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,
Departments of *Anesthesiology,
Pediatrics,
Surgery, and
Radiology, West Virginia University Children’s Hospital, West Virginia University School of Medicine, Morgantown
Address correspondence and reprint requests to David A. Rosen, MD, Robert C. Byrd Health Science Center, West Virginia University School of Med, PO Box 9134, Morgantown, WV 26506-9134. Address e-mail to rosend{at}rcbhsc.wvu.edu
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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.
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Introduction |
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In this case report, we present an epidural hematoma related to epidural analgesia in an adolescent who underwent cardiac surgery.
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Case Report |
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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).
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Discussion |
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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.
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