Epidural Hematoma After Epidural Anesthesia in a Patient with

Document Sample
Epidural Hematoma After Epidural Anesthesia in a Patient with Powered By Docstoc
					Epidural Hematoma After Epidural                                                             Anesthesia                      in a Patient
with Hepatic Cirrhosis
Hiroshi Morisaki, MD, Jun Doi,                             MD,   Ryoichi Ochiai,       MD,   Junzo Takeda,             MD,      and
Kazuaki Fukushima, MD
Department             of Anesthesiology,     School of Medicine,   Keio University,   Tokyo,   Japan




E
         pidural hematoma after spinal or epidural anes-                         any unusual pain during the procedure. General anesthesia
         thesia has been acknowledged as a rare but a                            was induced with thiopental           and succinylcholine        intrave-
         serious complication, which may cause perma-                            nously; the trachea was intubated, and anesthesia was main-
                                                                                 tained with isoflurane in nitrous oxide and oxygen. Twenty
nent neurologic deficits even though emergency lam-
                                                                                 minutes after the surgical incision, 5 mL of 1% mepivacaine
inectomy is performed (1,2). Previous reports have                               was administered      through the epidural catheter after it was
highlighted the substantial risk of this complication in                         reconfirmed     that no blood had been withdrawn               from the
patients receiving the subsequent anticoagulant or an-                           catheter. Ninety minutes after the incision, blood was with-
tiplatelet therapy (3,4). We report a case of epidural                           drawn via the epidural catheter when the second adminis-
hematoma accompanied by paraparesis after epidural                               tration of mepivacaine was planned. After 3 mL of normal
anesthesia in the patient with hepatic cirrhosis, which                          saline was administered,     local anesthetics were discontinued
was complicated by mild prolongation       of prothrom-                          for the remainder of the surgery. The total amount of blood
bin time and depression of platelet count.                                       loss during the 2-h surgery was 180 g. After surgery, bleed-
                                                                                 ing was noted at the insertion point of the catheter which
                                                                                 was then removed. During emergence from general anes-
                                                                                 thesia in the operation room, the patient was able to dorsi-
                                                                                 flex both feet on request. The patient was transferred to the
Case Report                                                                      general ward.
A 69-yr-old woman with a 2-yr history of hepatic cirrhosis                          Five hours after the surgery, a complaint by the patient of
was admitted and scheduled for partial resection of right                        the weakness of both lower extremities was followed up by
lower lobe of the lung under a diagnosis of lung cancer. All                     the surgeons. Because the neurologic          abnormalities        gradu-
biochemical    laboratory data were within normal range ex-                      ally worsened during the first postoperative            day (POD l),
cept the slight increase of serum transaminase         enzymes.                  the surgeons consulted the neurologist            the next day. The
Although platelet count was slightly decreased, the bleeding                     neurologic    examination      indicated    moderately       depressed
time by the Duke method was at the lower limit of the                            muscle motor tone of both lower extremities with hypesthe-
normal range (Table 1). Prothrombin        time was barely pro-                  sia and hypalgesia; the patient could not hold her knees
longed and fibrinogen         was at the lower limit of normal                   flexed. An emergency magnetic resonance imaging (MRT)
range, whereas activated partial thromboplastin        time and                  was performed and revealed a posteriorly placed hematoma
fibrin degradation     product were within normal range (Table                   extending from T4-8 on both Tl-proton                density and T2-
1). The patient had not taken any antiinflammatory         drugs                 weighted images (Figure 1). Because the neurologic findings
such as aspirin for more than a year.                                            had stabilized for several hours and seemed unlikely to get
   A combination     of epidural block with general anesthesia                  worse, the spine surgeon suggested conservative                   therapy
was planned for the surgery. On arrival at the operation                        with systemic administration            of hypertonic     glycerol and
room, the patient was placed in the left decubitus position. A
                                                                                 steroid. Both platelet count and prothrombin                time were
17-gauge Tuohy needle was advanced through the lateral
approach in the T7-8 interspace into the epidural          space,               further depressed on the POD 1 compared to preoperative
which was confirmed by loss of resistance technique. Since                       data (Table 1). The latter was reversed on POD 3 by the
dark blood was noted to drip from the needle, it was imme-                      infusion of 5 units of fresh frozen plasma for 2 days. By POD
diately removed and was reinserted           into the T9-10 in-                 4, the paraplegia     had gradually improved; the patient was
terspace without any difficulties. No blood was withdrawn                       able to dorsiflex the right foot, but was unable to dorsiflex or
at this time, and a catheter was easily advanced 5 cm ceph-                     move the left foot. Ten days after the surgery, the neurologic
alad into the epidural space. There was no paresthesia nor                      findings were further improved and the patient was able to
                                                                                stand and walk without           assistance. The MRl on POD 14
                                                                                showed that the area of hematoma was reduced but was still
  Accepted for publication December 8, 1994.                                    present at the same level (Figure 2). The patient was dis-
  Address correspondence      and reprint requests to Hiroshi
Morisaki, MD, Department of Anesthesiology, School of Medicine,                 charged 1 mo after the surgery with mild hypesthesia on
Keio University, Tokyo 160, Japan.                                              lower left leg.


