Epidural Hematoma Following Cessation of a Direct Oral Anticoagulant: A Case Report.

OBJECTIVE: In this case report, we describe a case of epidural hematoma following epidural analgesia in a patient with recent cessation of a direct oral anticoagulant (DOAC). CASE REPORT: An 89-year-old woman requiring upper abdominal surgery presented with multiple comorbidities, including a prior cerebrovascular accident resulting in a left-sided hemiparesis and atrial fibrillation requiring anticoagulation with rivaroxaban. In accordance with our departmental guidelines at the time of procedure, rivaroxaban was discontinued 4 days preoperatively. A thoracic epidural was placed at T8/9 immediately prior to induction. Venous thromboembolism prophylaxis was provided with compression devices, and every-12-hour unfractionated heparin initiated 5.5 hours after epidural placement. On postoperative day 2, the patient was noted to have a bilateral motor block, and imaging demonstrated a thoracic epidural hematoma extending from T6 to T11. Preexisting neurological deficits may have delayed detection. With patient agreement, neurosurgery recommended observation rather than surgical decompression because the patient was a poor surgical candidate and limited neurologic recovery was expected. The patient had modest motor recovery over the next few months. CONCLUSIONS: Guidelines for cessation of DOACs prior to neuraxial techniques are based on pharmacologic half-lives rather than accumulated experience. This case adds to the experience of neuraxial analgesia complications while following these guidelines. Patient risk may be increased by the combination of recent cessation of a DOAC, as well as the cumulative effect of multiple small risk factors. Continued vigilance and reporting of cases of epidural hematomas will enhance our understanding and ultimately improve patient care. Elderly patients and/or patients with prior neurological deficits may present further challenges for early detection and require frequent assessments with comparison to baseline status.

The effect of triple vs. double nonopioid therapy on postoperative pain and functional outcome after abdominal hysterectomy: a randomised double-blind control trial.

BACKGROUND: Movement-evoked pain is more severe than pain at rest and is likely to interfere more with functional recovery after surgery. OBJECTIVE: To compare triple vs. double nonopioid perioperative analgesic regimens in women undergoing abdominal hysterectomy. DESIGN: A randomised, parallel design, double-blind controlled trial. SETTING: A single-centre trial. Study period from November 2009 to July 2013. PATIENTS: Adults (>18 years) of American Society of Anesthesiologists' status 1 to 2 scheduled for abdominal hysterectomy. INTERVENTIONS: Patients were randomised to one of four study treatment groups: acetaminophen, meloxicam and gabapentin (AMG); acetaminophen and meloxicam; acetaminophen and gabapentin; and meloxicam and gabapentin. In addition to intravenous patient-controlled opioid analgesia, study treatments were administered for 48 h, starting 1 h preoperatively. MAIN OUTCOME MEASURES: The primary outcome was cough-evoked pain. Secondary outcomes included pain at rest, during sitting and peak expiration, opioid consumption, side effects, peak expiratory flow rate, timed up and go test (TUG), and modified Brief Pain Inventory (mBPI). RESULTS: Interim analysis indicated a minimal chance of demonstrating superiority of the triple regimen group over all three double regimen groups if the trial were to be recruited to planned sample size. Thus, the trial was prematurely terminated for futility. All four analgesic regimens were well tolerated. Exploratory analyses revealed consistent significant negative correlations between pain and TUG and between pain and interference with activity, walking and sleep. CONCLUSION: This trial failed to demonstrate substantial benefits with the addition of a third nonopioid analgesic to three different double-drug regimens. Further research is needed that will more definitively support expanding multimodal analgesic practices. Our results demonstrate consistent correlations between evoked pain and functional outcomes further emphasising the need for improved analgesic regimens that will accelerate postsurgical functional recovery. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number Register 12723675.

Modified electroconvulsive therapy in a patient with gastric adenocarcinoma and metastases to bone and liver.

Background. In addition to general anesthesia, muscle relaxants are given prior to electroconvulsive therapy (ECT) in order to prevent musculoskeletal injury. Higher doses of muscle relaxants have been suggested for patients at high risk for bone fractures; however, there are adverse side effects associated with these higher doses. Aims. We present a successful case of ECT to treat chronic major depressive disorder in a 62-year-old woman at high risk of bone fracture due to gastric adenocarcinoma with metastases to bone and liver. Case. Increasing doses of the muscle relaxant succinylcholine (0.45-0.74 mg/kg) were sufficient to prevent musculoskeletal complications throughout the course of 9 bifrontal ECT treatments. Following treatment, the patient reported and demonstrated markedly improved mood and functionality, enabling her transfer to a palliative care facility. Conclusion. Standard doses of succinylcholine were sufficient to mitigate the risk of pathological fractures in this patient with metastatic bone lesions. As there are established risks to using high doses of succinylcholine, with no evidence that higher doses reduce the incidence of fractures in high-risk populations, we suggest taking a conservative approach, using clinical observation and periodic plain radiography to dictate succinylcholine dose titration in such high-risk patients.