| JOURNAL HOME | CME HOME | THIS MONTH | PAST ISSUES | ETOC | COLLECTIONS |
| AUTHORS | REVIEWERS | EDITORIAL BOARD | FEEDBACK | RSS | HELP |
 
|
|
|
||
|
|
Anesth Analg 2004;98:966-969 © 2004 International Anesthesia Research Society doi: 10.1213/01.ANE.0000103267.37895.5B
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
Abstract |
|---|
 Top Abstract IntroductionCase ReportDiscussionReferences |
|---|
An 18-yr-old patient had a thoracic epidural placed under general anesthesia preceding an uneventful aortic valve replacement with a bioprosthetic valve. On the second postoperative day, he was anticoagulated and also received an antithrombotic medication. While ambulating, he experienced pain in his back, and there was blood in his epidural catheter. The catheter was removed, and he developed motor and sensory loss. Rapid surgical decompression resulted in recovery of his lost neurological function. Management and strategies for preventing this problem are discussed.
IMPLICATIONS: Epidural hematoma is a rare complication of epidural anesthesia and has not been reported in pediatric patients undergoing cardiac surgery. The successful treatment of this complication requires swift recognition, diagnosis, and surgical intervention.
|
Introduction |
|---|
|
TopAbstractIntroductionCase ReportDiscussionReferences |
|---|
Epidural analgesia for pediatric cardiac surgery has been described in the anesthesia literature (1–4). No epidural hematomas have been reported in these patients that could be attributed to the use of epidural catheters, subsequent heparinization, or maintenance of epidural analgesia into the postoperative period. Several authors have attempted to document the safety, efficacy, and benefits of perioperative epidural analgesia in these patients (1–4).
In this case report, we present an epidural hematoma related to epidural analgesia in an adolescent who underwent cardiac surgery.
|
Case Report |
|---|
|
TopAbstractIntroductionCase ReportDiscussionReferences |
|---|
An 18-yr-old, 67-kg man presented for bioprosthetic replacement of his aortic valve, secondary to aortic stenosis. Four years earlier, he successfully underwent an aortic valvotomy, with a perioperatively placed caudal epidural used for perioperative analgesia without complication. Because of his intense fear of needles and concerns about pain, general anesthesia was induced via mask before the insertion of any needles, as in his previous surgery. The epidural catheter (20-gauge, unstyleted, closed tip, radiopaque, and polyamide) was inserted in the T9-10 interspace and advanced 3 cm. Aspiration for blood or cerebrospinal fluid was negative. Injection of a 3-mL test dose (1.5% lidocaine with 1:200000 epinephrine) produced no change in heart rate or arterial blood pressure. Three hours later, the patient received 21,000 U of heparin in preparation for cardiopulmonary bypass (CPB).
Upon completion of the valve replacement and after measured reversal of heparin with protamine (Rapid point AccentTM, Bayer Corporation, East Walpole, MA) a double-lumen, peripherally inserted central venous catheter (PICC) was placed. The patient was transported to the pediatric intensive care unit (PICU) and tracheally extubated. A continuous epidural infusion of preservative free hydromorphone (3.0 µg · kg-1 · h-1) and 0.75% lidocaine (10 µg · kg-1 · min-1) was used for postoperative analgesia.
Postoperative day one was uncomplicated. The patient reported adequate pain control and ambulated without difficulty with the epidural catheter still in place. At 49 h after surgery, the PICU staff initiated IV heparin therapy for thrombo-prophylaxis for the prosthetic aortic valve. An initial IV bolus of 4500 U of heparin was followed by a continuous heparin infusion. Neither the anesthesiologist nor the surgeon were notified of this decision. Approximately 5 h later (53 h after surgery), the PICC line became dysfunctional, and each lumen was flushed with 2 mg of the thrombolytic drug alteplase. Within 2 h (57 h after surgery), while ambulating, the patient reported intense back pain. There was blood in the epidural catheter and at the catheter insertion site; the PICU team immediately removed the epidural catheter. The activated partial thromboplastin time (aPTT) value obtained from a blood sample at that time was 87.4 s (Table 1).
|
On removal of the epidural catheter, there was the sudden onset of numbness and weakness distal to T9. The anesthesiologist was contacted. Heparin therapy was then discontinued, a computed tomographic (CT) scan was obtained, and the spine surgery service was consulted. The initial CT imaging was inconclusive, requiring a magnetic resonance imaging (MRI) scan. The CT scan was obtained because it was immediately available; additionally, we believed that the MRI scanner’s magnet might heat the patient’s sternal wires and cause discomfort. In fact, the MRI scan was aborted before it was 50% complete because of the patient’s complaints of severe burning in his chest from his sternal wires being heated by the MRI magnet. However, MRI imaging confirmed the diagnosis of an epidural hematoma, and the patient was taken directly to the operating room for urgent decompressive laminectomy (Fig. 1).
