinded, placebo-controlled study.
Anesthesiology. 2002;96:1297-1304.
6. Ilfeld BM, Morey TE, Wang RD, Enneking FK. Continuous popliteal sciatic nerve block for
postoperative pain control at home: a randomized, double-blinded, placebo-controlled study.
Anesthesiology. 2002;97:959-965.
7. Ilfeld BM, Morey TE, Wright TW, Chidgey LK, Enneking FK. Continuous interscalene brachial
plexus block for postoperative pain control at home: a randomized, double-blinded, placebocontrolled study. Anesth Analg. 2003;96:1089-1095.
8. White PF, Issioui T, Skrivanek GD, Early JS, Wakefield C. The use of a continuous popliteal sciatic
nerve block after surgery involving the foot and ankle: does it improve the quality of recovery?
Anesth Analg. 2003;97:1303-1309.
9. Wu CL, Naqibuddin M, Rowlingson AJ, Lietman SA, Jermyn RM, Fleisher LA. The effect of pain
on health-related quality of life in the immediate postoperative period. Anesth Analg. 2003;97:1078-
1085.
0. Public health focus: surveillance, prevention, and control of nosocomial infections. MMWR CDC
Surveill Summ. 1992;41:783-787.
1. Wenzel RP, Edmond MB. The impact of hospital-acquired bloodstream infections. Emerg Infect
Dis. 2001;7:174-177.
2. Relman AS. The institute of medicine report on the quality of health care. N Engl J Med.
2001;345:702-703.
3. Leape LL. Institute of Medicine medical error figures are not exaggerated. JAMA. 2000;284:95-97.
4. Mushinski M. Average charges for hip replacement surgeries: United States, 1997. Stat Bull
Metrop Insur Co. 1999;80:32-40.
5. Mushinski M. Average charges for a total knee replacement: United States, 1994. Stat Bull Metrop
Insur Co. 1996;77:24-30.
6. Weinstein J. The Dartmouth Atlas of Musculoskeletal Health Care. Chicago, IL: AHA Press;
2000:72-78.
7. Ilfeld BM, Wright TW, Enneking FK, et al. Effect of interscalene perineural local anesthetic
infusion on postoperative physical therapy following total shoulder replacement. Reg Anesth Pain
Med. 2004;29:A18.
8. Ilfeld BM, Gearen PF, Enneking FK, et al. Effect of femoral perineural local anesthetic infusion on
postoperative functional ability following total knee arthroplasty. Anesthesiology. 2004;101:A945.
9. Ekatodramis G, Macaire P, Borgeat A. Prolonged Horner syndrome due to neck hematoma after
continuous interscalene block. Anesthesiology. 2001;95:801-803.
0. Ribeiro FC, Georgousis H, Bertram R, Scheiber G. Plexus irritation caused by interscalene brachial
plexus catheter for shoulder surgery. Anesth Analg. 1996;82:870-872.
1. Rawal N, Allvin R, Axelsson K, et al. Patient-controlled regional analgesia (PCRA) at home:
controlled comparison between bupivacaine and ropivacaine brachial plexus analgesia.
Anesthesiology. 2002;96:1290-1296.
2. Johnson T, Monk T, Rasmussen LS, et al. Postoperative cognitive dysfunction in middle-aged
patients. Anesthesiology. 2002;96:1351-1357.
3. Ilfeld BM, Morey TE, Wright TW, Chidgey LK, Enneking FK. Interscalene perineural ropivacaine
infusion: a comparison of two dosing regimens for postoperative analgesia. Reg Anesth Pain Med.
2004;29:9-16.
4. Ilfeld BM, Morey TE, Enneking FK. Infraclavicular perineural local anesthetic infusion: a
comparison of three dosing regimens for postoperative analgesia. Anesthesiology. 2004;100:395-
402.
5. Ilfeld BM, Morey TE, Enneking FK. Continuous infraclavicular perineural infusion with clonidine
and ropivacaine compared with ropivacaine alone: a randomized, double-blinded, controlled study.
Anesth Analg. 2003;97:706-712.
6. Ilfeld BM, Thannikary LJ, Morey TE, Vander Griend RA, Enneking FK. Popliteal sciatic perineural
local anesthetic infusion: a comparison of three dosing regimens for postoperative analgesia.