01995 by the         International Anesthesia ResearchSociety
0003~2999/95/$5.00                                                                                                  Anesth    Analg   1995;80:1033-5   1033
1034     CASE   REPORTS                                                                                                                    ANESTH       ANALG
                                                                                                                                               1995;80:1033-5




Table 1. Data of Bleeding and Coagulation Tests During
the Perioperative Period
                                                        1   3
                                         Preoperative POD POD
   Platelet count (150-350         X         121      101  74
         los/xnm3)
   Bleeding time (2-5 min)                        2
   Prothrombin time
      (C14.0 s)                                  14.1    15.7 12.6
      (70%-110%)                                 54      42   70
   Activated partial thrombo-                    37.8    38.8 34.8
         plastin time (28-38 s)
   Fibrinogen (180-360                         179       231   285
        mg/dL)
   Fibrin degradation product                    36      253   173
         (<lo0 ng/mL)
  The values in the parentheses   are normal   ranges.
  POD = postoperative    day.




                                                                            Figure   2. Sagittal magnetic      resonance      imaging    view of the spine
                                                                            2 wk after surgery.   A hyperintense        lesion (black arrow),     indicating
                                                                            subacute hematoma,     is still slightly   displacing     the cord anteriorly    at
                                                                            T4-8.

                                                                            anticoagulant    or antiplatelet therapy (3-5). Most re-
                                                                            ports, however, indicate that intra- or postoperative
                                                                            anticoagulation    therapy combined with the epidural
                                                                            or subarachnoidal      approach is the main reason for
                                                                            excessive bleeding in the epidural space (1,6). The only
                                                                            report of a patient who developed epidural hematoma
                                                                            and paraplegia without any coagulation disorder in-
                                                                            volved many lumbar punctures, which were consid-
                                                                            ered traumatic enough to cause bleeding (5). Since the
                                                                            epidural anesthesia in this case was performed by a
                                                                            well-trained    anesthesiologist  with more than 10 yr
                                                                            experience, we believe that the procedure by the epi-
                                                                            dural approach was not done in a rough manner com-
                                                                            pared to other cases. Considering the benefits of plac-
Figure  1. Sagittal magnetic  resonance    imaging   view of the spine 2
days after surgery.   A low intense     lesion (black arrow),     present   ing an epidural        catheter for perioperative     pain
behind the spinal cord, is displacing    the cord anteriorly   at T4-8.     management; we decided to apply epidural anesthesia
                                                                            to this patient, even though mild coagulation disorder
Discussion                                                                  was found.
                                                                               As seen in this case, hepatic cirrhosis is usually
Epidural hematoma usually occurs due to the inser-                          accompanied by coagulopathy,          associated with de-
tion of a needle into the epidural space, vascular ab-                      pressed platelet count and with the reduction in coag-
normalities  in the epidural venous plexus, and/or                          ulation factors, mainly due to hypersplenism       and/or
ANESTH         ANALG                                                                                                          CASE     REPORTS                1035
1995;80:1033-5




