Spinal Epidural Hematoma Following Epidural Catheter Removal in a Patient with Postoperative Urgent Coronary Intervention and Intra-Aortic Balloon Pumping (IABP): A Case Report
Unusual clinical course, Diagnostic / therapeutic accidents, Adverse events of drug therapy , Clinical situation which can not be reproduced for ethical reasons
Ryosuke Mimata, Midoriko Higashi, Madoka Yasui, Takanao Hirai, Ken Yamaura
(Department of Anesthesiology, Fukuoka University Hospital, Fukuoka City, Fukuoka, Japan)
Am J Case Rep 2019; 20:1356-1359
It is still challenging to remove an epidural catheter in a postoperative patient receiving urgent antiplatelet and anticoagulation therapy for acute coronary syndrome.
CASE REPORT: While under general anesthesia combined with thoracic epidural anesthesia, a 72-year-old male patient underwent right radical nephrectomy for renal cell carcinoma. On postoperative day 1 (POD1), the patient experienced bradycardia and a decrease in blood pressure, and he was diagnosed acute myocardial infarction. Intra-aortic balloon pumping (IABP) was induced for cardiogenic shock, and urgent thrombus aspiration and coronary balloon angioplasty were performed. On POD3, the surgeon removed the epidural catheter under both antiplatelet and anticoagulation therapy. At that time, the platelet count was 45×10⁹/L and the activated partial thromboplastin time (APTT) was 72.2 seconds. Four hours after the epidural catheter was removed, the patient complained of bilateral fatigue in legs and developed a loss of sensation. Six hours after the epidural catheter was removed, he developed motor paralysis and became completely paralyzed in both limbs after 9 hours. At 19 hours after the epidural catheter was removed, emergency magnetic resonance imaging detected a spinal epidural hematoma at the level of Th9-11 with compression of the spinal cord. Emergency laminectomy was performed to decompress and remove the spinal epidural hematoma at 18 hours after the onset of sensorimotor symptoms. After surgery and rehabilitation, these symptoms had only slightly improved.
CONCLUSIONS: In patients with urgent antithrombotic therapy for urgent percutaneous coronary intervention (PCI) with an IABP for acute coronary syndrome, the epidural catheter should not be removed until the IABP and heparin are discontinued, and platelet counts have recovered.
Keywords: Anesthesia, Epidural, Anticoagulants, Hematoma, Epidural, Spinal, Platelet Aggregation Inhibitors