|
Five hours from the onset of neurologic symptoms, the patient underwent surgical evacuation of the hematoma, which extended from the T8 to T11 levels. Intraoperatively, the patient received a platelet transfusion and a 30-mg/kg bolus of methylprednisolone. A methylprednisolone infusion was continued, as per our spinal cord injury protocol, at a rate of 5.4 mg · kg-1 · h-1 for 72 h. Twenty-four hours postlaminectomy, the patient demonstrated mild residual lower extremity motor and sensory deficits. Six weeks later, his neurological examination had returned to normal.
|
Discussion |
|---|
|
TopAbstractIntroductionCase ReportDiscussionReferences |
|---|
This patient developed a postoperative epidural hematoma related to epidural analgesia and concomitant anti-coagulant/thrombolytic therapy, resulting in an additional surgery and temporary neurological dysfunction.
Guidelines for use of neuroaxial techniques in patients receiving anticoagulants were published in 2003 (5). The role of epidural anesthesia/analgesia in patients undergoing cardiothoracic surgery is still a debatable subject. However, several published reports have attempted to document the safety of this technique in pediatric (1–4) and adult (6–9) patients undergoing surgery requiring intraoperative anticoagulation. In 1995, Flandin-Blety and Barrier (10) reported a review of more than 24,000 noncardiac pediatric patients who received an epidural anesthetic/analgesic, and only five complications related to the technique were reported, none of which were epidural hematoma formation.
Much of the argument against using spinal or epidural anesthesia in patients who have received or will receive heparin therapy is derived from the Ruff and Dougherty 1981 report (11) of 342 patients undergoing lumbar puncture followed by systemic heparinization. In this report, 7 of 342 (2%) patients developed a spinal hematoma.
There are no reports of spinal hematoma related to neuraxial anesthesia in patients undergoing CPB, nor are there any closed claims on file in the registry (5). However, with <1500 reports of the safe use of epidural anesthesia in children undergoing systemic heparinization for CPB, and only 30% of these thoracic (1–4), the total sample size lacks statistical power to make a definitive statement regarding the safety of this technique (Type II error). Based on Tryba’s (12) estimates of the incidence of spinal/epidural hematoma formation in nonanticoagulated patients receiving epidural (1:150,000) or spinal (1:220,000) anesthesia, a sample of nearly 200,000 patients would be required for 80% power to detect a 10-fold increase in the incidence of this complication (13). A mathematical analysis by Ho et al. (14), based on the 4583 epidural and 10,840 spinal anesthetics reported in cardiac patients, estimate the risk of epidural hematoma formation to be no more than 1:1528 for epidurals and 1:3610 for spinals. Thus, there is insufficient data to conclude that preoperative placement of an epidural catheter followed full heparinization one to three hours later is risk free (1–3).
The benefits of regional anesthesia in adult and pediatric cardiac surgery patients are well documented (1–4,15–19). Nader et al. (18) described multiple potential respiratory advantages of regional techniques, which are as follows: (a) perioperative respiratory depression was decreased when compared with IV narcotic therapy; (b) earlier extubation; and (c) lower postoperative PCO2.
Epidural hematoma, although rare, is a potentially devastating complication. In 1994, Vandermeulen et al. (20) reported 61 cases of epidural hematoma formation related to neuraxial anesthesia between 1906 and 1993. An epidural technique was used in 46 of 61 (69.5%) of these anesthetics; the remaining patients received a spinal anesthetic. An epidural catheter was used in 32 of 46 (66%) of these patients. The epidural bleeds occurred upon removal of the epidural catheter in 15 of 32 (47%) of these patients. More importantly, 42 of 61 (68%) of the epidural hematomas reported by Vandermeulen et al. (20) occurred in patients with impaired coagulation.
This patient’s coagulation system was altered in several ways. The aPTT at the approximate time of hematoma formation was 87.4 seconds (normal range, 24.8–37.3). Approximately one hour after receiving a 4-mg injection of alteplase into the PICC line, neurologic symptoms consistent with epidural hematoma formation were noted. Thrombocytopenia developed three days after intraoperative exposure to CPB and heparin and was diagnosed approximately 12 hours after initiation of postoperative heparin therapy via a blood sample obtained for the prelaminectomy coagulation profile. At that time, the platelet count was 76,000. Whether the thrombocytopenia was surgery related or rapid onset nonantibody-mediated heparin-induced thrombocytopenia and thrombosis syndrome (21) is unknown. Antibody-mediated heparin-induced thrombocytopenia and thrombosis syndrome usually occurs approximately five days after exposure to heparin (22). In this case, all screening tests for heparin-induced antiplatelet antibodies were negative.
