Intensive Care Unit Doctors Research Articles

Survey of airway management strategies and experience of non-consultant doctors in intensive care units in the UK

Airway problems continue to occur in intensive care setting. Management strategies, staffing, and availability of equipment can all have an influence. We undertook a standardized telephone survey of airway management strategies, staffing, and airway equipment availability in general intensive care units (ICUs) in the UK, before the reporting of the Fourth National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society. All 257 UK general ICUs were contacted and 77% replied. At the time of the survey, 6.3% of all ICU patients were judged by respondents to have an increased risk of airway complications. While 38% of respondents reported using individualized airway management plans for patients with higher risk airways, only 19% of the patients identified as 'at risk' had such a plan in place. Action plans for the management of unanticipated tracheal tube and tracheostomy displacement were available in 7% and 10% of ICUs, respectively, although 27% of respondents reported no training in recognition and management of these events. Few respondents could describe the equipment available for emergency transtracheal access on their ICU and 13% had no training in its use. More than half of the respondents (56%) routinely used continuous waveform capnography for patients with artificial airways. A fibrescope was available to all ICUs: immediately in 63% and after >5 min in 14%. In 33% of ICUs, the most junior doctor providing out-of-hours cover had not always obtained the Royal College of Anaesthetists initial assessment of competency in anaesthesia. One-third of ICU residents also had commitments outside the ICU. An additional anaesthetist for managing airway emergencies was available in all ICUs with 80% being on-site. There remains room for improvement in airway management strategies and resources in ICUs in the UK.

Universal Definition of Neurologic Criteria of Death May Improve Organ Donation and Prevent Unethical Treatment in ICU

Excellent results of organ transplantation have caused an enormous increase in the number of patients awaiting for such treatment. Organ recovery rate from deceased donors in European Countries in 2010 ranged from 2.7 p.m.p. in Bulgaria to 32 p.m.p. in Spain. Deceased donation rate p.m.p. in Italy and Poland amounted to 21.7 and 13.3 respectively. The reason of organ shortage is difficult to comprehend since significantly more patients die in intensive care units (ICUs) due to cerebral vascular events or head trauma. The aim of this study was to compare the potential of deceased organ donation with the real organ recovery rate in two European countries - Poland and Italy. The Italian Registry of Deaths with Acute Cerebral Lesion (DACL) in ICUs confirmed that BD declarations are consistently less than expected number. Over a 2-year period, BD declarations, i.e. potential DBD donors, were 43% of the 10,304 referred DACL. Considering 55% to 60% as possible benchmarking, approximately a 1000 BD declarations per year seem to be missing in Italy. The Italian law indicates that death must be determined by neurological criteria, regardless of potential organ donation, in all cases as soon as all the criteria of BD are completely fulfilled. All patients with neurological criteria of death, under mechanical ventilation in ICU, must be referred to the medical management of a hospital. Declaration of death by neurological criteria must be performed independently from potential organ donation and before any family interview about donation. Unfortunately, collected data suggest that many brain deaths are not declared in Italy (“silent BDs”): ICU doctors may wait for circulatory arrest under mechanical ventilation to avoid diagnostic procedures, excessive workload and BD explanations to the family. The data on missing donors (or “silent deaths”) in Poland are similar. In 2010, out of 55 000 patients treated In ICUs, 23,400 died. According to DOPKI donation index (EU) in approximately 3194 of these pts brain death could have been diagnosed. This translates into 1340 dead pts (42%), who could have been considered as potential donors. Regarding family refusal rate, logistic problems and medical contraindications (20%), organs could have been recovered from nearly 1100 deceased donors. In the same year, only 655 deceased pts were referred as potential donors and at least one organ was recovered and transplanted from 509 real donors. Conclusions: Clear and simple international guidelines should be defined and implemented by Scientific Societies and Health Authorities in all the European Countries to support intensivists in determining and declaring death by neurological criteria in all brain-dead patients and ensuring an immediate withdrawal of any treatment as soon as BD has been declared if organ donation is not planned. A universal death definition (and implementation) is needed, not only to increase organ recovery from deceased donors but mainly to meet clinical and ethical principles.

