Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1016/j.bjane.2021.02.036
Brazilian Journal of Anesthesiology
Case Report

Uneventful epidural catheter removal in a patient with postoperative acute coronary syndrome receiving emergency triple antithrombotic therapy: a case report

j.bjane.2021.02.036

Christina Orfanou, Ioannis Koutalas, Serena Valsami, Chryssoula Staikou

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Abstract

Background and objectives
Neuraxial hematoma are a rare complication of the epidural technique which is commonly used for high quality postoperative pain relief. In case of urgent initiation of multiple antithrombotic therapy, the optimal timing of epidural catheter removal and need for treatment modification may be quite challenging. There are no specific guidelines and published reports are scarce.

Case report
We present the uneventful removal of an indwelling epidural catheter in a patient who was put on emergency triple antithrombotic treatment with Low Molecular Weight Heparin (LMWH), aspirin and clopidogrel in the immediate postoperative period, due to acute coronary syndrome. In order to define the optimal conditions and timing for catheter removal, so as to reduce the risk of complications, various laboratory tests were conducted 3-hours after aspirin/clopidogrel intake. Standard coagulation tests revealed normal platelet count, normal prothrombin time and normal activated partial thromboplastin time, while Platelet Function Analysis (PFA-200) revealed abnormal values (increased COL/EPI and COL/ADP values, both indicating inhibition of platelet function). The anti-Xa level, estimated 4-hours after LMWH administration, was within therapeutic range. At the same time, Rotational Thromboelastometry (ROTEM) showed a relatively satisfactory coagulation status overall. The epidural catheter was removed 26-hours after the last dual antiplatelet dose and the next dose was given 2-hours after removal. Enoxaparin was withheld for 24-hours and was resumed after 6-hours. Neurologic checks were performed regularly for alarming signs and symptoms suggesting development of an epidural hematoma. No complications occurred.

Conclusion
Point-of-care coagulation and platelet function monitoring may provide a helpful guidance in order to define the optimal timing for catheter removal, so as to reduce the risk of complications. A case-specific management plan based on a multidisciplinary approach is also important.

Keywords

Epidural anesthesia;  Platelet aggregation inhibitors;  Anticoagulants;  Blood coagulation tests

Resumo

Justificativa e objetivos: O hematoma neuroaxial é uma complicação rara da técnica apidural comumente usada para o alívio da dor pós-operatória de alta qualidade. Em caso de início urgente de terapia antitrombótica múltipla, o momento ideal para a remoção do cateter epidural e a necessidade de modificação do tratamento pode ser bastante desafiador. Não há diretrizes específicas e os relatórios publicados são escassos. Relato do caso: Apresentamos a remoção sem intercorrências de cateter epidural de demora em paciente submetida a tratamento antitrombótico triplo de emergência com heparina de baixo peso molecular (HBPM), aspirina e clopidogrel no pós-operatório imediato, devido à síndrome coronariana aguda. A fim de definir as condições ideais e o momento para a remoção do cateter, a fim de reduzir o risco de complicações, vários exames laboratoriais foram realizados 3 horas após a ingestão de aspirina / clopidogrel. Os testes de coagulação padrão revelaram contagem de plaquetas normal, tempo de protrombina normal e tempo de tromboplastina parcial ativada normal, enquanto a análise da função plaquetária (PFA-200) revelou valores anormais (valores aumentados de COL / EPI e COL / ADP, ambos indicando inibição da função plaquetária). O nível de anti-Xa, estimado 4 horas após a administração de HBPM, estava dentro da faixa terapêutica. Ao mesmo tempo, a tromboelastometria rotacional (ROTEM) mostrou um estado geral de coagulação relativamente satisfatório. O cateter epidural foi removido 26 horas após a última dose dupla de antiplaquetária e a próxima dose foi administrada 2 horas após a remoção. A enoxaparina foi suspensa por 24 horas e reiniciada após 6 horas. As verificações neurológicas foram realizadas regularmente para sinais e sintomas alarmantes, sugerindo o desenvolvimento de um hematoma epidural. Não ocorreram complicações. Conclusão: A coagulação no local de atendimento e o monitoramento da função plaquetária podem fornecer uma orientação útil para definir o momento ideal para a remoção do cateter, a fim de reduzir o risco de complicações. Um plano de controle específico para o caso, com base em uma abordagem multidisciplinar, também é importante.

Palavras-chave

Anestesia epidural; inibidores da agregação plaquetária; anticoagulantes; testes de coagulação sanguínea

References

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