Anesthesiology. 2004;101:970-977.
7. Klein SM, Steele SM, Nielsen KC, et al. The difficulties of ambulatory interscalene and intraarticular infusions for rotator cuff surgery: a preliminary report. Can J Anaesth. 2003;50:265-269.
8. Denson DD, Raj PP, Saldahna F, et al. Continuous perineural infusion of bupivacaine for prolonged
analgesia: pharmacokinetic considerations. Int J Clin Pharmacol Ther Toxicol. 1983;21:591-597.
9. Pere P. The effect of continuous interscalene brachial plexus block with 0.125% bupivacaine plus
fentanyl on diaphragmatic motility and ventilatory function. Reg Anesth. 1993;18:93-97.
0. Smith MP, Tetzlaff JE, Brems JJ. Asymptomatic profound oxyhemoglobin desaturation following
interscalene block in a geriatric patient. Reg Anesth Pain Med. 1998;23:210-213.
1. Sardesai AM, Chakrabarti AJ, Denny NM. Lower lobe collapse during continuous interscalene
brachial plexus local anesthesia at home. Reg Anesth Pain Med. 2004;29:65-68.
2. Borgeat A, Perschak H, Bird P, Hodler J, Gerber C. Patient-controlled interscalene analgesia with
ropivacaine 0.2% versus patient-controlled intravenous analgesia after major shoulder surgery:
effects on diaphragmatic and respiratory function. Anesthesiology. 2000;92:102-108.
3. Salinas FV. Location, location, location: Continuous peripheral nerve blocks and stimulating
catheters. Reg Anesth Pain Med. 2003;28:79-82.
4. Coleman MM, Chan VW. Continuous interscalene brachial plexus block. Can J Anaesth.
1999;46:209-214.
5. Ganapathy S, Wasserman RA, Watson JT, et al. Modified continuous femoral three-in-one block for
postoperative pain after total knee arthroplasty. Anesth Analg. 1999;89:1197-1202.
6. Borgeat A, Dullenkopf A, Ekatodramis G, Nagy L. Evaluation of the lateral modified approach for
continuous interscalene block after shoulder surgery. Anesthesiology. 2003;99:436-442.
7. Borgeat A, Blumenthal S, Karovic D, Delbos A, Vienne P. Clinical evaluation of a modified
posterior anatomical approach to performing the popliteal block. Reg Anesth Pain Med.
2004;29:290-296.
8. Boezaart AP, de Beer JF, du Toit C, van Rooyen K. A new technique of continuous interscalene
nerve block. Can J Anaesth. 1999;46:275-281.
9. Salinas FV, Neal JM, Sueda LA, Kopacz DJ, Liu SS. Prospective comparison of continuous femoral
nerve block with nonstimulating catheter placement versus stimulating catheter-guided perineural
placement in volunteers. Reg Anesth Pain Med. 2004;29:212-220.
0. Chelly JE, Williams BA. Continuous perineural infusions at home: narrowing the focus. Reg Anesth
Pain Med. 2004;29:1-3.
1. Litz RJ, Vicent O, Wiessner D, Heller AR. Misplacement of a psoas compartment catheter in the
subarachnoid space. Reg Anesth Pain Med. 2004;29:60-64.
2. Cook LB. Unsuspected extradural catheterization in an interscalene block. Br J Anaesth.
1991;67:473-475.
3. Tuominen MK, Pere P, Rosenberg PH. Unintentional arterial catheterization and bupivacaine
toxicity associated with continuous interscalene brachial plexus block. Anesthesiology. 1991;75:356-
358.
4. Casati A, Borghi B, Fanelli G, et al. Interscalene brachial plexus anesthesia and analgesia for open
shoulder surgery: a randomized, double-blinded comparison between levobupivacaine and
ropivacaine. Anesth Analg. 2003;96:253-259.
5. Buettner J, Klose R, Hoppe U, Wresch P. Serum levels of mepivacaine-HCl during continuous
axillary brachial plexus block. Reg Anesth. 1989;14:124-127.
6. Wajima Z, Shitara T, Nakajima Y, et al. Comparison of continuous brachial plexus infusion of
butorphanol, mepivacaine and mepivacaine-butorphanol mixtures for postoperative analgesia. Br J
Anaesth. 1995;75:548-551.
