Neuraxial analgesia can be a very effective pain treatment in the injured warfighter, but special care must be taken to ensure that it is provided safely. Standard preservative free local anesthetics include ropivacaine and bupivacaine. The standard medication for aeromedical evacuation is 0.2% ropivacaine with sufficient volume for 3 days. Patients should be on stable doses of infusions prior to Aeromedical Evacuation (AE) transportation. The risk/benefit of epidural placement must be considered in the injured combat casualty who is also at risk for venous thromboembolic events. While all antiplatelet and anticoagulant medications increase the risk of bleeding, unfractionated heparin (UFH) and low molecular weight heparin (LMWH) use in patients undergoing epidural anesthesia greatly increases the risk of epidural hematoma, which can lead to paralysis. The APMS should maintain and provide input for standing orders to include:

1. All catheters should receive a 3 ml test dose of local anesthetic containing at least 1:400,000 epinephrine.

2. LMWH and UFH use in patients undergoing epidural anesthesia increases the risk of spinal or epidural hematoma, which may cause long term or permanent paralysis. We recommend against the use of LMWH in AE patients given the increased motion of delivery catheters during patient transport and resulting increased risk for spinal and epidural hematoma formation.

3. Before placement of an epidural catheter:

4. With an epidural catheter in place:

5. Before epidural catheter removal:

6. After epidural catheter removal:

These recommendations are consistent with the most recent ASRA (American Society of Regional Anesthesia) guidelines for the prevention of epidural hematoma.2

Note: Given that our patients are transported through a spectrum of care and across thousands of miles, the implementation of regional anesthesia should be integrated throughout the trauma system and must be safe and effective. An anesthesia provider is responsible for the initial placement and dosing of an epidural catheter. Only members of the APMS can change the dosing or infusion rate.

Appendix G is a summary of the ASRA guidelines as they relate to use of LMWH in combat casualties. The ASRA guidelines were originally developed for use of LMWH in the perioperative course.

Additionally, these recommendations change on a frequent basis; https://www.asra.com/  should be consulted for the most current recommendations.