iskander_epidural

8/7/2019 Iskander_Epidural

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Epidural Haematoma

MD, FFARCS, FIPP

Prof.of Anaesthesia &Algology

NATIONAL CANCERINSTITUTE - CAIROUNIVERSITY

Chairman of Pan-Arabic WIP

Section President Egyptian Chapter

World Society Pain Clinician(WSPC)

DR. MAGDI RAMZI

ISKANDER


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EH - Case I Continued

Doppler velocimetry showed left carotid arterystenosis and echocardiogram detected thrombus inleft ventricle.

Neurologist recommended immediate IVheparinization to prevent cerebral ischaemia aftertransient ischaemic attack.

Removal of epidural catheter was decided althoughshe received enoxaparin 2 h before.


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30 min. later, and before IVH she complained ofbackache, lower extremity sensory deficit & flacccidparaplegia.

MRI showed an epidural hematoma at T11 &decompressive laminectomy failed to reverseparaplegia.

Minimal delay of 10-12 h after an injection ofprophylactic low molecular weight herparinshould be follow ed before EC removal, even ifimmediate IVH is needed.

OusmaneML,Fleyfel M,Vallet B.EpiduralHaematoma after catheterremoval.Anaesth Analg 2000;90:1250


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EH - Case II

70kg, 82 years old man presented for anteriorresection for rectal adenocarcinoma.

He was a former smoker, chronic airway limitation.Unfractionated heparin 5000 u., s.c. twice daily, wasstarted and calf compression stockings were appliedon the morning of surgery

To wean the patient from ventilation in ICU throracicepidural was decided .

On day 1, 7 h after administration of unfractionatedheparin and 5 h before the next dose of unfractionatedheparin, a thoracic epidural catheter was inserted atthe T8-9 interspace with the patient sedated.


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EH - Case II Continued

On day 2 patient was weaned from ventilation.Between days 2-5 effective epidural analgesia.

On day 5, the epidural catheter was removed 3 h after

the morning dose of unfractionated heparin. Days 5-8were uneventful, and the patient was able to ambulatewith assistance.

Day 8, the patient complained of pleuritic chest painand a clinical diagnosis of pulmonary embolism wasmade. Enoxaparin 60 mg s.c. twice daily wascommenced, replacing unfractionated heparin.


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Day 11, the patient complained of sudden severe backand interscapular pain. No obvious cause was found atthe initial examination by the ward resident. However,flaccid paraplegia with a sensory deficit to T4 was

discovered 7 h later (6 days after removal of theepidural catheter). An urgent MRI scan revealed a T4-L1 epidural haematoma.

In this patient, removal of epidural catheter 3 hafter a dose of unfractionated heparin on day 5and the unmonitored use of high doseenoxaparin were implicated.YinB,Barratt SM,Pow er I ,Percy J.Epidural hematoma after

removal of epidural catheterin a patient receiving high-doseenoxa arin. Br J Anaesth 1999 82:288-90


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EH - Case II I

A 33-year-old gravida 2 nulliparous patient at 36weeks gestation presented with severe pre-eclampsiaand pruritic urticarial papules controlled with

prednisone. Magnesium prophylaxis was started andlabor was induced. An epidural catheter was placed atthe L3-4 level using standard aseptic technique.Bupivacaine was incrementally injected to achieve a

T10 sensory level and analgesia was maintained usinga continuous infusion of 0.0625% bupivacaine withfentanyl.


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EH - Case II I continued

Nine days post-delivery, the patient developed backpain radiating to her right leg, but she was otherwiseasymptomatic. She was afebrile with a slightly tender,non-erythematous.

1 cm nodule at the epidural catheter site. Motor andsensory examinations were normal at that time.However, the patient returned 24 hours later andfurther investigations revealed WBC 17,800 mm3,erythrocyte sedimentation rate 50 mm/ hr (normal:0-20 mm/ hr)and C-reactive protein 8.8 mg/ dl(normal: 0-0.5 mg/ dl) .


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Detection & Management of EpiduralHaematoma:

A national UK surveyIncidence of epidural haematoma is 1:190 000, but islikely to be an underestimate as it is based on casesreported in the literature.

Classically, epidural haematoma cause radicular pain,motor impairment, sensory loss, and urinaryretention.

But in a review of 61 epidural haematomas related tocentral neuraxial block, pain was the presentingcomplaint in only 38% of cases. The most reliable

sign of a developing haematoma in a patient with anepidural infusion is the development of motor block


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A national UK survey. continuedA review reported that 50% of haematomas relatingto epidural catheters occurred after their removal.There have been several case reports of haematomas

occurring more than 12 h after catheter removal.