Acute Liver Damage and Anorexia Nervosa: A Case Report and Review of the Literature

We treated a patient suffering from severe anorexia nervosa [body mass index (BMI), 10.5 kg/m2] complicated with hepatic insufficiency. The treatment consisted of rehydration and the correction of her malnutrition, using adapted protocols to avoid the development of the refeeding syndrome. In view of her successful progress she was discharged from the hospital on day 50. Although we do not perform a hepatic biopsy, the mechanism seems to be related to autophagy more than hypoperfusion because of the extremely low BMI. This observation also highlights the need of following a multidisciplinary approach in these difficult cases (BMI < 13 kg/m2), involving intensive care unit doctors, gastroenterologists, endocrinologists and psychiatrists. Abbreviations: BMI: Body mass index; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; CT: Computed tomography.

Case study thoracic radiotherapy in an elderly patient with pacemaker: The issue of pacing leads

To assess clinical outcome of patients with pacemaker treated with thoracic radiation therapy for T8-T9 paravertebral chloroma. A 92-year-old male patient with chloroma presenting as paravertebral painful and compressive (T8-T9) mass was referred for radiotherapy in the Department of Radiation Oncology, Institut Curie. The patient presented with cardiac dysfunction and a permanent pacemaker that had been implanted prior. The decision of Multidisciplinary Meeting was to deliver 30 Gy in 10 fractions for reducing the symptoms and controlling the tumor growth. The patient received a total dose of 30 Gy in 10 fractions using 4-field conformal radiotherapy with 20-MV photons. The dose to pacemaker was 0.1 Gy but a part of the pacing leads was in the irradiation fields. The patient was treated the first time in the presence of his radiation oncologist and an intensive care unit doctor. Moreover, the function of his pacemaker was monitored during the entire radiotherapy course. No change in pacemaker function was observed during any of the radiotherapy fractions. The radiotherapy was very well tolerated without any side effects. The function of the pacemaker was checked before and after the radiotherapy treatment by the cardiologist and no pacemaker dysfunction was observed. Although updated guidelines are needed with acceptable dose criteria for implantable cardiac devices, it is possible to treat patients with these devices and parts encroaching on the radiation field. This case report shows we were able to safely treat our patient through a multidisciplinary approach, monitoring the patient during each step of the treatment.

Organizational Model for a National System of Donation and Transplantation from Deceased Donors in Nicaragua

System organization is one of the principal elements for success of a country's donation and transplantation activities. Nicaragua still does not have a specific institution that organizes and coordinates donation and transplantation; it does not perform transplantations from brain dead donors. With the counsel of the Transplant Coordination Service of the Hospital Clinic, Barcelona, Spain, we documented the current donation and transplant situation of Nicaragua, its health services and institutions, and their relevant demographic aspects. We analyzed some organizational models implemented around the world and in Latin America as well as the essential elements of “The Spanish Model”, proposing an organizational model adapted to the Nicaraguan reality. For a small country with specialized services concentrated in the capital, Managua, we envisioned the creation of a two-tier system: First, a national cooordination of transplants who leads a group that is decentralized and subordinate to the hierarchy of the Ministry of Health, to organize and coordinate donation and transplantation activities. Second, a hospital coordinator who works with doctors in intensive care units and neurosurgical intensive care units to detect potential organ donors and communicate with the national coordinator of transplants, who directs the process. Nicaragua has the basic conditions for implementation of donation and transplantation from deceased donor, as well as institutions with the capacity to maintain their function as documented by this viable, functional organizational model.

Dignified death: Concept development involving nurses and doctors in Pediatric Intensive Care Units

The aim of this study was to develop the concept of the dignified death of children in Brazilian pediatric intensive care units (PICUs). The Hybrid Model for Concept Development was used to develop a conceptual structure of dignified death in PICUs in an attempt to define the concept. The fieldwork study was carried out by means of in-depth interviews with nine nurses and seven physicians working in PICUs. Not unexpectedly, the concept of dignified death was found to be a complex phenomenon involving aspects related to decisions made by the multidisciplinary team as well as those related to care of the child and the family. Knowledge of the concept's dimensions can promote reflection on the part of healthcare professionals regarding the values and beliefs underlying their conduct in end-of-life situations. Our hope is that this study may contribute to theoretic and methodological development in the area of end-of-life care.