7. Bergman BD, Hebl JR, Kent J, Horlocker TT. Neurologic complications of 405 consecutive
continuous axillary catheters. Anesth Analg. 2003;96:247-252.
8. Borgeat A, Kalberer F, Jacob H, Ruetsch YA, Gerber C. Patient-controlled interscalene analgesia
with ropivacaine 0.2% versus bupivacaine 0.15% after major open shoulder surgery: the effects on
hand motor function. Anesth Analg. 2001;92:218-223.
9. Singelyn FJ, Gouverneur JM: Extended “three-in-one” block after total knee arthroplasty:
continuous versus patient-controlled techniques. Anesth Analg. 2000;91:176-180.
0. Singelyn FJ, Seguy S, Gouverneur JM. Interscalene brachial plexus analgesia after open shoulder
surgery: continuous versus patient-controlled infusion. Anesth Analg. 1999;89:1216-1220.
1. Singelyn FJ, Vanderelst PE, Gouverneur JM: Extended femoral nerve sheath block after total hip
arthroplasty: continuous versus patient-controlled techniques. Anesth Analg. 2001;92:455-459.
2. Ekatodramis G, Borgeat A, Huledal G, Jeppsson L, Westman L, Sjovall J. Continuous interscalene
analgesia with ropivacaine 2 mg/ml after major shoulder surgery. Anesthesiology. 2003;98:143-150.
3. Kaloul I, Guay J, Cote C, Halwagi A, Varin F. Ropivacaine plasma concentrations are similar
during continuous lumbar plexus blockade using the anterior three-in-one and the posterior psoas
compartment techniques. Can J Anaesth. 2004;51:52-56.
4. Anker-Moller E, Spangsberg N, Dahl JB, Christensen EF, Schultz P, Carlsson P. Continuous
blockade of the lumbar plexus after knee surgery: a comparison of the plasma concentrations and
analgesic effect of bupivacaine 0.250% and 0.125%. Acta Anaesthesiol Scand. 1990;34:468-472.
5. Ilfeld BM, Morey TE, Enneking FK. The delivery rate accuracy of portable infusion pumps used for
continuous regional analgesia. Anesth Analg. 2002;95:1331-1336.
6. Ilfeld BM, Morey TE, Enneking FK. Delivery rate accuracy of portable, bolus-capable infusion
pumps used for patient-controlled continuous regional analgesia. Reg Anesth Pain Med. 2003;28:17-
23.
67. Ilfeld BM, Morey TE, Enneking FK. Portable infusion pumps used for continuous regional
analgesia: delivery rate accuracy and consistency. Reg Anesth Pain Med. 2003;28:424-432.
68. Ilfeld BM, Morey TE. Use of term “patient-controlled” may be confusing in study of elastometric
pump. Anesth Analg. 2003;97:916-917.
69. Ilfeld BM, Morey TE, Enneking FK. New portable infusion pumps: real advantages or just more of
the same in a different package? Reg Anesth Pain Med. 2004;29:371-376.
70. Ilfeld BM, Gearen PF, Enneking FK, et al. Effect of femoral perineural local anesthetic infusion on
postoperative functional ability following total knee arthroplasty. Anesthesiology. 2004;101:A945.
71. Klein SM, Nielsen KC, Greengrass RA, Warner DS, Martin A, Steele SM. Ambulatory discharge
after long-acting peripheral nerve blockade: 2382 blocks with ropivacaine. Anesth Analg.
2002;94:65-70.
72. Grant SA, Nielsen KC. Continuous peripheral nerve catheters for ambulatory anesthesia. Curr
Anesthesiol Reports. 2000;2:304-307.
73. Borgeat A, Ekatodramis G, Kalberer F, Benz C. Acute and nonacute complications associated with
interscalene block and shoulder surgery: a prospective study. Anesthesiology. 2001;95:875-880.
74. Cuvillon P, Ripart J, Lalourcey L, et al. The continuous femoral nerve block catheter for
postoperative analgesia: bacterial colonization, infectious rate and adverse effects. Anesth Analg.
2001;93:1045-1049.
75. Souron V, Reiland Y, De Traverse A, Delaunay L, Lafosse L. Interpleural migration of an
interscalene catheter. Anesth Analg. 2003;97:1200-1201.
