Part of TopicBrowse Topic in full-screen mode
A timed dilemma – management of neuraxial analgesia in a patient with post-operative coagulopathy and in need of anticoagulation
Introduction: Neuraxial analgesia has been widely used in open abdominal surgery as part of the multimodal pain management. Not only does it provide intra- and post-operative analgesia, it also decreases the incidence of post-operative respiratory, thromboembolic, cardiovascular and gastroenteral complications by obtunding the acute stress response induced by surgery, thus contributes to enhanced recovery1. However, the need to initiate anticoagulation in the presence of epidural catheter is a timed dilemma that requires to be handled with great caution to avoid detrimental complications such as spinal epidural hematoma and associated neurological dysfunctions.
Case: A 43-year-old male with cholangiocarcinoma was scheduled for right liver lobectomy, cholecystectomy, resection of vena cava and portal lymphadenectomy. Pre-operative workup showed normal platelet count and coagulation. Epidural catheter was placed pre-operatively at T9-10 level and 1mg hydromorphone was given via the catheter intraoperatively. Epidural infusion with hydromorphone/0.125% bupivacaine provided good pain relief post-operatively. Surgical blood loss was estimated 1300ml which caused unanticipated coagulopathy secondary to ischemic hepatitis. The acute pain service could not remove the epidural catheter on post-operative day 7 as planned because of the coaguloapathy, as reflected by the INR level at 1.73. Meanwhile patient was found to have a portal vein thrombus extending to the superior mesenteric vein requiring heparin infusion as immediate treatment. A carefully timed plan was carried out by the acute pain service together with the primary team. The following is the coordinated sequence of the events: 1) patient received vitamin K and fresh frozen plasma to correct the coagulopathy; 2) he was given oral oxycodone 30 minutes prior to discontinuation of the epidural infusion; 3) INR was 1.42 after transfusion and the epidural catheter was immediately removed; 4) heparin infusion was started within 2 hours after epidural catheter removal. Patient was neurologically assessed every 2 hours for any signs of spinal compression. He reported adequate pain control with oral medications, and denied back pain, lower extremity weakness, saddle anesthesia or incontinence after epidural catheter removal. Patient was eventually discharged from the acute pain service.
Discussion: Spinal epidural hematoma is a rare but serious complication associated with neuraxial anesthesia2. Incidence of hemorrhagic complication is significantly elevated in the population with underlying coagulopathy. Guidelines provide recommendations on time intervals before and after neuraxial block and catheter removal3. However clinical decisions should be made individually based on patient’s underlying pathology, comorbidities and risk factors. We demonstrate here the challenge of anticoagulation therapy for a patient with epidural analgesia which is complicated by underlying coagulopathy. This requires thorough communication, careful planning, and close monitoring, but can be done safely with great patient satisfaction regarding pain control.