Knowledge and practices regarding prevention of infections associated with central venous catheters: A survey of intensive care unit medical and nursing staff

Infections associated with central venous catheters (CVCs) are associated with considerable morbidity and mortality. We conducted a survey to evaluate the theoretical knowledge and practices of intensive care unit doctors and nursing staff regarding CVC-related infections. A questionnaire was distributed to 345 doctors and nurses. The response rate was 71.6%. Of the responders, 84.9% worked in public hospitals, 40% had been trained in CVC-related infection issues, and 27% were familiar with the relevant Centers of Disease Control and Prevention guidelines. The mean percentage of correct answers (± standard deviation) on the 3 parts of the questionnaire were 42.9% ± 16.2%, 86.9% ± 9.5%, and 85.4% ± 7.2%. In the subset of questions referring to procedures that were doctors' exclusive responsibility, 13.6% of the doctors answered all questions correctly. Age >37 years, awareness of relevant official guidelines, working in a private hospital, and being a doctor were identified as independent variables associated with high scores in knowledge regarding the prevention of CVC-related infections. Female sex and training in infection prevention were associated with higher scores on the part evaluating adherence to specific practices regarding CVC insertion, whereas being a nurse was associated with higher scores on the part evaluating CVC maintenance. Our findings suggest that there is a need for increased theoretical knowledge and improvement in practices regarding CVC care. Educational programs directed at doctors and nurses working in intensive care units may aid this effort.

Coagulopathy in neuro trauma - a prospective analysis of the incidence and causes of coagulopathy in patients with pure neuro trauma and mixed trauma admitted to the National Hospital Sri Lanka

Background : Coagulopathy is probably universal in patients with severe trauma. The pathogenesis of coagulopathy in trauma patients is complex. The precise cause is difficult to identify and is likely to be multifactorial. Clotting factor and platelet loss associated with vascular disruption as well as by intravascular consumption of clotting factors associated with massive endothelial damage are implicated in the coagulopathy in severe trauma patients. Coagulopathy in trauma patients is exacerbated by dilution, acidosis and hypothermia. Coagulopathy also occurs when brain or fat embolism leads to disseminated intravascular coagulation, hepatic injury leads to synthetic insufficiency or renal damage leads to uraemia and platelet dysfunction. Method: During the study period 100 patients with moderate to severe trauma were admitted to the neuro surgical intensive care units (ICU) in National Hospital, Sri Lanka and were analysed in the study sample. The two groups were pure neuro trauma and mixed trauma (neuro trauma and other injuries). A questionnaire was kept at the three neuro surgical ICUs at NHSL, to be attached to the notes of all the patients admitted to the neurosurgical ICU following trauma. These were filled by the ICU doctors as the results came in. Results: During the study period 100 patients with moderate to severe trauma were admitted to the Neuro Surgical ICU in National Hospital, Sri Lanka and were analysed in the study sample. The two groups were pure neuro trauma and mixed trauma (neuro trauma and other injuries). For the purpose of the study each patient was assessed for the 1st 24 hours in the Neuro Surgical ICU. Coagulopathy was taken as positive if INR > 1.5 or platelet count Activated partial thromboplastin time (APTT) was not an available test in the NHSL laboratory. Conclusion: Results from this audit did not show a significant difference between the coagulopathy associated with pure neuro trauma and mixed trauma. A slight increase in trend in coagulopathy was seen in pure neuro trauma group compared with mixed trauma. There was no significant difference between the presence of a particular factor favoring coagulopathy and the presence of coagulopathy in the two study groups. The coagulopathy in the above two groups is likely to be multi factorial. Key words: neurotrauma; coagulopathy DOI: 10.4038/slja.v19i1.2855 Sri Lankan Journal of Anaesthesiology Vol.19(1) 2011 pp.26-32

Attitudes towards ethical problems in critical care medicine: the Chinese perspective

Critical care doctors are frequently faced with clinical problems that have important ethical and moral dimensions. While Western attitudes and practice are well documented, little is known of the attitudes or practice of Chinese critical care doctors. An anonymous, written, structured questionnaire survey was translated from previously reported ethical surveys used in Europe and Hong Kong. A snowball method was used to identify 534 potential participants from 21 regions in China. A total of 315 (59%) valid responses were analysed. Most respondents (66%) reported that admission to an intensive care unit (ICU) was commonly limited by bed availability, but most (63%) would admit patients with a poor prognosis to ICU. Only 19% of respondents gave complete information to patients and family, with most providing individually adjusted information, based on prognosis and the recipient's educational level. Only 28% disclosed all details of an iatrogenic incident, despite 62% stating that they should. The use of do not resuscitate orders or limitation of life-sustaining therapy in terminally ill patients reported as uncommon and according to comparable reports, both are more common practice in Hong Kong or Europe. In contrast to European practices, doctors were more acquiescent to families in decision-making at the end of life. A number of differences in ethical attitudes and related behaviour between Chinese, Hong Kong and European ICU doctors were documented. A likely explanation is differing cultural background, and doctors should be aware of likely expectations when treating patients from a different culture.