This patient’s first symptom was severe radicular back pain; this is but one way in which the onset of epidural hematoma symptoms can initially present. New onset muscle weakness (46%), back pain (38%), sensory deficit (14%), and urinary retention (8%) are all reported as possible initial signs and symptoms of epidural hematoma (20). Interestingly, this patient presented with back pain yet remained neurologically intact until after the epidural catheter was removed. We hypothesize that blood loss through the epidural catheter helped to decrease the pressure effects of the developing hematoma. The same progression of symptoms may have been observed over a longer period of time if the catheter had not been extracted.
The only effective treatment for a compressing epidural hematoma is decompressive laminectomy with evacuation of the hematoma (20). Final neurologic outcome depends on: (a) the speed with which the hematoma develops; (b) the severity of the preoperative neurological deficit; (c) the size of the hematoma; and (d) the time between hematoma formation and surgical evacuation (20,23,24). In patients with good neurologic outcomes, decompression occurs within eight hours of the initial development of neurologic signs or symptoms (20).
Epidural analgesia offers many potential benefits in the treatment of postoperative pain compared with parenteral opiates. An alert comfortable patient is able to change position, cough, and ambulate. These advantages prevail, even if the epidural catheter can only be maintained for 24–48 hours, because the effects can last long after the catheter is removed. There are likewise some rare but significant potential complications in the patient who has had a prosthetic valve placed. The risks and benefits must be reviewed for each patient. The risk of potential life-threatening hemorrhage after anticoagulation is so great in children that a prosthetic valve must be avoided if at all possible. When a prosthetic valve is the only option, a bioprosthetic valve may be chosen as a way to minimize the need for long-term anticoagulation. Management of pediatric cardiac surgery patients involves several care teams, and communication among all providers is vital. All providers must understand the potential for hematologic complications in these patients.
In summary, this case report documents the occurrence of a postoperative epidural hematoma in a patient whose coagulation system was altered during surgery and after surgery with heparin and the thrombolytic drug alteplase. Additionally, postoperative thrombocytopenia was present, further contributing to derangement of his coagulation system. These factors contributed to the development of an epidural hematoma on postoperative Day 2. More importantly, removal of the epidural catheter in the presence of impaired hemostasis may have increased the bleeding and further compounded the problem.
|
References |
|---|
|
TopAbstractIntroductionCase ReportDiscussionReferences |
|---|
- Rosen DA, Rosen KR, Hammer GB. Pro: Regional anesthesia is an important component of the anesthetic technique for pediatric patients undergoing cardiac surgical procedures. J Cardiothorac Vasc Anesth 2002; 12: 374–8.
- Peterson KL, DeCampli WM, Pike NA, et al. A report of two hundred twenty cases of regional anesthesia in pediatric cardiac surgery. Anesth Analg 2000; 90: 1014–9.
[Abstract/Free Full Text] - Hammer GB, Ngo K, Macario A. A retrospective examination of regional plus general anesthesia in children undergoing open heart surgery. Anesth Analg 2000; 90: 1020–4.
[Abstract/Free Full Text] - Rosen KR, Rosen DA. Caudal epidural morphine for control of pain following heart surgery in children. Anesthesiology 1989; 70: 418–21.[Web of Science][Medline]
- Horlocker TT, Wedel DJ, Benzon H, et al. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 2003; 28: 172–97.[Web of Science][Medline]
- Rao TL, El-Etr AA. Anticoagulation following placement of epidural and subarachnoid catheters: an evaluation of neurologic sequelae. Anesthesiology 1981; 55: 618–20.[Web of Science][Medline]
- Baron HC, LaRaja RD, Rossi G, Atkinson D. Continuous epidural analgesia in the heparinized vascular surgical patient: a retrospective review of 912 patients. J Vasc Surg 1987; 6: 144–6.[Web of Science][Medline]
- Odoom JA, Sih IL. Epidural analgesia and anticoagulant therapy: experience with one thousand cases of continuous epidurals. Anaesthesia 1983; 38: 254–9.[Web of Science][Medline]
- Scherer R, Schmutzler M, Giebler R, et al. Complications related to thoracic epidural analgesia: a prospective study in 1071 surgical patients. Acta Anaesthesiol Scand 1993; 37: 370–4.[Web of Science][Medline]
- Flandin-Blety C, Barrier G. Accidents following extradural analgesia in children: the results of a retrospective study. Paediatr Anaesth 1995; 5: 41–6.[Web of Science][Medline]
- Ruff RL, Dougherty JH Jr. Complications of lumbar puncture followed by anticoagulation. Stroke 1981; 12: 879–81.