76. Hogan Q, Dotson R, Erickson S, Kettler R, Hogan K. Local anesthetic myotoxicity: a case and
review. Anesthesiology. 1994;80:942-947.
77. Chelly JE, Greger J, Gebhard R. Ambulatory continuous perineural infusion: are we ready? [letter].
Anesthesiology. 2000;93:581-582.
78. Ilfeld BM, Esener DE, Morey TE, Enneking FK. Ambulatory perineural infusion: the patients’
perspective. Reg Anesth Pain Med. 2003;28:418-423.
79. Ilfeld BM, Enneking FK. Continuous nerve blocks at home: a review. Anesth Analg.
2005;100:1822–1833.
8
Regional Anesthesia in the Anticoagulated Patient
Honorio T. Benzon
Intraspinal Hematoma
The incidence of intraspinal hematoma is approximately 0.1 per 100,000 patients per year.1
It is more
likely to occur in anticoagulated or thrombocytopenic patients, patients with neoplastic disease, or in
those with liver disease or alcoholism.2
The incidence of neurologic dysfunction resulting from
hemorrhagic complications associated with neuraxial blockade is estimated to be <1 in 150,000
epidural procedures and <1 in 220,000 with spinal anesthetics. The risk of formation of intraspinal
hematoma after administration of neuraxial injections is increased in patients who received
anticoagulant therapy or have a coagulation disorder, technical difficulties in the performance of the
neuraxial procedures due to anatomic abnormalities of the spine, and multiple or bloody punctures.
The American Society of Regional Anesthesia and Pain Medicine (ASRA) issued recommended
guidelines for the safe performance of neuraxial blocks in patients who are on anticoagulants.3,4 The
third edition of the ASRA guidelines was published in 2010.
Antiplatelet Therapy
Antiplatelet medications inhibit platelet cyclo-oxygenase and prevent the synthesis of thromboxane
A2. Thromboxane A2 is a potent vasoconstrictor and facilitates secondary platelet aggregation and
release reactions. An adequate, although potentially fragile, clot may form.5
Platelet function in
patients receiving antiplatelet medications should be assumed to be decreased for 1 week after
treatment with aspirin and 1 to 3 days with nonsteroidal anti-inflammatory drugs (NSAIDs). New
platelets are produced every day, and these new platelets partly explain the relative safety of
performing neuraxial procedures in these patients.
Although Vandermeulen et al6
implicated antiplatelet therapy in 3 of the 61 cases of spinal
hematoma occurring after spinal or epidural anesthesia, the results of several large studies
demonstrated the relative safety of neuraxial blockade in combination with antiplatelet therapy. The
Collaborative Low-Dose Aspirin Study in Pregnancy Group7
included 1422 high-risk obstetric
patients who were administered 60 mg aspirin daily and underwent epidural anesthesia without any
neurologic sequelae. The studies of Horlocker et al,8,9 of approximately 1000 patients in each study,
showed no spinal hematomas, although blood was noted during needle or catheter placement in 22%
of the patients. A later study in patients who were on NSAIDs and underwent epidural steroid
injections did not develop the signs and symptoms of intraspinal hematoma.10 A review of the case
reports of intraspinal hematoma in patients on aspirin and NSAIDs showed complicating factors that
included concomitant heparin administration, epidural venous angioma, and technical difficulty when
performing the procedure.11
The thienopyridine drugs, ticlopidine and clopidogrel, prevent platelet aggregation by inhibiting
adenosine diphosphate (ADP) receptor-mediated platelet activation. Ticlopidine is rarely used
because it causes neutropenia, thrombocytopenic purpura, and hypercholesterolemia. Clopidogrel is
preferred because of its increased safety profile and proven efficacy. The maximal inhibition of ADPinduced platelet aggregation with clopidogrel occurs 3 to 5 days after the initiation of a standard dose
(75 mg), but within 4 to 6 hours after the administration of a large loading dose of 300 to 600 mg.12
There is a case report of spinal hematoma in a patient on ticlopidine13 and a case of quadriplegia in a
patient on clopidogrel, diclofenac, and possibly aspirin.14
Neuraxial blocks can be safely performed on patients taking aspirin or NSAIDs.4
It is safe to
perform neuraxial blocks on patients taking cyclo-oxygenase (COX)-2 inhibitors. For the
thienopyridine drugs, it is recommended that clopidogrel be discontinued for 7 days and ticlopidine
for 10 to 14 days before a neuraxial injection. It is possible for epidural catheters to be removed or
neuraxial injections to be performed 5 days, and not 7 days, after clopidogrel is discontinued.15 If a
neuraxial injection is to be performed in a patient on clopidogrel before 7 days of discontinuation, a
P2Y12 assay, a new assay of residual antiplatelet activity, can be performed; <10% activity probably
means that a neuraxial block is safe.16
Here is a summary of current recommendations:
. Neuraxial blocks can be performed on patients taking aspirin or NSAIDs.4
. It is safe to perform neuraxial blocks on patients taking COX-2 inhibitors.
