Anesth Analg 2004;99:1267-1268
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000133950.13310.2A
LETTERS TO THE EDITOR
Epidural Hematoma After Anticoagulation with a Thoracic Epidural Catheter in Place: A Mere Coincidence?
Thomas M. Hemmerling, MD DEAA,
Jean-François Olivier, MD,
Fadi Basile, MD FRCP(S), and
Ignatio Prieto, MD FRCP(S)
Perioperative Cardiac Research Group (PECARG), Department of Anesthesiology
Perioperative Cardiac Research Group (PECARG), Department of Cardiac Surgery, Université de Montréal, Montréal, Canada
To the Editor:
We read with great interest the article by Rosen et al. (1), who present a case of epidural hematoma after aortic valve surgery. Since we regularly use epidural analgesia in aortic valve surgery (2), we would like to comment on a few issues of the above-mentioned article.
1. There are plenty of cases in the literature where epidural hematomas occurred in patients under anticoagulation or with coagulative disorders without surgery and without epidural catheter in place (3–6). The combination of full heparinization and the application of a thrombolytic drug greatly increase the risk of hematoma formation (7). The mere fact that there is an epidural catheter in place (for almost 50 h without problems) and blood is apparent in the catheter does not necessary mean that the catheter is the reason for bleeding. In a causal sense, the hematoma was formed when the patient was fully heparinized and a thrombolytic drug was injected more than 49 h after surgery and placement of the catheter—it could also have occurred without the catheter.
2. The authors hypothesized that blood loss through the catheter helped to decrease the pressure effects and that—had the catheter not been removed but left in place—the same progression of symptoms would have occurred, only over a longer period of time. We believe that another hypothesis is also possible: since the disturbed coagulation was the key factor to cause the problems, would a correction of these disturbances before catheter removal not have avoided the formation of hematoma? Until the correction of the apparent coagulation problems, the catheter could have been used to release the pressure (and the blood); after removal of the catheter during normal coagulation, no hematoma might have had developed.
3. It is very important to note that the initial anticoagulation during surgery did not create problems; almost 50 h after surgery went by without any complication.
There is one study (8) presenting more than 300 cases of epidural catheters in aortic valve surgery without any neurological complication. However, epidural analgesia after heart valve surgery is more complicated because of the need of anticoagulation whenever a mechanical prosthesis is installed. It is important to remove the catheter before warfarin causes an elevation of INR of more than 1.5 (7). Removal of epidural catheter at a greatly elevated aPTT has been causing hematomas before in other types of surgery (9). It is not a unique feature of cardiac surgery. It is very important that major disturbances of the coagulation system are corrected or, if possible, avoided in any patient having an epidural catheter in place.
We would like to stress that the formation of epidural hematoma in this patient occurred at inadvertent postoperative anticoagulation with full heparinization and application of a thrombolytic drug. This, in our view, would have been able to occur after any type of surgery, with or without epidural catheter. The disturbances of coagulation after surgery are common after other types of major surgery where the use of epidural anesthesia is well established, such as major vascular surgery or abdominal surgery.
References
- Rosen DA, Hawkinberry DW 2nd, Rosen KR, et al. An epidural hematoma in an adolescent patient after cardiac surgery. Anesth Analg 2004; 98: 966–9.[Abstract/Free Full Text]
- Hemmerling TM, Choiniere JL, Basile F, et al. Immediate extubation after aortic valve surgery using high thoracic epidural anesthesia. Heart Surg Forum 2004; 7: 16–20.