Attitude of the Macedonian Intensivists Regarding Withdrawal of therapy in Intensive Care Patients: Curriculum for Policy Development

Ethical confusion regarding withdraw of therapy led to the aim of the study in which the knowledge and attitude of the Macedonian Intensive Care Unit (ICU) doctors and their impact on decision making process were assessed. Knowledge, Attitude and Practice (KAP) study has been conducted on a national sample of 217 ICU doctors (response rate 83.87%), applying restructured EURELD 2002 questionnaire as study instrument. CHI-square test was used for cross tabulations. 103 responders were females and 79 males with mean age 40, 2 years +/- 3 y. Significant percent of the doctors didn't know what is withdraw of therapy, chi-square 34.47 (p < 0.0001) and for most there was no difference between withdraw of therapy and euthanasia, chi-square 41.482 (p < 0.0001). Most of doctors didn't have any formal training (67%) and didn't know whether they had experience with withdraw or withhold. Similarly to other countries, for significantly higher percentage of the Macedonian intensivists patient's wishes and patient autonomy have to be main criteria for decision. Significantly higher group of doctors (p < 0.0001) would prefer to leave their own advanced directives. Legal principles in end of life care must be established in the country. Courts should have drawn a distinction between intentionally causing a patient's death (euthanasia) and allowing a patient to die as a result of the withdrawal of life support treatment. There is a need of additional improvement of postgraduate curriculum and continuous professional development of ICU doctors working with end-of-life patients.

Does PACS facilitate work practice innovation in the intensive care unit?

Picture Archiving and Communication Systems (PACS) allow the fast delivery of imaging studies to clinicians at the point-of-care, supporting quicker decision-making. PACS has the potential to have a significant impact in the Intensive Care Unit (ICU) where critical decisions are made on a daily basis, particularly during ward rounds. We aimed to examine how accessing image information is integrated into ward rounds and if the presence of PACS produced innovations in ward round practices. We observed ward rounds and conducted interviews with ICU doctors at three hospitals with differing levels of PACS availability and computerization. Imaging results were infrequently viewed by clinicians during ward rounds in two ICUs: one without PACS and one which had both PACS and bedside computers. In the third ICU, where PACS was only available at a central workstation, images were frequently viewed throughout the daily round and integrated into decisions about patient care. The presence of bedside computers does not automatically result in innovations to work practice. Despite the ability to utilize PACS at the bedside to support decision-making, use was varied. Research to understand how the complexities and context of the ICU contribute to work practice innovation and why practice changes differ is required.

Training and performance on CPR in Spanish Intensive Care Units

Purpose of the study: The Spanish Intensive Care Medicine Society (SEMICYUC), by means of his training school on Resuscitation, PNRCP, has been pioneering in Spain in training on Cardiopulmonary Resuscitation (CPR). The Intensive Care Unit (ICU) would have to be the hospital service where more and better training and performance on CPR was made. In order to evaluate this hypothesis, the PNRCP made a survey of national scope between the Spanish ICUs. Materials and methods: The survey was sent to 200 Spanish ICUs. The survey contained sections that made reference to, general hospital and ICU characteristics, professional competences of ICU members, welfare activities related to Resuscitation (participation in CPR team, postcardiac arrest protocol, hypothermia, cardiac arrest registry), training on CPR received by hospital and ICU staff, and training on CPR provided by ICU staff. Results: 96 surveys were answered. 86.3% of the hospitals have structured staff training on CPR. In 93.7% of ICUs one or more doctor is Advanced Life Support (ALS) Instructor and in 34.7% one or more nurse is ALS Instructor. 63.2% of ICU doctors receive initial training in ALS, but only 23.2% each receives recyclings before 2 years. 70.5% of ICU nurses receive initial formation in ALS, and 31.6%, recyclings before 2 years. In 76.8% of hospitals, doctors and nurses participate in CPR hospitalary team, 32.6% have a postcardiac arrest protocol, 77.9% perform therapeutic hypothermia and 22.1% have cardiac arrest registry. Conclusions: Almost all ICU have CPR Instructors. Most hospitals declare to make regulated training, generally with ICU trainers. The percentage of initial training and recyclings is suboptimal, but better for nurses than doctors. Although the involvement of ICU staff in activities related to resuscitation is outstanding, there are areas for improvement related to registry and post cardiac arrest care.

