Risk Of Epidural Hematoma Research Articles

Managing anticoagulant and antiplatelet drugs in patients who are receiving neuraxial anesthesia and epidural analgesia: a practical guide for clinicians

Managing patients who are receiving anticoagulant or antiplatelet drugs and are undergoing surgery with neuraxial anesthesia, is a common and challenging clinical problem because for many of these drugs there is no reliable laboratory test to measure whether an anticoagulant or antiplatelet effect is present. In patients who are to receive neuraxial anesthesia, normalized hemostasis is required to minimize the risk for epidural hematoma. This review has three objectives: (1) to provide an overview of existing and novel antithrombotic drugs used in clinical practice, and to provide suggested management guidelines regarding the management of patients who are receiving these drugs in the perioperative period; (2) to address the practical management of patients who require withholding antithrombotic drugs before elective surgery with neuraxial anesthesia, require reversing the antithrombotic effect of these drugs before emergent or urgent surgery with neuraxial anesthesia, and are receiving postoperative continuous epidural analgesia and require resumption of antithrombotic drugs; and (3) to provide a practical approach to the management of patients who are receiving postoperative epidural analgesia and are at high risk for deep vein thrombosis, in whom coadministration of low-molecular-weight heparin for thromboprophylaxis is clinically indicated.

Analgésie péridurale obstétricale chez une patiente présentant une macrothrombocytopénie familiale

Epidural analgesia is often considered as risk of epidural haematoma in a patient with thrombocytopenia. In this observation, uncomplicated epidural analgesia was performed in a pregnant woman with hereditary macrothrombocytopenia. She received continuous epidural labour analgesia for a vaginal delivery with a platelet count at 63 × 10 9/l but platelets with high mean platelet volume (20 fL) and normal function. No neurological sequelae or excessive bleeding occurred.

Analgésie péridurale chez une femme enceinte atteinte d’une thrombocytémie essentielle

Epidural analgesia is often considered as risk of epidural haematoma in patient with essential thrombocythaemia because of the platelet disorder. In this observation, uncomplicated epidural analgesia was performed in a pregnant woman with asymptomatic essential thrombocythaemia, because the absence of bleeding symptoms was associated with normal thrombo-elastography and time of occlusion by PFA-100 ® suggesting normal platelet function. PFA-100 ® is a biological test evaluating platelet function in whole blood, which is easy and quick to perform. This case study suggests that this test might be useful in evaluating platelet function in obstetrics but must be validated before recommending its extensive use.

Epidural hematoma after epidural anesthesia: a case report of non-surgical management

Abstract Neuraxial block with intraoperative intravenous (IV) heparin use is considered to be a safe technique. The risk of epidural hematoma is low as long as concomitant anti-coagulation is not used [ASRA: Neuraxial Anesthesia and Anticoagulation Consensus Statements, 1998]. We describe a patient who developed epidural hematoma under those circumstances and was successfully treated without surgical intervention. A 75-year-old female underwent aorto-mesenteric arterial bypass for chronic mesenteric ischemia. Combined general and epidural anesthesia was used and IV heparin (total 6000 IU) was given intraoperatively. In the recovery room, aspiration of blood was noted through the epidural catheter. The next day, she developed severe back pain without sensory or motor deficit. Magnetic resonance imaging (MRI) scan revealed an epidural hematoma with spinal cord compression. Neurosurgical consultation resulted in a decision to monitor for neurological changes. She never developed a neurological deficit and was discharged from the hospital on post-operative day 7. Our case suggests that epidural hematoma may not be uncommon phenomena in patients with neuraxial block and intraoperative IV heparin use. Implications for the decision as to which of these patients should be imaged and which should not are discussed.

Continuous epidural anesthesia and postoperative epidural narcotics in vascular surgery

A combination epidural technique using local anesthetics intraoperatively and morphine postoperatively is shown to offer many advantages. These benefits include inhibition of the surgical stress response, decreased cardiorespiratory depression, decreased blood loss, decreased intubation and pulmonary infection, decreased thromboembolism, decreased hyperglycemic and hypertensive response, nitrogen sparing, a stable resting metabolic rate, prevention of immunosuppression, simplification of cerebral status monitoring, and earlier ambulation and hospital discharge. The main disadvantage in patients undergoing vascular procedures is the risk of epidural hematoma. A review of the literature confirms the extreme rarity of this risk and, in view of the emerging benefits, argues for reconsideration of epidural technique in vascular patients. The addition of epidural morphine to this combined technique affords a postoperative pain-free continuum unmatched by any other method. This significantly decreased pain stress in cardiac patients increases safety and comfort. In conclusion, epidural anesthesia and postoperative epidural narcotics provide a safe and reliable method of management for patients undergoing vascular procedures.

Caudal Administration of Morphine Sulfate in Anticoagulated and Thrombocytopenic Patients

Anticoagulation and profound thrombocytopenia are among the few absolute contraindications to regional anesthesia (1,2). The risk of epidural hematoma is well documented as a rare complication in fully anticoagulated patients given spinal or epidural anesthesia (1,3–6). The issue of the relative safety of regional anesthesia in patients on “minidose” heparin remains unsettled. Should surgery be necessary in an anticoagulated patient, general anesthesia is considered a safer option. Unfortunately for the patient who is suffering from intractable pain of malignant origin and who is also receiving anticoagulants, the options of techniques for pain relief other than regional anesthesia are more limited. We report on 37 patients that were fully anticoagulated and 19 patients with profound thrombocytopenia suffering from intractable pain of malignant origin who underwent 336 caudal blocks with morphine sulfate and bupivacaine for pain control, and we review the safety of this approach.