. For the thienopyridine drugs, the ASRA recommendation is that clopidogrel be discontinued for 7
days and ticlopidine for 10 to 14 days before a neuraxial injection.
. Epidural catheters can be removed safely and neuraxial injections can be performed 5 days (not 7
days, as once advised) after clopidogrel is discontinued.15
. If a neuraxial injection is to be performed in a patient on clopidogrel before 7 days of
discontinuation, a P2Y12 assay, a new assay of residual antiplatelet activity, is performed; <10%
activity probably means that a neuraxial block is safe.16
Oral Anticoagulants
Warfarin exerts its anticoagulant effect by interfering with the synthesis of the vitamin K–dependent
clotting factors (VII, IX, X, and thrombin).17 It also inhibits the anticoagulants protein C and S. Factor
VII and protein C have short half-lives (6–8 hours), and the prolongation of the international
normalized ratio (INR) during the early phase of warfarin therapy is the result of the competing
effects of reduced factor VII and protein C.18 Adequate anticoagulation is not achieved until the levels
of biologically active factors II (half-life of 50 hours) and X are sufficiently depressed, that is, 4 to 6
days.
Few data exist regarding the risk of spinal hematoma in patients with indwelling spinal or epidural
catheters who are subsequently anticoagulated with warfarin. Horlocker et al19 and Wu and Perkins20
found no neuraxial hemorrhagic complications in patients who received postoperative epidural
analgesia in conjunction with low-dose warfarin after total knee arthroplasty. Because intraspinal
hematomas have occurred after removal of the catheter,6
some have recommended that the same
laboratory values apply to placement and removal of an epidural catheter.21 The current ASRA
guidelines recommends an INR value of ≤1.4 as acceptable for the performance of neuraxial blocks.4
The value was based on studies that showed excellent perioperative hemostasis when the INR value
was ≤1.5. The concurrent use of other medications, such as aspirin, NSAIDs, and heparins that affect
the clotting mechanism, increases the risk of bleeding complications without affecting the INR.
A controversy exists regarding whether or not the epidural catheter can be removed on
postoperative day 1, or 12–14 hours after warfarin is started, when the INR is >1.4. In the absence of
other risk factors for increased bleeding, the catheter can probably be removed. The factor VII
activity should be determined if risk factors such as low platelets, advanced age, kidney failure, or
intake of other anticoagulants are present.18
Warfarin is metabolized primarily by the CYP2C9 enzyme of the cytochrome P450 system.
Mutations in the gene coding for the cytochrome P450 2C9 hepatic microsomal enzyme affect the
elimination clearance of warfarin by impairing the patient’s ability to metabolize S-warfarin. Other
genetic factors affecting the warfarin dose–response relationship include polymorphisms of the
vitamin K oxide reductase (VKOR) enzyme. Mutations in the gene encoding for isoforms of the
protein that can lead to enzymes with varied sensitivities to warfarin is rare, and the American
College of Chest Physicians (ACCP) advises against pharmacokinetic-based initial dosing of
warfarin at this time.17
Intravenous Heparin
Heparin is a complex polysaccharide that exerts its anticoagulant effect by binding to antithrombin III.
The conformational change in antithrombin accelerates its ability to inactivate thrombin, factor Xa,
and factor IXa. The anticoagulant effect of subcutaneous heparin takes 1 to 2 hours, but the effect of
intravenous heparin is immediate. Heparin has a half-life of 1.5 to 2 hours. The activated partial
thromboplastin time (aPTT) is used to monitor the effect of heparin; therapeutic anticoagulation is
achieved with a prolongation of the aPTT to >1.5 times the baseline value.
