P Pu ur rp po os se e: : Spinal epidural hematoma following epidural anesthesia is extraordinarily rare in association with low-dose sc heparin, and the prognosis for neurologic recovery without rapid surgical decompression poor. We report a case of spinal epidural hematoma in a nonagenarian who received low-dose sc unfractionated heparin postoperatively in accordance with standard guidelines, presented with no back pain, and made full neurologic recovery without surgical intervention.C Cl li in ni ic ca al l f fe ea at tu ur re es s: : A 90-yr-old female with gastric adenocarcinoma presented for subtotal gastrectomy. Her past medical history and physical examination were largely unremarkable and she had no bleeding diathesis. She took no medications other than preoperative ranitidine, and had a normal coagulation profile. A thoracic epidural catheter was placed uneventfully before induction of general anesthesia. Postoperatively, low-dose sc unfractionated heparin was started 12 hr after the epidural catheter insertion. On postoperative day two, the patient developed flaccid lower extremity paralysis and paresthesia without back pain. Her coagulation profile remained normal. Subsequent magnetic resonance imaging showed a large epidural hematoma extending from T3 to T11. With conservative treatment and no surgery, the patient slowly made full neurologic recovery and was discharged home on postoperative day 56.C Co on nc cl lu us si io on n: : Complete neurologic recovery from flaccid paralysis following spinal epidural hematoma occurred without surgical decompression in a nonagenarian. Low-dose sc heparin may be a greater risk factor for spinal epidural hematoma than previously assumed, and the absence of back pain does not rule out this diagnosis. PINAL epidural hematoma is a rare complication of epidural anesthesia with an estimated incidence of 1:190,000 and potentially devastating consequences. 1 Identified risk factors include difficult or traumatic needle/catheter insertion, ankylosing spondylitis, and anticoagulation/coagulopathy 1,2 whereas treatment with low-dose unfractionated heparin is generally considered safe. 3 Typical presentation is with sharp back pain and associated motor and sensory deficit progressing to paraplegia, with a poor prognosis of recovery if decompressive laminectomy is not performed within eight hours. Here, we report a case of spinal epidural hematoma in a 90-yr-old patient with no history of coagulopathy, multiple/traumatic needle insertion or catheter manipulation who received low-dose sc unfractionated heparin postoperatively in accordance with current standard guidelines, presented with no back pain, and made full neurologic recovery without surgical intervention. ObjectifC Ca as se e r re ep po or rt t A 90-yr-old Caucasian female [weight, 57 kg; American Society of Anesthesiologists (ASA) physical status class II] presented with gastric adenocarcinoma and was taken to the operating room for subtotal gastrectomy with creation of a Roux-en-Y anastomosis and feeding jejunosto...
The manufacturers of thiopentone recommend that after reconstitution, it should be kept only for 24 hr to reduce the risk of contamination. However, there are no studies to support this practice and compliance with this recommendation has economic implications. The reasons for discarding a reconstituted bottle of thiopentone are related to concerns about chemical and physical (pH) stability, contamination with infectious agents, and contamination with cellular material. We studied the incidence of bacterial contamination and pH stability of thiopentone in clinical use, as well as the pH stability of thiopentone not in clinical use, and surveyed the eight hospitals affiliated with the University of British Columbia to determine their protocols for thiopental preparation and storage. Cost comparisons were made between our current practice of discarding thiopentone when depleted and the practice of routinely discarding it 24 hr after reconstitution. Samples of thiopentone in clinical use were cultured daily and the pH was measured. The bottles had been in clinical use from 1 to 25 days (mean 4.23 +/- 4.32 SD). Of 106 samples there were no positive bacteriological cultures and there were only minor changes in pH. The telephone survey of the eight hospitals revealed that only one had a policy to discard thiopentone after 24 hr. Cost comparisons indicate that discarding thiopentone 24 hr after reconstitution would result in increased cost. In conclusion, reconstituted thiopentone retains its alkalinity for up to four weeks, and has an acceptably low risk of bacterial contamination for periods beyond 24 hr, therefore thiopentone need not be discarded after 24 hr.
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