Abstract
Background and Objectives: Based on the case reports of hemorrhagic complications, recommendations for the removal of lumbar plexus catheters in anticoagulated patients were created. These guidelines are controversial as they limit the use of lumbar plexus blocks in postoperative anticoagulated patients. This study was designed to evaluate the incidence of hemorrhagic complications and coagulation status using International Normalized Ratio (INR) at the time of lumbar plexus catheter removal in patients receiving warfarin after total hip replacement. Methods: A retrospective study of 371 patients on warfarin thromboprophylaxis who received continuous lumbar plexus catheters for postoperative analgesia after total hip surgery was performed. The primary outcome measure was the incidence of bleeding complications after catheter removal; secondary outcome measures included warfarin dose, bridge therapy, incidence of deep vein thrombosis, pulmonary embolism (DVT/PE) and INR values upon catheter removal. Results: Almost all lumbar plexus catheters (93%; 344/371) were removed at 72 hours. At the time of catheter removal, mean INR was 1.99 [1.42-2.41] (p = 0.015); 67% of patients had an INR > 1.5 and half of these patients had INRs between 2.0-3.0; 5% had INR’s between 3.0-4.0. There were no adverse bleeding complications or nerve injury after the removal of catheters. Conclusions: We observed no incidence of bleeding after lumbar plexus catheter removal despite 67 % of patients demonstrating INR’s > 1.5. Our retrospective analysis illustrates the relative safety of catheter removal in anticoagulated patients and suggests that the removal of lumbar plexus catheters can be safely performed with an INR > 1.5 in patients receiving warfarin.
Highlights
Deep venous thrombosis and pulmonary embolism (DVT/ PE) prophylaxis guidelines call for the use of adjustedwarfarin or low molecular weight heparin in total hip arthroplasty patients [1,2,3]
Our findings demonstrate that the uncomplicated removal of lumbar plexus catheters from postoperative anti-coagulated hip replacement patients is possible with International Normalized Ratio (INR) values of greater than 1.4
Our results, when taken in the context of other retrospective studies illustrate the likelihood that current recommendations for the maintenance of lumbar plexus catheters in anti-coagulated patients may be too conservative leading to their premature removal, often depriving patients of effective postoperative analgesia
Summary
Deep venous thrombosis and pulmonary embolism (DVT/ PE) prophylaxis guidelines call for the use of adjustedwarfarin or low molecular weight heparin in total hip arthroplasty patients [1,2,3]. Regional anesthesia practice guidelines in these anticoagulated patients previously addressed the question of the safety of neuraxial techniques following reports of increased risk of spinal hematoma, a rare but serious complication [4] These recommendations, to some degree, prompted a resurgence of peripheral nerve block techniques with lumbar plexus block, an effective analgesic technique in total hip arthroplasty patients [5,6]. Patients Receiving Warfarin Thromboprophylaxis: A Retrospective Analysis posed that while probably “more restrictive than necessary,” practice guidelines originally developed for neuraxial blockade techniques should be applied to deep plexus and peripheral blockade techniques These recommendations are controversial given the lack of available clinical study data but their divergence with therapeutic anticoagulation recommendations and their implications for post operative pain management in patients undergoing major orthopedic surgery. Our retrospective analysis illustrates the relative safety of catheter removal in anticoagulated patients and suggests that the removal of lumbar plexus catheters can be safely performed with an INR > 1.5 in patients receiving warfarin
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