The Titanic Is Not the Best Analogy for Enoxaparin
1999; Lippincott Williams & Wilkins; Volume: 88; Issue: 1 Linguagem: Inglês
10.1213/00000539-199901000-00047
ISSN1526-7598
Autores Tópico(s)Case Reports on Hematomas
ResumoTo the Editor: My feathers are ruffled by Horlocker and Wedel's recent editorial on low-molecular-weight heparin and "smooth sailing on the Titanic" [1], which implies that practitioners like me may share the faults of Captain Smith. One of my patients suffered an epidural hematoma associated with epidural catheter placement and enoxaparin. In June of 1997, an 81-yr-old woman presented for total knee replacement, which was performed under epidural anesthesia. The catheter was left in place for postoperative analgesia with a continuous infusion of fentanyl and bupivacaine. Thirty-two hours after traumatic catheter placement and 20 h after the first enoxaparin injection, signs of an epidural hematoma were detected. Permanent and devastating paraplegia resulted despite decompressive laminectomy. I am proud that my community hospital was aware of all facets of the debate related to enoxaparin raised by Horlocker and Wedel Analogies with heparin, the impressive safety data from Europe, and recommendations of Vandermeulen et al. [2] led our hospital to maintain concurrent use of enoxaparin with epidural catheters. Consultation with two fellowship-trained pain specialists early in 1997 also led us to believe that this was a safe and beneficial practice. Plenty of reasonable anesthesiologists thought that enoxaparin was safe to use. Terrible consequences resulted. Perhaps Horlocker and Wedel are carried away with a search for hubris among anesthesiologists. The current Titanic mania makes forceful analogies too easy. I prefer to think of the analogy of the sinking of the Lusitania by a German U-boat. Hundreds of innocent passengers died by an underwater menace that didn't play by the civilized rules then known by Captain William Turner. The lesson from enoxaparin is not just about hand-wringing, but about vigilance for the unexpected threat. Sean S. Adams, MD Anesthesia Section; Burlington Medical Center; Burlington, IA 52601
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