RODNEY G. MEEKS, MD SHANNON C. CARROLL, DO Dr. Meeks is professor and Winfred L. Wiser Chair of Gynecologic Surgery, and Dr. Carroll is assistant professor, department of obstetrics and gynecology, University of Mississippi, Jackson, Miss.
The risk of hematoma appears to be lower with single-dose spinal or single-dose epidural anesthesia. While the incidence of epidural or spinal hematoma is not known, some cases have been associated with long-term neurologic sequelae, including permanent paralysis.
Responding to this concern, the US Food and Drug Administration issued a 1997 advisory noting the risk of spinal hematoma in patients receiving enoxaparin plus conduction anesthesia or lumbar spinal puncture. Most anesthesiologists significantly restrict the use of conduction anesthesia in patients requiring heparin prophylaxis.33
Cost-effectiveness
The cost of perioperative prophylaxis has been compared with the cost of immediate therapy for thromboembolic disease and long-term therapy for postthrombotic syndrome. Across the board, universal prophylaxis with pharmacotherapy or mechanical devices in patients undergoing abdominal surgery is less expensive than no prophylaxis, based on a reduced incidence of DVT. Pneumatic compression seems to be more cost-effective than pharmacotherapy.34
Because LDUH is substantially less expensive than LMWH in the United States, it has a better cost profile when pharmacotherapy is warranted. In Europe, where the cost of heparin compounds is not an issue, LMWH has a slight advantage.
The authors report no financial relationships relevant to this article.
