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To block or not to block: superficial peripheral nerve blockade in anticoagulated patients
Daniel Shoham, M.D., Johanna deHaan M.D., Nadia Hernandez, M.D., Sudipta Sen, M.D., Dallis Clendinnin M.D., William Harvin M.D.
Department of Anesthesiology, McGovern Medical School, Houston, TX
It is a well-known and much debated fact that there are currently no published guidelines for performing peripheral nerve blockade on anticoagulated patients. Concern for hematoma formation is well documented in neuraxial blockade, and ASRA guidelines to the timing of neuraxial placement and anticoagulant administration is followed closely.(1) The introduction of ultrasound in experienced providers has been shown to reduce complications of peripheral nerve blockade including hematoma formation.(2) It was brought to our attention by a surgical colleague that anesthesiologists at outside institutions are following the ASRA anticoagulation neuraxial guidelines for peripheral nerve blockade. We began a review of our peripheral nerve block procedures performed on anticoagulated patients and examine for incidence of hematoma. We started this review using fascia iliaca blocks because many are performed on elderly patients who may be anticoagulated for vascular or cardiac reasons following falls resulting in a broken hip or arthroplasties. Fascia iliaca blockade is frequently used for pain control at our institution following procedures involving the femur and lower extremity skin graft harvesting, wherein skin is taken from the anterolateral thigh. In this case series, we discuss four patients who received fascia iliaca blockade while on medically necessary therapeutic anticoagulation.
At our institution, we perform the fascia iliaca block under ultrasound guidance using the “bowtie method.” A high frequency linear transducer is placed on the hip in a longitudinal orientation over the anterior superior iliac spine, and then translated medially until the bowtie formed by the fascia iliaca between the sartorius muscle and internal oblique on top of the iliacus muscle comes into view. Then a single shot block needle is advanced in plane to pierce the middle of the bowtie, and local anesthetic is deposited underneath the fascia iliaca on top of the iliacus muscle.
Patient one: a 40 year old male with high voltage electrical burns to bilateral hands, right ankle, left thigh, and chest. He had an open wound with exposed bone on his right ankle requiring a free muscle flap to cover the wound. For this reason he was therapeutically anticoagulated with a heparin infusion. He presented following the flap and split thickness skin graft to cover his hand wounds. We were asked to provide analgesia for the skin graft donor site at the right thigh. Therefore, a right fascia iliaca block was performed. The patient did not have any occurrence of hematoma formation.
Patient two: a 41 year old female who was in the hospital for elective myomectomy for uterine fibroids. On post operative day two, the patient experienced shortness of breath followed by bradycardia and PEA arrest; ultimately she was diagnosed with a saddle pulmonary embolus. She underwent CPR for 30 minutes at which point the ECMO team was consulted, and the patient was placed on VA ECMO. While on ECMO she required fasciotomies for bilateral lower extremity compartment syndrome and also experienced abdominal compartment syndrome. She eventually required skin grafts to cover these wounds, for which we provided analgesia by performing fascia iliaca blocks. At that time she was no longer on ECMO, but continued to be on heparin drip anticoagulation following the massive saddle pulmonary embolus as she transitioned to anticoagulation with warfarin. She did not experience any hematoma formation.
Patient three: a 66 year old male with history of atrial fibrillation, two myocardial infarctions with stent placements with an AICD who experienced burns following explosion of a propane tank. He was on a heparin infusion for his atrial fibrillation at the time of skin grafting for wound coverage. Fascia iliaca block was performed while on the heparin infusion following his split thickness skin graft. He did not experience any hematoma formation
Patient four: a 50 year old male who experienced a gunshot wound to his abdomen and chest. Over the course of his hospitalization, he experienced pulmonary embolism as well as right atrial thrombus. For this he was on a heparin drip and transitioned to therapeutically dosed enoxaparin at the time of our fascia iliaca block (Figure), which was performed for analgesia following split thickness skin graft from his thigh to his abdomen to cover a non-healing wound. He did not experience any hematoma formation.
In this review of four medically challenging cases, hematoma formation in the setting of fascia iliaca blockade was not observed. Both ASRA and ESRA have determined that each clinician take caution when a patient has received either prophylactic or therapeutic anticoagulation.(3) While there is currently no time table for waiting time with each anticoagulant for single shot peripheral nerve blockade, it is agreed upon that neuraxial, deep plexus and introduction of nerve catheters into a patient with active chemical anticoagulation should abide by current guidelines. The fascia iliaca block is often performed away from the medial portion of the fascia iliaca, safely away from the femoral artery. At our institution, we also perform this block with ultrasound guidance, whether it is a single shot or a catheter placement. We believe that eventually publishing our data on incidence of hematoma formation following peripheral nerve blockade will help add to the discourse regarding peripheral nerve blocks on anticoagulated patients.
1. Horlocker TT; et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine evidence-based guidelines (Third edition). Regional Asnesthesia and Pain Medicine. 2010 (35:64-101).
2. Walker KJ; McGrattan K; Aas-Eng K; Smith AF. Ultrasound guidance for peripheral nerve blockade. Cochrane Database of Systematic Reviews. 2009 (4): CD00645.
3. Li, J; Halasynski, T. Neuraxial and peripheral nerve blocks in patients taking anticoagulant or thromboprophylactic drugs: challenges and solutions. Local and Regional Anesthesia. 2015 (8:21-32).