Epidural hematoma after thoracic epidural analgesia in a patient treated with ketorolac, mefenamic acid, and naftazone: a case report
A 26-year-old male (height: 174 cm, weight, 72 kg, American Society of Anesthesiologists physical status class I) was scheduled for wedge resection of bullae and bleeding control. His past medical history was negative for cardio-respiratory diseases, diabetes mellitus, bleeding diathesis, or easy bruising. The patient had received medications for hemorrhoid for six days until the day before admission. Physical examination and laboratory findings were unremarkable.\nHe referred from other hospital to our emergency room to treat hemo-pneumothorax with massive bleeding. When he admitted to our hospital, approximately 400 ml of bloody fluid was drained from the chest drainage tube, and his hemoglobin (Hb) was11.0 mg/dl. Two units of packed red blood cells (PRBC) were infused to treat tachycardia (95 beats/min) with mild hypotension (95/50 mmHg). His admission coagulation profiles were within normal limit (prothrombin time (PT); 13.0 seconds, International normalized ratio (INR); 1.12, activated partial thromboplastin time (aPTT); 24.7 seconds, platelet count; 245,000/mm3). The patient's bleeding time was not checked.\nTwo hours later, his lab findings were Hb 10.5 mg/dl, Hct 30.4%, and platelet count 220,000 mm3. One unit of PRBC and three units of fresh frozen plasma (FFP) were infused. Eight hours after admission, more than 400 ml of bloody fluid was drained again, and his lab findings were Hb 11.5, Hct 33.6, and platelet count was 158,000 mm3. Thirteen hours after admission, he was transferred to operating room.\nA thoracic epidural catheter at the T5-T6 level was inserted through a 17 gauge Tuohy needle using loss of resistance to air technique. First attempt at T6-T7 level, inadvertent dural puncture occurred and blood tinged CSF was seen in the syringe. Second attempt at T5-6 level was performed uneventfully. No blood or paresthesia was noted during the successful needle and catheter insertion. A test dose of 2 ml of 2% lidocaine and 5 µg epinephrine was injected through the epidural catheter and hypaesthesia was confirmed at T4-6 dermatome with a cold alcohol swab. There was no specific symptom related to epidural analgesia during the surgery.\nBullectomy, hematoma evacuation and bleeding control was conducted under general anesthesia. The operation time was 2 hours and 40 minutes and the total infused fluids were crystalloid 900 ml, colloids 400 ml, and PRBC 2 units. Following operation, the hemoglobin level was 11.6 mg/dl, and the platelet count was 175,000 /mm3. Epidural patient controlled analgesia (PCEA) with 0.2% ropivacaine with fentanyl 3 µg/ml was started after the operation.\nOn the first postoperative day (POD 1) oral mefenamic acid 250 mg, three times a day was started to treat mild fever. On POD2 the patient complained of headache and oral acetaminophen 1,300 mg was given two times a day. PCEA infusion was stopped. On POD3 at 6:00 AM, the patient complained of headache, neck stiffness, dizziness, and nausea and vomiting during ambulation. These symptoms were aggravated with upright position, and decreased with supine position. The patient was treated with hydration and absolute bed rest, and the epidural catheter was removed at 5:00 PM. On POD4 the neurologist was consulted. The impression was rule out post-dural puncture headache and conservative treatment was recommended. The patient was treated with hydration, bed rest, mefenamic acid 250 mg three times a day, oral acetaminophen 1,300 mg two times a day. However, the patient complained headache and intravenous injection of ketorolac 30 mg was given three times within 20 hours.\nAt 5:20 AM on POD5, the patient complained of neck pain and right arm pain with tingling sensation. At 6:10 AM, the patient complained of weakness with numbness in both lower legs. The motor power of both lower limbs was 1/5 in all muscle groups and dorsiflexion of both feet was impossible. Deep tendon reflexes were absent bilaterally. Urgent magnetic resonance imaging of the patient () revealed a massive anterior epidural hematoma compressing the spinal cord from the first thoracic vertebrae to the first lumbar vertebrae. At 8: 45 AM, decompressive laminectomy and hematoma evacuation was performed from T1 to T9. At 10:30 AM, the surgeon reported coagulopathy on the operating field, but intraoperative lab findings which performed just before surgical incision were unremarkable (Hb: 10.8 mg/dl, platelet count 266,000 /mm3, PT: 13.7 (INR: 1.23), aPTT: 26.9, fibrinogen 506.7). We conducted a platelet function test with PFA-100® (Siemens, New York, USA) to rule out platelet dysfunction and found significant platelet dysfunction (collagen/epinephrine: more than 300 seconds [normal range: 61-192], collagen/Adenine di-phosphate: 124 seconds [normal range: 61-110]).\nAfter 10 units of platelet concentrate (PC) infusion, bleeding tendency of the operation field was improved. After the end of surgery, the patient recovered uneventfully and transferred to intensive care unit. The operation time was 10 hours and 5 minutes. Therefore, we transfused ten units of PC, nine units of FFP, and five units of PRBC during the operation. Following the operation (6:50 PM), his motor function in both lower limbs was 4/5 with tingling sensation. We asked the local clinic (where the patient's hemorrhoid was treated) about his medications and informed that he had been administered 10 mg of naftazone, three times a day, for seven days. On the POD2, the patient's motor and sensory function returned to normal in both limbs. On POD3, tramadol 37.5 mg with acetaminophen 325 mg three times a day was started instead of ketorolac or other NSAIDs. On POD8, four days after stop taking any kinds of NSAIDs or anticoagulants, his platelet function analysis value decreased to normal range (collagen/epinephrine; >300 → 107 seconds, collagen/ADP; 124 → 70 seconds).\nOn POD 13, the patient transferred to the rehabilitation department and to treat neurologic sequelae (neurogenic bladder and bowel). He was discharged on POD36 without specific complications except mild voiding difficulty.