Orthopedic surgery, DVT prophylaxis and regional anesthesia

Orthopedic surgery is associated with a high incidence of thromboembolism and orthopedic surgeons have been among the most aggressive with respect to DVT prophylaxis.  Traditionally anesthesiologists have viewed many orthopedic surgery procedures as “perfect” for regional techniques such as spinal or epidural anesthesia.  Rowlingson et al is optimistic about the continued use of regional anesthesia in orthopedic patients who are receiving LMWH.  They note that “the key to optimizing patient safety however, depends on a careful calibration of the total daily dose and the timing of the first and subsequent doses of LMWH with the timing and management of the regional anesthetic procedure.”  I am not convinced that this degree of coordination and cooperation is possible particularly given the consequences (paralysis).  Dr. Richman at Penn Presbyterian Medical Center notes that most of their orthopedic surgeons use LMWH for post operative DVT prophylaxis and that patients receiving LMWH never get epidural anesthesia.  For knee surgery the anesthesiologists are using femoral nerve catheters sometime in combination with PCA.  They are willing to do spinal anesthesia as long the LMWH is not started until after surgery.  He notes that most of their orthopedic surgery patients receive general anesthesia (personal communication).

            

REF: Rowlingson JC, Hanson PB: Neuraxial anesthesia and low-molecular-weight heparin prophylaxis in major orthopedic surgery in the wake of the latest American Society of Regional Anesthesia Guidelines.  Anesth Analg 2005;100:1482-8

David S. Smith, M.D., Ph.D.