There were no spinal hematomas in >4000 patients who underwent lower extremity vascular
surgery under continuous spinal or epidural anesthesia.22 In this study, patients with preexisting
coagulation disorders were excluded, heparinization occurred at least 60 minutes after catheter
placement, the level of anticoagulation was carefully monitored, and the indwelling catheters were
removed at a time when heparin activity was low. Ruff and Dougherty23 noted the occurrence of
spinal hematomas in patients who underwent lumbar puncture with subsequent heparinization. The
presence of blood during the procedure, concomitant aspirin therapy, and heparinization within 1 hour
were identified as risk factors for the development of a spinal hematoma.
When intraoperative anticoagulation is planned, neuraxial technique should be avoided in patients
with coexisting coagulopathies. The following considerations are in order:
. There should be at least a 1-hour delay between needle placement and heparin administration.
. The catheter should be removed 1 hour before subsequent heparin administration and 2 to 4 hours
after the last heparin dose.4
. The partial thromboplastin time or activated clotting time should be monitored to avoid excessive
heparin effect.
Subcutaneous Heparin
The therapeutic basis of low-dose subcutaneous heparin (5000 units every 8–12 hours) is heparinmediated inhibition of activated factor X. Following intramuscular or subcutaneous injection of 5000
units of heparin, maximum anticoagulation effect is observed in 40 to 50 minutes and returns to
baseline within 4 to 6 hours. The aPTT may remain in the normal range and often is not monitored.
However, wide variations in individual patient responses to subcutaneous heparin have been
reported. Neuraxial techniques are not contraindicated during subcutaneous (mini-dose) prophylaxis.
Some have suggested that the risk of bleeding can be further reduced by delay of the heparin
administration until after the block.4
The 2008 ACCP guidelines have suggested a more frequent dosing of subcutaneous heparin to
three times a day.24 Case reports show an increased risk for bleeding in patients receiving thricedaily subcutaneous heparin.25 In view of this increased bleeding and in the absence of prospective
studies that looked into the implications of neuraxial injections in this setting, the third edition of the
ASRA guidelines will advise that patients not receive thrice-daily heparin when receiving epidural
infusions.
Low Molecular Weight Heparin
The anticoagulant effect of low molecular weight heparin (LMWH) is similar to unfractionated
heparin, that is, activation of antithrombin and acceleration of its interaction with thrombin and factor
Xa.26 LMWH has a greater activity against factor Xa; unfractionated heparin has equivalent activity
against thrombin and factor Xa. The plasma half-life of the LMWH ranges from 2 to 4 hours after an
intravenous injection and 3 to 6 hours after a subcutaneous injection. Its half-life is two to four times
that of standard heparin. The recovery of anti-factor Xa activity after a subcutaneous injection of
LMWH approaches 100%. This characteristic makes laboratory monitoring unnecessary, except in
patients with renal insufficiency or those with body weight <50 kg or >80 kg.
The summary of recommendations for patients receiving LMWH and neuraxial anesthesia are as
follows4
:
. The administration of other anticoagulant medications with LMWHs may increase the risk of spinal
hematoma.
. The presence of blood during needle placement and catheter placement does not necessitate
postponement of surgery. However, the initiation of LMWH therapy should be delayed for 24 hours
postoperatively.
. The first dose of LMWH prophylaxis should be given no earlier than 24 hours postoperatively and
only in the presence of adequate hemostasis.
. In patients who are on LMWH, needle/catheter placement (or catheter removal) should be performed
at least 12 hours after the last prophylactic dose of enoxaparin or 24 hours after higher doses of
enoxaparin (1 mg/kg every 12 hours), and 24 hours after dalteparin (120 U/kg every 12 hours or 200
U/kg every 12 hours) or tinzaparin (175 U/kg daily).
. The LMWH can be administered 2 hours after the epidural catheter is removed.
. Monitoring of anti-Xa level is not recommended.
