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Journal of Obstrectic Anaesthesia and Critical Care
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 Table of Contents  
LETTER TO THE EDITOR
Year : 2014  |  Volume : 4  |  Issue : 2  |  Page : 89-90

Surgical management to secure prolonged epidural site bleeding


1 Clinical Fellow in Neuroanesthesia and Spine Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
2 Department of Anesthesiology, Newham University Hospital, Barts Health NHS Trust, London, England, UK

Date of Web Publication1-Nov-2014

Correspondence Address:
Rajkalyan Chakrabarti
Flat 3, Oakside Court, Fencepiece Road, Barkingside, Ilford, Essex, IG6 2PH, United Kingdom

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4472.143881

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How to cite this article:
Chakrabarti R, Patel K. Surgical management to secure prolonged epidural site bleeding . J Obstet Anaesth Crit Care 2014;4:89-90

How to cite this URL:
Chakrabarti R, Patel K. Surgical management to secure prolonged epidural site bleeding . J Obstet Anaesth Crit Care [serial online] 2014 [cited 2020 Nov 29];4:89-90. Available from: https://www.joacc.com/text.asp?2014/4/2/89/143881

Sir,

Heavy bleeding from epidural site is a rare and unusual complication of labor epidural analgesia in an otherwise uneventful labor. Extensive literature search yield little information about surgical intervention to control bleeding at the epidural site.

A 25-year-old gravid 1 para 0 presented at 40 weeks of gestation for augmentation of labor with stable vital signs. She was started on oxytocin infusion and continuous cardiotocography monitoring after establishing venous access. She was in excellent health and on no medication. She requested for an epidural for labor analgesia. An epidural was instituted aseptically without any complication at L4/L5 interspace with 16G Tuohy needle. Using a midline approach epidural space was found at the first attempt without difficulty at 5 cm depth with the loss of resistance technique to saline. Catheter was introduced and fixed at 9 cm on the skin. Aspiration test was negative. We used a transparent sterile dressing. Test dose was given initially; followed by 10 ml of 0.125% bupivacaine with 2 μg/ml fentanyl as initial bolus. After that the epidural infusion was started at the rate of 10ml/h. Patient enjoyed satisfactory pain relief during the whole labor. After 2 h, anesthesiologist was informed by the midwife about an evolving hematoma at the epidural site. Anesthesiologist took the dressing off and removed a big blood clot amounting approximately 200 ml. There was a continuous oozing from the epidural site. It was neither spurting nor bright red. Constant pressure with gauze and ice was applied to the patient back for over 10 min without successful hemostasis. Consultant anesthesiologist and hematologist were informed and involved. Another 100 ml of blood was lost during this time. Pressure dressing with gauze soaked in Tranexamic acid was applied to the epidural site according to the recommendation of consultant hematologist. The surgeons were informed. Patient vitals were stable, and she was having good sensory block of T8 on both side. Aspiration of the catheter was negative again. Blood was sent for full blood count and coagulation profile. Patient continued to bleed despite having normal coagulation profile.

A multidisciplinary team of consultant obstetrician, anesthesiologists, hematologist and surgeon decided to deliver the baby. Ventouse delivery was conducted in theater by senior obstetrician, while surgeons were present. Baby's Apgar score was 9 at 1 min, 10 at 5 min, and 10 at 10 min. After delivery of the placenta anesthesiologist removed the epidural catheter and the site was still bleeding. Surgeon put a purse string suture and secured the bleeding under local infiltration. Altogether blood loss was estimated to be over 500 ml. Patient was kept under observation in high dependency unit. An urgent magnetic resonance imaging (MRI) Scan was performed after discussing with consultant radiologist. MRI scan [Figure 1] showed streaky and focal increase in densities within the erector spine muscle group on both side at the level of L4, L5, and S1 suggestive acute bleed. Epidural and spinal site was normal. Patient had an uneventful recovery and again the coagulation profile sent later was normal. Suture was removed after 48 h,and there was no further bleeding.

Epidural site bleeding is a very rare complication. Local infiltration with 1% lignocaine with 1 in 200,000 adrenaline at the time of insertion reduces the chance of superficial bleeding from epidural site. [1] Epidural site bleeding can lead to subcutaneous hematoma warranting longer hospital stay. [2] Pressure dressing with Tranexamic acid soaked gauze failed to work on this occasion. Use of low dose adrenaline with tuberculin syringe around the catheter site has been reported to have a successful outcome. [3] Use of purse string suture and resetting of the catheter is another successful way of treating. [4] In either cases post procedure MRI has not been considered. Possibility of presence of aberrant vessels around the epidural insertion site could be the cause of this dreaded complication. MRI [Figure 1] done on this occasion clearly showed an acute bleed and erector spine hematoma suggestive of aberrant vessel injury. This report raises awareness and opens the discussion about the need to mention epidural site bleeding as neuroaxial block complication when taking consent from the patient.
Figure 1: Magnetic resonance imaging scan of the spine

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  References Top

1.
Carvalho B, Fuller A, Brummel C, Cohen SE. Local infiltration of epinephrine-containing lidocaine with bicarbonate reduces superficial bleeding and pain during labor epidural catheter insertion: A randomized trial. Int J Obstet Anesth 2007;16:116-21.  Back to cited text no. 1
    
2.
Katz Y, Poppa E, Segal DC, Rozenberg B. Large subcutaneous hematoma complicating epidural block. Acta Anaesthesiol Belg 2002;53:41-2.  Back to cited text no. 2
    
3.
Cohen S, Kis G, Burley E. Prolonged bleeding from epidural catheterisation reconsidered. Anaesthesia 1999;54:719.  Back to cited text no. 3
    
4.
Ananthanarayan C, Haley S. Prolonged bleeding from epidural insertion site. Can J Anaesth 1988;35:322.  Back to cited text no. 4
    


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