Epidural Hematoma After Anticoagulation with a Thoracic Epidural Catheter in Place: A Mere Coincidence?

Abstract

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. David A. Rosen, MD Professor of Pediatrics and Anesthesia Denzil W. Hawkinberry, MD Resident in Anesthesia Department of Anesthesia Robert C. Byrd Health Science Center West Virginia University School of Medicine Morgantown, WV