Thrombolytic Therapy
Thrombolytic agents actively dissolve fibrin clots that have already formed, secondary to the action
of plasmin. Plasminogen activators, such as streptokinase and urokinase, dissolve thrombus and affect
circulating plasminogen leading to decreased levels of both plasminogen and fibrin. Clot lysis leads
to elevation of fibrin degradation products, which have an anticoagulant effect by inhibiting platelet
aggregation. Fibrinogen and plasminogen are maximally depressed at 5 hours after thrombolytic
therapy and remain significantly depressed at 27 hours.4,27
Although epidural or spinal needle and catheter placement with subsequent heparinization appears
relatively safe, the risk of spinal hematoma in patients who receive thrombolytic therapy is less welldefined. Cases of spinal hematoma in patients who received neuraxial injections and thrombolytic
agents were reported recently in the medical literature.
Fibrinolytic and thrombolytic agents pose a unique problem when performing neuraxial anesthesia.
The time frame for avoidance of these drugs and puncture of noncompressible vessels is 10 days.
Except in highly unusual circumstances, patients who received fibrinolytic or thrombolytic drugs
should be cautioned against receiving spinal or epidural anesthesia.4,27 There are no available data to
clearly determine the length of time after discontinuation of these drugs for the safe performance of a
neuraxial technique. There is no definitive recommendation on the timing of removal of neuraxial
catheters in patients who unexpectedly receive fibrinolytic or thrombolytic therapy. Measurement of
fibrinogen levels may be helpful in guiding a decision about removal of the catheter.
Herbal Therapy
Herbal preparations do have some effect on platelet aggregation. For example, garlic inhibits platelet
aggregation and its effect on hemostasis appears to last 7 days. Ginkgo biloba inhibits plateletactivating factor and its effect lasts 36 hours. These effects last 24 hours with the use of ginseng.4
The
effects of dietary supplements on platelet function and coagulation are not well described, and
outcomes are difficult to predict.28 In spite of these characteristics, herbal preparations appear to
present no added significant risk in the development of spinal hematoma in patients having epidural or
spinal anesthesia. At this time, there appears to be no specific concerns as to the timing of neuraxial
block in relationship to the dosing of herbal therapy, postoperative monitoring, or the timing of
neuraxial catheter removal.4
Fondaparinux
Fondaparinux is a synthetic anticoagulant that produces its antithrombotic effect through selective
inhibition of factor Xa.29 The drug exhibits consistency in its anticoagulant effect because it is
chemically synthesized and its bioavailability is 100%. Rapidly absorbed, it reaches maximum
concentration within 1.7 hours of administration. Its half-life is 17 to 21 hours, allowing once-daily
dosing.30 The actual risk of spinal hematoma with fondaparinux is unknown. The daily dosing makes
safe catheter removal harder to predict. The ASRA4
recommends against the use of fondaparinux in
the presence of an indwelling epidural catheter. These recommendations were based on the sustained
and irreversible antithrombotic effect of fondaparinux, early postoperative dosing (6 hours after
surgery), and the spinal hematoma reported during initial clinical trials. Performance of neuraxial
techniques should occur under the conditions used in clinical trials (single needle pass, atraumatic
needle placement, and avoidance of indwelling neuraxial catheters).4
A 2007 study showed no complications in patients who had neuraxial injections or deep
peripheral nerve blocks.31 In this study, the catheters were removed 36 hours after the last dose of
fondaparinux and dosing was delayed for 12 hours after the catheter was removed. In a review
article, Rosencher et al32 recommended that catheter removal should be delayed at least 36 hours
(equivalent to two half-lives) and that the subsequent injection should be timed to at least 7 hours
after the removal of the catheter.
anesthesia hadzic's peripheral vision
anesthesia hadzic's peripheral nervous system
anesthesia hadzic's peripheral neuropathy
anesthesia hadzic's peripheral analysis
anesthesia hadzic's peripheral artery disease
anesthesia hadzic's peripheral attention
anesthesia hadzic's peripheral artery disease treatment
anesthesia hadzic's peripheral blood mononuclear cells
anesthesia hadzic's peripheral book
anesthesia hadzic's peripheral brain for the pharmacist
anesthesia hadzic's peripheral blood smear
anesthesia hadzic's peripheral blood
anesthesia hadzic's peripheral cyanosis
anesthesia hadzic's peripheral chemoreceptors
anesthesia hadzic's peripheral circulation
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