The investigation of choice for a suspected epiduralhaematoma is an MRI scan.

A referral to a neurosurgical unit should be arrangedthrough a protocol to minimize delays ininvestigation and treatment.


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EPIDURAL HAEMATOMACase I

41kg, 48 year old woman received enoxaprin forthromboprophylaxis 20mg daily.

Had a T7-T8 epidural catheter before left thoractomyand lobectomy.

Effective analgesia was ascertained.

3rd. Post operative day patient complained of bilateralhand paresthesias with dysarthrias.


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Doppler velocimetry showed left carotid arterystenosis and echocardiogram detected thrombus inleft ventricle.

Neurologist recommended immediate IVheparinization to prevent cerebral ischaemia aftertransient ischaemic attack.

Removal of epidural catheter was decided althoughshe received enoxaparin 2 h before.


17/26


30 min. later, and before IVH she complained ofbackache, lower extremity sensory deficit & flacccidparaplegia.

MRI showed an epidural hematoma at T11 &decompressive laminectomy failed to reverseparaplegia.

Minimal delay of 10-12 h after an injection ofprophylactic low molecular weight herparinshould be followed before EC removal, even ifimmediate IVH is needed.

OusmaneML,Fleyfel M,Vallet B.EpiduralHaematoma after catheter

removal.Anaesth Analg 2000;90:1250


18/26

EH - Case II

70kg, 82 years old man presented for anteriorresection for rectal adenocarcinoma.

He was a former smoker, chronic airway limitation.Unfractionated heparin 5000 u., s.c. twice daily, wasstarted and calf compression stockings were appliedon the morning of surgery

To wean the patient from ventilation in ICU throracicepidural was decided .

On day 1, 7 h after administration of unfractionatedheparin and 5 h before the next dose of unfractionatedheparin, a thoracic epidural catheter was inserted atthe T8-9 interspace with the patient sedated.


19/26


On day 2 patient was weaned from ventilation.Between days 2-5 effective epidural analgesia.

On day 5, the epidural catheter was removed 3 h after

the morning dose of unfractionated heparin. Days 5-8were uneventful, and the patient was able to ambulatewith assistance.

Day 8, the patient complained of pleuritic chest painand a clinical diagnosis of pulmonary embolism wasmade. Enoxaparin 60 mg s.c. twice daily wascommenced, replacing unfractionated heparin.


20/26


Day 11, the patient complained of sudden severe backand interscapular pain. No obvious cause was found atthe initial examination by the ward resident. However,flaccid paraplegia with a sensory deficit to T4 was

discovered 7 h later (6 days after removal of theepidural catheter). An urgent MRI scan revealed a T4-L1 epidural haematoma.

In this patient, removal of epidural catheter 3 hafter a dose of unfractionated heparin on day 5and the unmonitored use of high doseenoxaparin were implicated.YinB,Barratt SM,Power I,Percy J.Epidural hematoma after

removal of epidural catheterin a patient receiving high-doseenoxa arin. Br J Anaesth 1999 82:288-90


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EH - Case III

A 33-year-old gravida 2 nulliparous patient at 36weeks gestation presented with severe pre-eclampsiaand pruritic urticarial papules controlled with

prednisone. Magnesium prophylaxis was started andlabor was induced. An epidural catheter was placed atthe L3-4 level using standard aseptic technique.Bupivacaine was incrementally injected to achieve a

T10 sensory level and analgesia was maintained usinga continuous infusion of 0.0625% bupivacaine withfentanyl.


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EH - Case III continued

Nine days post-delivery, the patient developed backpain radiating to her right leg, but she was otherwiseasymptomatic. She was afebrile with a slightly tender,non-erythematous.

1 cm nodule at the epidural catheter site. Motor andsensory examinations were normal at that time.However, the patient returned 24 hours later andfurther investigations revealed WBC 17,800 mm3,erythrocyte sedimentation rate 50 mm/ hr (normal:0-20 mm/ hr)and C-reactive protein 8.8 mg/ dl(normal: 0-0.5 mg/ dl) .


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A national UK surveyIncidence of epidural haematoma is 1:190 000, but islikely to be an underestimate as it is based on casesreported in the literature.

Classically, epidural haematoma cause radicular pain,motor impairment, sensory loss, and urinaryretention.

But in a review of 61 epidural haematomas related tocentral neuraxial block, pain was the presentingcomplaint in only 38% of cases. The most reliable

sign of a developing haematoma in a patient with anepidural infusion is the development of motor block


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