 depressed protein synthesis (7). Although the platelet        clinical evidence of an epidural hematoma. Another
 count was slightly depressed preoperatively,       the nor-   report showed that none of 950 patients receiving oral
 mal bleeding time indicated that the platelet function        anticoagulants    at the time of epidural catheter place-
 was intact, and that the patient probably had no prob-        ment developed neurologic dysfunction (12). How-
 lem with the primary coagulation process. However,            ever, the second MRI examination of the spinal cord
 the prolonged prothrombin        time suggested the mod-      (Figure 2) might suggest that the presence of a hema-
 erate deterioration   of the secondary coagulation pro-       toma in itself does not always cause neurologic defi-
cess, while activated partial thromboplastin      time was     cits. Epidural hematoma may occur more often than
within normal range. Furthermore,         the preoperative     expected and with no clinical symptoms after the in-
data on fibrinogen       and fibrin degradation     product    sertion of an epidural catheter.
suggested that fibrynolysis, which possibly might be               We conclude that the indication for epidural anes-
accelerated in hepatic cirrhosis, was not observed in          thesia should be considered carefully in patients with
this case (8). In addition to the coagulation abnormal-        hepatic cirrhosis. If epidural anesthesia is undertaken
ities, hepatic cirrhosis causes portal vein hypertension,      in such patients, a suspicion of epidural hematoma is
resulting in the development of collateral venous flow         warranted.
from splanchnic circulation (7). The epidural veins,
like the azygous or hemiazygous thoracic veins would
be swollen and their walls would become thin. Thus,            References
in patients with hepatic cirrhosis, the epidural venous
plexus can be damaged easily by attempting an epi-              1. Dickman          CA, Shedd SA, Spetzler                   RF, et al. Spinal epidural
                                                                    hematoma         associated       with epidural         anesthesia: complications              of
dural puncture and then neurologic deficits become                  systemic heparinization                in patients receiving            peripheral      vascu-
more readily apparent, with less blood pooling in the              lar thrombolytic            therapy.      Anesthesiology           1%;72:947-50.
limited epidural space. Even when the epidural veins            2. Tekkok        IH, Catalteue          0, Tahta K. Bertan V. Extradural                    hema-
are ripped by epidural puncture, the bleeding is usu-              toma after continuo;s              extradural        anaesthesia.       Br J Anaesth 1991;
                                                                   67112-5.
ally minimal      and the blood leaks through the inter-        3. Owens        EL, Kasten GW, Hessel II EA. Spinal subarachnoidal
vertebral foramina. Distended epidural venous plexus               hematoma           after lumbar           puncture       and heparinization:             a case
might be able to interrupt these routes. Therefore, we             report,      review       of the literature,          and discussion            of anesthetic
                                                                   implications.          Anesth Analg 1986;65:1201-7.
believe that various factors associated with hepatic            4. Greensite        ES, Katz J. Spinal subdural              hematoma           associated     with
cirrhosis were probably responsible for the develop-               attempted         epidural       anesthesia       and subsequent            continuous       spi-
ment of epidural hematoma in this case.                            nal anesthesia.           Anesth Analg 1980;59:72-3.
    After signs of prolonged weakness, it is desirable to       5. Lemer        SM, Gutterman             I’, Jenkins F. Epidural               hematoma        and
                                                                   paraplegia         after numerous            lumbar       punctures.        Anesthesiology
take active diagnostic measures much sooner than                    1973;39:550-1.
occurred in our case report. Although it has been               6. Helperin          SW, Cohen             DD.      Hematoma           following         epidural
emphasized that only emergency decompressive lam-                  anesthesia:        report of a case. Anesthesiology                   1971;35:641-4.
inectomy is able to provide good outcome (l), this case         7. Sherlock S, Dooley J. Diseases of the liver and bilary system. 9th
                                                                   ed. London:           Blackwell       Scientific    Publications,         199344-9.
indicated the possibility of spontaneous remission of           8. Francis RB Jr, Feinstein                DI. Clinical      significance         of accelerated
hematoma and compressive force on the spinal cord                  fibrinolysis        in liver disease. Haemostasis                 1984;14:460-5.
by conservative therapy, as previously reported (9,lO).         9. Ballin NC. Paraplegia              following       epidural      analgesia. Anaesthesia
                                                                   1981;36:952-3.
Given the fact that neurologic deficits were improved          10. Harik      SI, Raichle ME, Reis DJ. Spontaneous                            remitting     spinal
by treatment with glycerol and steroid administration,             epidural       hematoma         in a patient on anticoagulants.                 N Engl J Med
edema of the spinal cord, rather than the compressive              1971;2&1:1355-7.
force of hematoma,        was the primary cause of the         11. Rao TLK, El-Etr AA. Anticoagulation                           following         placement       of
                                                                   epidural        and subarachnoid              catheters:     an evaluation           of neuro-
neurologic sequale. Rao and El-Etr (11) reported 3993              logic sequelae. Anesthesiology                    1981;55:618-20.
cases with continuous epidural or subarachnoid anes-           12. Odoom         JA, Sih IL. Epidural             analgesia      and anticoagulant            ther-
thesia and intraoperative       heparin therapy without            apy. Anaesthesia             1983;38:254-9.