Peripheral nerve blockade (PNB) is superior to neuraxial anesthesia and/or opioid therapy for perioperative analgesia in total knee\nreplacement (TKR). Evidence on the safety of PNB in patients with coagulopathy is lacking. We describe the first documented\naccount of continuous femoral PNB for perioperative analgesia in a patient with VonWillebrand Disease (vWD). Given her history\nof opioid tolerance and after an informative discussion, a continuous femoral PNB was planned for in this 34-year-old female\nundergoing TKR. A Humate-P intravenous infusion was started and the patient was positioned supinely. Using sterile technique\nwith ultrasound guidance, a Contiplex 18 Gauge Tuohy needle was advanced in plane through the fascia iliaca towards the femoral\nnerve. A nerve catheter was threaded through the needle and secured without complications. Postoperatively, a levobupivacaine\nfemoral catheter infusion was maintained, and twice daily Humate-P intravenous infusions were administered for 48 hours;\nenoxaparin thromboprophylaxis was initiated thereafter. The patient was discharged uneventfully on postoperative day 4. Given\ndocumentation of delayed, unheralded bleeding from PNB in coagulopathic patients, we recommend individualized PNB in vWD\npatients. Multidisciplinary team involvement is required to guide factor supplementation and thromboprophylaxis, as is close\nfollow-up to elicit signs of bleeding throughout the delayed postoperative period.
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