Controle de infecção oral em pacientes internados: uma abordagem direcionada aos médicos intensivistas e cardiologistas

This paper aims to find the current level of periodontal med-care knowledge, as well as the possible existence of some oral infection control protocol regarding hospitalized patients. Our sample gathered 110 cardiologists and intensive care units doctors selected from medical teams of five Rio de Janeiro hospitals. Preliminary numbers: 75.4% said to have heard something about Periodontal Medicine, although only 30% out of this group admitted to have read something concerning such subject. On the other side, only 2.7% of the sample informed to do consistent information searching along their patients anamnese, while 58.2% out of this group admitted such procedure conditional to the patient's general state at the due moment. Through such numbers, we tend to come up to the conclusion that, be it either through direct or indirect Periodontal Medicine technical information (and consequently with regards to the absolut importance of preservation and control of oral biofilm and its impact on one's systemic health), the matter has been dimly spread among medical groups. The search also revealed the probability that Rio de Janeiro hospitals lack either units or agents designed for prevention and control of oral infection; consequently, such organizations do not have any kind of protocols, reliable or not, concerned to oral infections.

Intensive care reimbursement practices: results from the ICUFUND survey

To assess patterns of intensive care reimbursement practices. A detailed questionnaire about basic intensive care unit (ICU) characteristics and ICU reimbursement practices was created, and then members of the European Society of Intensive Care (ESICM) were asked by e-mail to participate in the survey and complete the web-based questionnaire. There were a total of 447 responses analyzed. Of respondents, 51.5% stated that their ICU received detailed financial information; however, only 15.4% of respondents could identify each cost item for each patient. A majority of respondents (77.6%) stated that their unit's reimbursement system was included in the hospital reimbursement. ICU reimbursement systems were most commonly based on previous year's ICU expenditure (51.0%) and diagnosis-related group weights (36%). Selecting European respondents (n = 306) showed that supplying detailed financial information makes ICU doctors significantly more satisfied (p = 0.019) with their reimbursement system. Regarding ICU funding elements, the most satisfied with their ICU reimbursement system were those respondents from ICUs where nursing workload score was used (p = 0.018). Our result indicates that ICU physicians who receive detailed financial information about their units are more satisfied with their reimbursement system than those not receiving this information. Nursing workload score may have advantage over other forms of reimbursement practices. ICU physicians would like to be more involved in their unit's financial aspects and would prefer separate funding from hospital.

An incremental knowledge acquisition-based system for supporting decisions in biomedical domains

In Intensive Care Units doctors have to manage several alarm situations in patients. When a doctor analyzes the state of the patient, (s)he has to decide if there is an alarm situation and make dec...

Cost-utility of molecular adsorbent recirculating system treatment in acute liver failure

To determine the short-term cost-utility of molecular adsorbent recirculating system (MARS) treatment in acute liver failure (ALF). A controlled retrospective study was conducted with 90 ALF patients treated with MARS from 2001 to 2005. Comparisons were made with a historical control group of 17 ALF patients treated from 2000 to 2001 in the same intensive care unit (ICU) specializing in liver diseases. The 3-year outcomes and number of liver transplantations were recorded. All direct liver disease-related medical expenses from 6 mo before to 3 years after ICU treatment were determined for 31 MARS patients and 16 control patients. The health-related quality of life (HRQoL) before MARS treatment was estimated by a panel of ICU doctors and after MARS using a mailed 15D (15-dimensional generic health-related quality of life instrument) questionnaire. The HRQoL, cost, and survival data were combined and the incremental cost/quality-adjusted life years (QALYs) was calculated. In surviving ALF patients, the health-related quality of life after treatment was generally high and comparable to the age- and gender-matched general Finnish population. Compared to the controls, the average cost per QALY was considerably lower in the MARS group (64,732 euros vs 133,858 euros) within a timeframe of 3.5 years. The incremental cost of standard medical treatment alone compared to MARS was 10,928 euros, and the incremental number of QALYs gained by MARS was 0.66. MARS treatment combined with standard medical treatment for ALF in an ICU setting is more cost-effective than standard medical treatment alone.

