Spinal Epidural Hematoma Following Epidural Catheter Removal in a Patient with Postoperative Urgent Coronary Intervention and Intra-Aortic Balloon Pumping (IABP): A Case Report

Abstract

Patient: Male, 72Final Diagnosis: Spinal epidural hematomaSymptoms: ParalysisMedication: HeparinClinical Procedure: LaminectomySpecialty: AnesthesiologyObjective:Rare diseaseBackground:It is still challenging to remove an epidural catheter in a postoperative patient receiving urgent antiplatelet and anticoagulation therapy for acute coronary syndrome.Case Report:While under general anesthesia combined with thoracic epidural anesthesia, a 72-year-old male patient underwent right radical nephrectomy for renal cell carcinoma. On postoperative day 1 (POD1), the patient experienced bradycardia and a decrease in blood pressure, and he was diagnosed acute myocardial infarction. Intraaortic balloon pumping (IABP) was induced for cardiogenic shock, and urgent thrombus aspiration and coronary balloon angioplasty were performed. On POD3, the surgeon removed the epidural catheter under both anti-platelet and anticoagulation therapy. At that time, the platelet count was 45×109/L and the activated partial thromboplastin time (APTT) was 72.2 seconds. Four hours after the epidural catheter was removed, the patient complained of bilateral fatigue in legs and developed a loss of sensation. Six hours after the epidural catheter was removed, he developed motor paralysis and became completely paralyzed in both limbs after 9 hours. At 19 hours after the epidural catheter was removed, emergency magnetic resonance imaging detected a spinal epidural hematoma at the level of Th9-11 with compression of the spinal cord. Emergency laminectomy was performed to decompress and remove the spinal epidural hematoma at 18 hours after the onset of sensorimotor symptoms. After surgery and rehabilitation, these symptoms had only slightly improved.Conclusions:In patients with urgent antithrombotic therapy for urgent percutaneous coronary intervention (PCI) with an IABP for acute coronary syndrome, the epidural catheter should not be removed until the IABP and heparin are discontinued, and platelet counts have recovered.

Health-Related Quality of Life and Functional Status Following Intensive Neurorehabilitation in a Patient after Severe Head Injury with Spinal Epidural Hematoma: A Case Report

“…On the other hand, there are case reports of patients who underwent surgery immediately or relatively quickly after the onset of symptoms (even up to 18 h) for whom rehabilitation was effective, but only slightly, as described Mimata et al [27]. For this reason, the work of Liu et al [28], based on a description of 23 cases of SEH and observations, highlights the second prognostic factor of recovery: the degree of preoperative neurological deficit.…”

Uneventful epidural catheter removal in a patient with postoperative acute coronary syndrome receiving emergency triple antithrombotic therapy: a case report

“…The overall incidence of neuraxial hematoma is about 1:150,000 epidurals, but the risk increases significantly in patients receiving combination therapy with antiplatelets, anticoagulants and/or thrombolytics. 1 , 2 Epidural hematomas usually occur after epidural catheter removal and may lead to permanent neurologic deficits. 2 The American Society of Regional Anesthesia and Pain Medicine (ASRA) recommends that clopidogrel should be discontinued 5–7 days prior to neuraxial procedures and can be resumed immediately, provided that a loading dose is omitted.…”

“…It usually occurs after epidural catheter removal and may have disastrous neurologic consequences. 1 , 2 In case of urgent multiple antithrombotic treatment, appropriate timing for epidural catheter removal is not clearly defined by guidelines and remains challenging.…”

Efficacy of Perioperative Intercostal Analgesia via a Multimodal Analgesic Regimen for Chronic Post-Thoracotomy Pain During Postoperative Follow-Up: A Big-Data, Intelligence Platform-Based Analysis

“…8 Thoracic epidural analgesia is effective in thoracotomy patients, but epidural analgesia may result in epidural hematoma, dural perforation, and urinary retention. 9,10 Intercostal analgesia with a single intercostal catheter could avoid such complications. 11 In a review, using thoracic epidural anaesthesia in five of seven included studies showed the strongest effect, but whether other interventions such as intercostal analgesia have the same effect is unknown.…”