P024: TIMING OF EPIDURAL CATHETER WITHDRAWAL IN AN ANTICOAGULATED PATIENT: HOW LONG IS TOO LONG?
Michelle Lipton, MD, Bradley Budde, MD, Steven Porter, MD; Mayo Clinic
A 71 year old male with past medical history significant for gastric adenocarcinoma status post partial gastric resection, distal esophagectomy and splenectomy in 1976 was found to have recurrence of adenocarcinoma on surveillance endoscopy. A left thoracoabdominal total esophagogastrectomy was planned. The patient did not take anticoagulants pre-operatively and had a normal platelet count. A T5-T6 epidural was placed pre-operatively for peri-operative analgesia. Surgery was completed without complication, the patient was transported to the ICU, and extubated on POD #1. Following complaints of severe surgical pain, the epidural site was assessed and the catheter was determined to be dislodged. The epidural was replaced, at the same T5-T6 level, in the ICU at 13:00 without complications. At 16:40 the patient suffered a cardiac arrest secondary to large bilateral pulmonary-emboli associated with severe right heart strain. ACLS was initiated, the patient was intubated, and ROSC was achieved. The epidural infusion was stopped, systemic anticoagulation with intravenous heparin was initiated as well as Norepinephrine and Vasopressin for blood pressure support. On POD #2, an IVC filter was placed and blood pressure support and sedation were weaned. The patient was extubated and again reported pain, prompting resumption of the epidural infusion. On POD #4, the patient was reintubated for progressive respiratory distress and the epidural infusion was stopped due to persistent hypotension. On POD #5, the epidural was capped, rather than removed, due to an INR of 4.9, secondary to shock liver. There was an appreciable decline in cognitive function, likely due to hepatic encephalopathy, and all sedation medications were held. His WBC continued to trend up and broad spectrum antibiotics were started. Despite concern for infection, the risk of epidural hematoma prompted the decision to leave the catheter in place until his coagulation status normalized. On POD #12, the heparin infusion was held for four hours prior to undergoing tracheostomy. On the day of the procedure, his INR was 1.6 and TEG was normal. Given the relative improvement of his coagulation status, the decision was made to remove the epidural catheter. No acute complications were noted. Frequent neurochecks were performed and confirmed spontaneous lower extremity movements. The heparin infusion was restarted three hours following tracheostomy. The patient was discharged to a rehabilitation center on POD #47 without any noted neuraxial complications.
The actual risk in terms of epidural withdrawal and hematoma is unknown. This case was additionally complicated by the risk of neuraxial infection with leaving the catheter in place for a prolonged period of time. The incidence of neuraxial epidural catheter infection increases if kept beyond 48 hours[1, 2]. At the time the catheter was removed the INR was elevated, however given the circumstances of ongoing infection, normal TEG, and a temporary hold of anticoagulation, this was deemed the most clinically appropriate time for removal[3-5]. In medically complex cases such as this, the communication and expertise of a multidisciplinary team approach is essential for positive patient outcomes.