Summary
Background. It is well known that a patient´s coagulation status should be optimised at the time of epidural needle/catheter placement. Indwelling catheters should not be removed in the presence of therapeutic anticoagulation, because this appears to significantly increase the risk of spinal haematoma. We describe a case of a heparinized patient in whom massive neuraxial bleeding followed epidural catheter removal. Case report. A 52-yr-old woman underwent emergency thrombolectomy of an abdominal aorta "Y” graft under epidural anaesthesia, and received a continuous infusion of 1000 U h^-1 of unfractioned heparin in the postoperative period. Twenty hours after surgery, when the APTT was 156 sec, the patient complained of low back pain and a surgeon removed the epidural catheter. On the next day, the patient reported headache and neck stiffness, followed by partial quadriplegia and respiratory distress. The heparin infusion was stopped and she received 50 mg of protamine sulphate. Immediate CT and MRI scans revealed subarachnoid and intraspinal bleeding accompanied by two epidural haematomas without compression of the spinal cord. Spinal malacia was suspected, and a bolus dose of methylprednisolone, 30 mg kg^-1 was given, followed by 5.4 mg kg h^-1 continuous infusion. This resulted in rapid improvement of muscle tone in the upper limbs, while the lower limb paraplegia resolved over the next three weeks. Discussion and conclusion. The increased risk of bleeding in patients having surgery under epidural anaesthesia, while receiving heparin, should be always be considered. Unfortunately, in the described case, an anaesthesiologist was not consulted before the catheter was removed. It is not clear however, if this was the direct cause of neuraxial bleeding or if it was simply a rare complication of antithrombotic therapy. Conservative treatment resulted in almost complete recovery. We conclude that in any case of massive neuraxial bleeding a careful and multi disciplinary approach is essential.