51st Annual Regional Anesthesiology and Acute Pain Medicine Meeting

Epidural Hematoma in a Patient With Dementia Following Thoracic Epidural Placement and the Challenges in Monitoring: A Case Report

Blake St. Louis, DO, Dominic Jose, MD,

Priyanka Singla, MD, Brett Elmore, MD

University of Virginia Health System Charlottesville, VA

INTRODUCTION

•Postoperative Delirium is associated with increased mortality, prolonged length of stay, and worsening of cognitive decline1

•Risk factors for postoperative delirium include uncontrolled postoperative pain and opioid use1

•Epidural Catheters can improve postoperative pain control while minimizing postoperative opioid use but are associated with various risk include epidural hematoma2,3

CASE REPORT

•78-year-old female presented to the Emergency Department with abdominal pain and ”poor coloring”

•Past medical History: Dementia, Hypertension, Diastolic Heart Failure, Chronic Kidney Disease Stage 3, COPD, Alpha-1-Antitrypsin Deficiency, Amyloidosis, Cervical Myelopathy with previous cervical fusion

•Work up revealed leukocytosis with CT abdomen showing severe sigmoid diverticulitis complicated by contained perforation adjacent to the sigmoid colon tracking along the left pelvic sidewall

•Abscess drainage and drain placement performed by Interventional Radiology

•Patient continued to have abdominal pain with worsening abdominal and cecal distension.

•Patient scheduled for exploratory laparotomy with sigmoid resection and end colostomy with Hartmann rectal pouch

•Thoracic epidural placed preoperatively for postoperative pain control

•Platelets 389, PT/INR 12.8/1.1

•Last dose of 40mg subcutaneous enoxaparin > 12 hours

•Placement required multiple attempts by multiple providers as well as challenging due to patient cooperation and lateral decubitus positioning

•POD 0 – Transferred to the ICU for hemodynamic and mechanical ventilation support

•POD 1 – Patient extubated and pain well controlled, however with worsening cognitive status which made neurological exams difficult to perform - Moving bilateral lower extremities spontaneously.

•POD 2 – Continued difficulty performing neurological exams; however, patient was no longer spontaneously moving bilateral lower extremities

•MRI performed which showed T8-L2 large posterior epidural hematoma with significant mass effect on the thecal sac resulting in severe spinal canal stenosis

•Emergent Evacuation of thoracic epidural hematoma and spinal fixation with T6-12 PSIF, T6-L1 laminectomies with decompression

•POD 3-11 – Neurological exams continued to be difficult, however patient noted to have improved strength in bilateral lower extremities. Patient subsequently discharged to inpatient rehabilitation center.

•One Month Follow up – Patient noted to be doing well and walking with a walker.

Epidural Catheter Placements:

1) Can be utilized to minimize risk factors for postoperative delirium however,

2) Can be associated with severe neurological complications

Clinicians must consider the ability to monitor for these complications prior to placement

51st Annual Regional Anesthesiology and Acute Pain Medicine Meeting

Epidural Hematoma in a Patient With Dementia Following Thoracic Epidural Placement and the Challenges in Monitoring: A Case Report

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