Epidural hematoma following epidural analgesia in a patient receiving unfractionated heparin for thromboprophylaxis

Background and Objectives: The practice of providing postoperative epidural analgesia for patients receiving deep venous thromboprophylaxis with unfra ctionated heparin is common. This case report is intended to heighten aware ness of comorbid risk factors for epidural hematoma and to bring attention to the new ASRA consensus guidelines on the management of neuraxial anesthe sia in the presence of standard heparin. Case Report: A 79-year-old woman with apparently normal coagulation and rec eiving no antiplatelet agents required an abdominoperineal resection for re current squamous cell carcinoma of the anus. Approximately 2 hours after he r preoperative dose of 5,000 U unfractionated heparin, an epidural catheter was placed on the third attempt. Subcutaneous heparin was subsequently adm inistered every 12 hours. Her international normalized ratio became slightl y elevated during surgery while the partial thromboplastin time and platele t count remained normal. The catheter was removed on postoperative day 3;, 6 hours after the last dose of heparin. The patient developed signs of an e pidural hematoma requiring surgical evacuation on postoperative day 4. The presence of previously undiagnosed spinal stenosis may have contributed to her symptoms. Conclusion: Management of postoperative epidural analgesia in the patient r eceiving thromboprophylaxis with unfractionated heparin requires appropriat e timing of epidural insertion and removal, monitoring of coagulation statu s and vigilance.