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An Intervention for Prevention of Epidural Hematomas following Neuraxial Anesthesia
Abstract Number: T-57
Abstract Type: Case Report/Case Series
A 28 year old G3P1 parturient presented to our facility for induction of labor at 40 0/7 WGA. She was diagnosed with severe pre-eclampsia on admission. Her platelet count at this time was 118, and an epidural was placed for labor analgesia upon patient request. Five hours later the anesthesiology team was notified of severe deep variable decelerations. The patient was also complaining of new onset abdominal pain at this time although she had been comfortable with her epidural prior. The patient was immediately moved to the operating suite for emergent cesarean delivery under general endotracheal anesthesia. A viable infant was delivered 6 minutes after the decision to deliver. Placental abruption was noted at this time. The parturient continued to hemorrhage following delivery and stat labs confirmed the diagnosis of disseminated intravascular coagulation (DIC). Blood products were transfused in the OR and the patient was transferred to the ICU with an INR of 1.9. An order was written to not remove the patient’s epidural catheter and nursing staff was notified. Despite these efforts, an obstetric intern on another ICU service was asked by nursing staff to remove the patient’s epidural catheter and did so. Luckily, the patient suffered no neurologic sequelae.
Coagulopathy is a contraindication to neuraxial anesthesia. This is of concern both during neuraxial placement and removal, as the incidence of epidural hematoma has been estimated to be as high as 1/150,000 neuraxial anesthetics1. Although the patient ultimately did well, great morbidity could have resulted from this failure. After discussing this case over grand rounds utilizing the healthcare matrix2, a system-based improvement plan was instituted. All labor epidurals placed in parturients at risk for worsening coagulopathy are now tagged with a brightly colored “To be removed by anesthesia only” label. This is similar to the “difficult intubation” labels many institutions have begun placing around endotracheal tubes in patients with difficult airways3. Labeling these catheters avoids miscommunication, information being lost during handovers, and easily alerts all providers to a patient who could potentially have neurologic sequelae due to their neuraxial anesthetics. Normal coagulation studies and platelet counts are drawn as deemed appropriate before these catheters are removed by an anesthesia provider.
1. Chestnut D, Polley L, Tsen L, Wong C. Chestnut’s Obstetric Anesthesia: Principles and Practice. Philadelphia: Mosby 2009.
2. Bingham JW, Quinn DC, Richardson MG, Miles PV, Gabbe SG. Using a healthcare matrix to assess patient care in terms of aims for improvement and core competencies. Jt Comm J Qual Patient Saf. 2005 Feb;31(2):98-105.
3. Terman GW. UVA launches difficult intubation label. Anesthesia Patient Safety Foundation newsletter. Fall 2011.