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Abstract
Background and Aims Epidural analgesia (EA) in patients undergoing liver resection remains controversial because of the increased risk of epidural haematoma (EH), although extremely rare [1]. We report a case of EH in a patient submitted to a hepatic metastesectomy, after EA.
Methods A 71-year-old, diagnosed with metastatic cholangiocarcinoma and previously submitted to cephalic pancreatoduodenectomy, was admitted for elective metastasectomy (2×3 centimeters). Her history included hypertension on bisoprolol and chemotherapy two years previously. Preoperative assessment revealed minor changes, as described in table 1. The patient consented a combination of EA with general anaesthesia and a lower thoracic epidural catheter (T9-T10) was uneventfully placed.
Results A two-hour surgery was performed successfully, with insignificant blood loss. On postoperative day 2, the patient underwent emergent reintevertion due to severe hemoperitoneum but no vascular bleeding point was detected and therefore, coagulopathy was assumed. After transfusion of 3 units of fresh frozen plasma (FFP) and 1 platelet concentrate (PC), haemorrhage resolved and the epidural catheter was removed the next day, considering a 12 hour interval since the last administration of prophylactic enoxaparin. 18 hours later, the patient presented with severe lumbar and inferior limb pain and paraparesis. A CT scan revealed an EH from T8-T10, and emergent laminectomy was performed. 1 PC, 4 FFP and 1000U of prothrombin complex concentrate were administered, ROTEM guided. After several months of rehabilitation, the patient managed to walk unassisted.
Perioperative coagulation and liver function tests
Thoracic and lumbar CT scan. A hyperintense lesion displacing the cord anteriorly at T8-T10
ROTEM8 Thromboelastometry showing no activation of dot formation in EXTEM
Conclusions Despite following every recommendation for epidural catheter handling, masked coagulopathy can prevail and thus a high level of EH suspicion should always subsist.