- Kirazli Y, Akkoc Y, Kanyilmaz S. Spinal epidural hematoma associated with oral anticoagulation therapy. Am J Phys Med Rehabil 2004; 83: 220–3.[Web of Science][Medline]
- Van Schaeybroeck P, Van Calenbergh F, Van De Werf F, et al. Spontaneous spinal epidural hematoma associated with thrombolysis and anticoagulation therapy: report of three cases. Clin Neurol Neurosurg 1998; 100: 283–7.[Web of Science][Medline]
- Horcajadas A, Katati M, Arraez MA, et al. Spontaneous epidural spinal hematoma: report of 2 cases and review of the literature [in Spanish]. Neurologia 1998; 13: 401–4.[Medline]
- Baron EM, Burke JA, Akhtar N, Young WF. Spinal epidural hematoma associated with tissue plasminogen activator treatment of acute myocardial infarction. Catheter Cardiovasc Interv 1999; 48: 390–6.[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]
- Canto M, Casas A, Sanchez MJ, et al. Thoracic epidurals in heart valve surgery: neurologic risk evaluation. J Cardiothorac Vasc Anesth 2002; 16: 723–6.[Web of Science][Medline]
- Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg 1994; 79: 1165–77.[Free Full Text]
Response
David A. Rosen, MD, and
Denzil W. Hawkinberry, MD
Professor of Pediatrics and Anesthesia
Resident in Anesthesia, Department of Anesthesia, Robert C. Byrd Health Science Center, West Virginia University School of Medicine, Morgantown, WV
In Response:
We would like to express our appreciation to Dr. Hemmerling for taking the time to submit a Letter to the Editor regarding our case report on an epidural hematoma formation in a cardiac surgery patient. We would also like to address some of the issues that he raises and offer some suggestions.
As Dr. Hemmerling has suggested, there are cases of epidural hematoma formation in the current literature unrelated to neuraxial anesthesia (1–4). While it is difficult to say with absolute certainty in this case, the development of this complication at this time was most likely related to the presence of the epidural catheter in association with marked coagulopathy in an ambulating patient. We agree that, since 57 hours had elapsed between catheter placement and the onset of neurologic symptoms, placement of the epidural catheter was not the cause of the hematoma. The combination of coagulopathic derangements in the postoperative period, created by the administration of therapeutic heparinization, the potent antithrombotic agent alteplase (used to flush the PICC line), and the thrombocytopenia, and the fact that the patient was ambulating, is the most likely cause of the hematoma at that specific time.
The presenting symptom in this case was the sudden onset of radicular back pain. Blood was then noted in the lumen of the epidural catheter. It was not until after the prompt removal of the catheter by the PICU staff that neurologic deficits were noted in this patient. We feel that there are two possible explanations for this: 1) the epidural catheter may have acted as a vent for the increasing pressure in the epidural space, caused by the expanding hematoma, and 2) the removal of the catheter may have increased bleeding. Most likely, it was a combination of these two factors. In 47% of the cases of catheter related epidural hematomas reported by Vandermeulen et al. (5) in 1994 the hematoma occurred during removal of the catheter. We believe that the onset of symptoms was due to the formation of the hematoma and that delaying decompressive laminectomy in order to correct this patients coagulation system at this point would not have been the best course of action. Neurologic outcomes in patients that have developed an epidural hematoma are improved greatly if the definitive treatment, decompressive laminectomy, occurs within 8 hours from the onset of symptoms (5,6). We feel that the best course of action in future cases would be to leave the epidural catheter in place during diagnostic imaging, use it as a vent to drain blood from the forming hematoma if possible, while simultaneously attempting to correct coagulopathies, and arrange for definitive treatment as soon as possible. The catheter left in position could then serve as a guide to the surgeon in determining which spinal levels to approach
We also stress the need for continued communication between all perioperative care providers particularly in those patients with postoperative epidural catheters. An understanding of the appropriate management of patients with epidural catheters and an awareness of potential complications, along with the proper management of these complications in these patients, is crucial for high quality care.
References
- Kirazli Y, Akkoc Y, Kanyilmaz S. Spinal epidural hematoma associated with oral anticoagulation therapy. Am J Phys Med Rehabil 2004; 83: 220–3.
- Van Schaeybroeck P, Van Calenbergh F, Van De Werf F, et al. Spontaneous spinal epidural hematoma associated with thrombolysis and anticoagulation therapy: report of three cases. Clin Neurol Neurosurg 1998; 100: 283–7.
- Horcajadas A, Katati M, Arraez MA, et al. Spontaneous epidural spinal hematoma: report of 2 cases and review of the literature [in Spanish]. Neurologia 1998; 13: 401–4.
- Baron EM, Burke JA, Akhtar N, Young WF. Spinal epidural hematoma associated with tissue plasminogen activator treatment of acute myocardial infarction. Catheter Cardiovasc Interv 1999; 48: 390–6.
- Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg 1994; 79: 1165–77.
- Lawton MT, Porter RW, Heiserman JE, et al. Surgical management of spinal epidural hematoma: relationship between surgical timing and neurological outcome. J Neurosurg 1995; 83: 1–7.[Web of Science][Medline]
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