Epidural hematoma following epidural catheter removal after a single dose of clopidogrel
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CORRESPONDENCE
Epidural hematoma following epidural catheter removal after a single dose of clopidogrel Micheline Nguyen, MD, FRCPC . Stephan R. Williams, MD, PhD . Jean-Franc¸ois Gagne´, MD
Received: 18 June 2019 / Revised: 10 September 2019 / Accepted: 11 September 2019 Ó Canadian Anesthesiologists’ Society 2019
To the Editor, The American Society for Regional Anesthesia (ASRA) guidelines attempt to balance the risk of withholding antiplatelet medication against that of epidural hematoma after neuraxial anesthesia.1 We present a case of epidural hematoma occurring after epidural catheter removal in a patient who had received only a single postoperative dose of clopidogrel. An elderly patient with colorectal cancer and a past medical history of stable angina, chronic back pain, mild chronic renal insufficiency, past abdominal aortic aneurysm repair, and diabetes mellitus presented for open lower anterior resection. The patient was on clopidogrel 75 mgday-1 (withheld seven days prior to surgery) and aspirin 81 mgday-1 (which was continued perioperatively). Before induction of general anesthesia, a T9-T10 thoracic epidural catheter (Flextip PlusTM; Teleflex Medical Canada, Oshawa, ON, Canada) was placed on the first pass using a standard technique and a 17G PerisafeTM Tuohy needle (BD-Canada, Mississauga, ON, Canada). Anesthesia and surgery proceeded uneventfully. On postoperative day (POD) 3, the patient was noted to have a persistent troponin elevation and after cardiologic consultation, clopidogrel 75 mg (without a loading dose) was administered, and manually charted, therefore bypassing the electronic medical record surveillance. The Acute Pain Service was subsequently advised of the need for antiplatelet therapy, and proceeded to remove the
M. Nguyen, MD, FRCPC S. R. Williams, MD, PhD J.-F. Gagne´, MD (&) Department of Anesthesiology and Pain Medicine, Centre hospitalier de l’Universite´ de Montre´al (CHUM), Montre´al, QC, Canada e-mail: [email protected]
epidural catheter, after being assured by the nursing staff and verifying in the electronic medical record that no clopidogrel administration had occurred (though the 75 mg dose had in fact been administered 30 hr before). The last dose of subcutaneous heparin 5,000 units had been given eight hours prior to catheter removal; coagulation laboratory values (international normalized ratio, 0.98; platelet count, 225 9 109L-1) were normal. During catheter removal, excessive bleeding was noted through the catheter and at the insertion site. The patient immediately complained of sudden and intense back pain coinciding with catheter removal. Despite the pain, the initial neurologic exam was normal. Upon further scrutiny of the patient’s medical record, the manually charted dose of clopidogrel administered before catheter removal was discovered. The consulting neurosurgeon recommended stopping all anticoagulants and administration of an adult dose of platelets. It was decided to proceed with urgent imaging only if other neurologic symptoms
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