[Abstract/Free Full Text] - Tryba M. Epidural regional anesthesia and low molecular heparin: Pro. Anasthesiol Intensivmed Notfallmed Schmerzther 1993; 28: 179–81.[Medline]
- Urmey WF, Rowlingson J. Do antiplatelet agents contribute to the development of perioperative spinal hematoma? Reg Anesth Pain Med 1998; 23: 146–51.[Web of Science][Medline]
- Ho AM, Chung Dc, Joynt GM. Neuroaxial blockade and hematoma in cardiac surgery: estimating the risk of a rare adverse event that has not (yet) occurred. Chest 2000; 117: 551–5.
[Free Full Text] - Stenseth R, Bjella L, Berg EM, et al. Effects of thoracic epidural analgesia on pulmonary function after coronary artery bypass surgery. Eur J Cardiothorac Surg 1996; 10: 859–65;discussion 66.
- Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia: their role in postoperative outcome. Anesthesiology 1995; 82: 1474–506.[Web of Science][Medline]
- Chaney MA. Benefits of neuraxial anesthesia in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth 1997; 11: 808–9.[Web of Science][Medline]
- Nader ND, Peppriell J, Panos A, Bacon DR. Potential beneficial effects of intrathecal opioids in cardiac surgical patients. Internet J Anesthesiol 2000; 4.
- Priestley MC, Cope L, Halliwell R, et al. Thoracic epidural anesthesia for cardiac surgery: the effects on tracheal intubation time and length of hospital stay. Anesth Analg 2002; 94: 275–82.
[Abstract/Free Full Text] - Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg 1994; 79: 1165–77.
[Free Full Text] - Warkentin TE, Kelton JG. Temporal aspects of heparin-induced thrombocytopenia. N Engl J Med 2001; 344: 1286–92.
[Abstract/Free Full Text] - Warkentin TE, Levine MN, Hirsh J, et al. Heparin-induced thrombocytopenia in patients treated with low-molecular-weight heparin or unfractionated heparin. N Engl J Med 1995; 332: 1330–5.
[Abstract/Free Full Text] - Foo D, Rossier AB. Preoperative neurological status in predicting surgical outcome of spinal epidural hematomas. Surg Neurol 1981; 15: 389–401.[Web of Science][Medline]
- McQuarrie IG. Recovery from paraplegia caused by spontaneous spinal epidural hematoma. Neurology 1978; 28: 224–8.
[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
 |
|
  O. J. Benavidez, K. Gauvreau, P. D. Nido, E. Bacha, and K. J. Jenkins Complications and Risk Factors for Mortality During Congenital Heart Surgery Admissions Ann. Thorac. Surg., July 1, 2007; 84(1): 147 - 155. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. M. Hemmerling, G. Djaiani, P. Babb, and J. P. Williams The Use of Epidural Analgesia in Cardiac Surgery Should Be Encouraged Anesth. Analg., December 1, 2006; 103(6): 1592 - 1592. [Full Text] [PDF]
|
|
|
|
|
|
M. A. Chaney Intrathecal and Epidural Anesthesia and Analgesia for Cardiac Surgery Anesth. Analg., January 1, 2006; 102(1): 45 - 64. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. F. Olivier, N. Le, J. L. Choiniere, I. Prieto, F. Basile, and T. Hemmerling Comparison of three different epidural solutions in off-pump cardiac surgery: pilot study Br. J. Anaesth., November 1, 2005; 95(5): 685 - 691. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. H. Lundstrom, E. Nygard, L. B. Hviid, F. M. Pedersen, J. Ravn, J. Aldershvile, and J. Rosenberg The Effect of Thoracic Epidural Analgesia on the Occurrence of Late Postoperative Hypoxemia in Patients Undergoing Elective Coronary Bypass Surgery: A Randomized Controlled Trial Chest, September 1, 2005; 128(3): 1564 - 1570. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. S. Myles and D. McIlroy Fast-Track Cardiac Anesthesia: Choice of Anesthetic Agents and Techniques Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2005; 9(1): 5 - 16. [Abstract] [PDF]
|
|
|
|
|
|
G. Djaiani, L. Fedorko, and W. S. Beattie Regional Anesthesia in Cardiac Surgery: A Friend or A Foe? Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2005; 9(1): 87 - 104. [Abstract] [PDF]
|
|
|
|
|
|
T. M. Hemmerling, J.-F. Olivier, F. Basile, I. Prieto, D. A. Rosen, and D. W. Hawkinberry Epidural Hematoma After Anticoagulation with a Thoracic Epidural Catheter in Place: A Mere Coincidence? * Response Anesth. Analg., October 1, 2004; 99(4): 1267 - 1268. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