An incremental knowledge acquisition-based system for supporting decisions in biomedical domains

In Intensive Care Units doctors have to manage several alarm situations in patients. When a doctor analyzes the state of the patient, (s)he has to decide if there is an alarm situation and make decisions about what actions to perform. It is desirable to detect these situations before they occur, because the solution could be easier and the doctor has more time to react. An intelligent system could analyze the information, extract conclusions, format and order the causes leading to the severe condition. This would be helpful for a doctor, and would make the decision-making process easier. A system capable of performing such operations is presented here. This is not a diagnosis application but a tool to detect alarm situations for patient safety. A prototype capable of making retrospective evaluation of the condition of the patients has been developed. This system is based on the MCRDR technology, which has been extended to deal with the requirements of this domain. The evaluation of the system is also reported in this paper.

Building trust through communication in the intensive care unit: HICCC*

The goal of this study was to explore the role of communication in building trust between intensivists and parents in the pediatric intensive care unit. Semistructured qualitative interviews were administered to English-speaking parents of children who were admitted to the pediatric intensive care unit for at least 48 hrs. Parents were asked about the factors impacting trust and communication in the pediatric intensive care unit. Qualitative data were managed with NVIVO software (QSR International, Southport, UK) and analyzed for themes. Participants were 122 parents (41% black, 40% white). Most parents articulated that communication is integral to building trust. Specifically, parents described that they wanted healthcare workers to communicate in ways that were Honest, Inclusive, Compassionate, Clear and Comprehensive, and Coordinated, which can be summarized using the acronym, HICCC. In addition, nonwhite parents were more likely than white parents to report instances when they felt doctors did not listen to them (p = 0.0083). Parents from minority groups reported instances of self-experienced or observed discrimination in healthcare with greater frequency than white parents. When asked to identify their pediatric intensive care unit doctor, 46% of parents were either unable to do so or named doctors from other hospital departments. Communication is vital to building trust in the pediatric intensive care unit. Developed from parents' own observations and perspectives, HICCC is an accessible framework that can help doctors to remember what parents value in communication in the acute care setting. In addition, pediatric intensivists would benefit from targeted cultural competency training to reduce physician bias.

Admission of incompetent patients to intensive care: Doctors’ responsiveness to family wishes*

When a patient is incompetent, the family is often considered to be a natural surrogate. The doctors' responsiveness to family wishes may vary. We explored if doctors' personal characteristics were associated with responsiveness to the relatives' wishes when admission to the intensive care unit (ICU) is considered. In a mail survey, we asked all Swiss ICU doctors to decide on the admission of a hypothetical incompetent patient presenting with hemolytic uremic syndrome. Each participant was randomly allocated to a version of the scenario in which the family asked either that "everything be done" or that the patient be "spared useless suffering." Overall, 232 (60.9%) questionnaires were returned. When the family asked that "everything be done," 60% of doctors chose to admit the hypothetical patient, but when the family asked that she be spared useless suffering, only 39% did so (odds ratio [OR] 2.6, confidence interval 1.5-4.6). This OR captures responsiveness to family wishes. It varied across subgroups of ICU doctors. Characteristics associated with greater responsiveness to family wishes were older age (OR 6.0 vs. 1.2, p = 0.002), nonuniversity work setting (OR 4.2 vs. 1.0, p = 0.012), less time devoted to intensive care practice (OR 4.0 vs. 1.5, p = 0.036), and greater self-confidence in ethical knowledge (OR 3.4 vs. 1.7, p = 0.044). Older doctors and those working in regional hospitals were more responsive to family wishes when assessing an incompetent patient for ICU admission. These findings emphasize the need for effective advance care planning.

A Case Report of Epidural Hematoma after Partial Liver Resection

Epidural hematoma is an extremely rare but serious complication of epidural anesthesia. The time between the onset of paraplegia to surgery is critically important for determining the neurologic outcomes of the patients. This is a case report of epidural hematoma that developed after the removal of an epidural catheter in a patient who underwent a partial liver resection. Because a subdermal hematoma was noted at the insertion point of the epidural catheter upon admission to the intensive care unit (ICU) after the surgery, the epidural catheter was removed to stop continuous subdermal bleeding. The platelet count at that time had decreased to 64,000/μl and prothrombin time was prolonged to 53% in activity. Ten hours later, the patient complained of paraplegia in both lower extremities which the ICU doctor on duty attributed to persistent epidural anesthesia. Given that neurologic abnormalities persisted for four hours, an emergency MRI was performed that revealed a posteriorly-placed epidural hematoma extending from T6-T11. Despite emergency laminectomy, the neurologic outcome was poor. This case report highlights the importance of recognizing the potential risks of epidural hematoma following epidural catheter placement and the need for prior communication with anesthesiologists in case clinical coagulopathy occurs.