Introduction: Epidural hematoma is a rare but potentially devastating complication of neuraxial anesthesia (1). We present the case of a patient who received a heparin infusion for a presumptive myocardial infarction in the presence of an indwelling epidural catheter who developed an epidural hematoma following removal of the catheter despite adherance to current guidelines. Case: A 78 year old woman who was status post thoracotomy and closure of bronchopleural fistula required a thoracic epidural for analgesia and assistance in weaning from mechanical ventilation. While the epidural was in place, a heparin infusion was started for treatment of a suspected myocardial infarction without contacting the Pain management service. The epidural was removed 4 days later with standard guidelines adhered to and normal coagulations studies. Despite this, the patient developed a large epidural hematoma and required a C5-T9 decompressive laminectomy.

Discussion: This case highlights several critical issues: Despite adherence to strict guidelines regarding anticoagulation and neuraxial anesthesia, the patient still developed an epidural hematoma. There are case reports (2) of patients suffering this complication despite adherence to clinical guidelines, suggesting the need for increased vigilance in the presence of anticoagulation. Also, in institutions with electronic ordering, instituting sytem-wide hold orders requiring interdisciplinary discussion before anticoagulation may be started in a patient with an indwelling neuraxial catheter may decrease incidence of bleeding complications. Finally, further testing (thromboelastography) may play a role in identifying patients at risk for this complication.

Conclusion: There is incomplete evidence regarding full anticoagulation and neuraxial anesthesia (3). This case suggests that in such situations, adherence to guidelines may be insufficient in protecting patients from this complication. Vigilance for changes in neurologic status and communication of such changes are essential. Where possible, systems-based changes in electronic ordering may be implemented to avoid anticoagulation in patients with epidural catheters.