Highlights from #EAST2014 - Enoxaparin dosing for epidural catheters

Although this study was conducted for patients with combat wounds and epidural catheters, could the results be applied to our trauma patients with epidural catheters?  Or to our trauma patients in general?

EPIDURAL PLACEMENT DOES NOT RESULT IN AN INCREASED INCIDENCE OF VENOUS THROMBOEMBOLISM (VTE) IN COMBAT-WOUNDED PATIENTS.

Joseph David Caruso, MD, Allison B. Weisbrod, MD, MPH, Eric Elster, MD, FACS, Carlos J. Rodriguez, DO, MBA, FACS*
Walter Reed National Military Medical Center

Presenter: Joseph David Caruso, MD Discussant: Donald Jenkins, MD, Mayo Clinic

Objectives: Patient-controlled epidural analgesia (PCEA) decreases the amount of systemic opioid required for adequate analgesia and decreases the rate of opioid induced side effects. Given the location of catheters required to deliver analgesics and potential for epidural hematoma, the American Society of Regional Anesthesia and Pain Medicine recommends modification of the standard trauma VTE prophylaxis regimen of enoxaparin 30mg BID to 40mg daily. The objective of this retrospective study was to determine if 40mg daily dosing would increase the incidence of VTE.

Methods: With IRB approval, records of all combat casualties admitted to our institution between November 2010 and November 2012 were reviewed for demographics, VTE prophylaxis regimen, PCEA days, and incidence of VTE. Patients who arrived without VTE were the study cohort. Rates of VTE were compared between PCEA and no-PCEA groups. Variables were analyzed with Mann-Whitney U, Pearson’s Χ2, and Fisher’s Exact tests. A p-value ≤0.05 was considered significant.

Results: 565 records were reviewed. 484 met inclusion criteria. 181(37.4%) patients had PCEA for 13(6,25) days. Age and sex were similar between the groups. PCEA patients were more often injured by dismounted IEDs (75.1% vs. 39.3%, p<0.001), had longer hospital stays (38 vs. 17 days, p<0.001), higher ISS (14 vs. 12, p=0.033), and were more likely to have an amputation (66.1% vs. 20.4%, p<0.001). 23(12.7%) PCEA patients developed VTE vs. 32(10.6%) no-PCEA patients (p=0.464). 11(47.8%) VTE events occurred with the catheter in place, while 12(52.2%) occurred 6(2,15) days after removal.

Conclusions: Though PCEA catheters were more often placed in patients prone to VTE, there was no difference in incidence of VTE with their use. This data suggests that enoxaparin 40mg daily in patients with PCEA is not inferior to 30mg BID for VTE prophylaxis in combat-wounded patients.