This case involves a female patient who experienced paralysis after she was given an epidural for pain management after undergoing surgery. Before the epidural was administered, the patient underwent a surgery to remove a section of her colon as a treatment for Crohn’s disease. After the surgery was completed, she had an epidural which was placed pre-operatively by the anesthesiologist for the purpose of administering a pain block. In addition to the epidural, it was also noted that the patient had received anti-coagulation medication. The patient did not complain of any abnormal symptoms until several hours after the surgery was completed, at which point she told her nurses that she was experiencing decreased sensation and mobility in her legs. The epidural was stopped, however the numbness persisted. Eventually, doctors discovered the presence of a hematoma on the lower portion of the patient’s spine. Doctors performed emergency surgery to relieve pressure on the patient’s spinal cord, however the patient never regained the use of her legs. It is alleged that the negligent placement of the epidural, combined with the anti-coagulation treatment that the patient was given, directly contributed to her paralysis.
Question(s) For Expert Witness
- 1. Do you routinely perform epidural for post operative pain management?
- 2. On a patient with an epidural, are there restrictions on anti-coagulation?
Expert Witness Response E-009321
I perform epidural analgesia for postoperative analgesia, on the order of several every month. There are restrictions on anti-coagulation and epidural anesthesia, but the American Society of Regional Anesthesia does not consider the amount/type of anti-coagulant given here to be a contraindication to epidural analgesia, but most authorities recommend waiting 8 hours after the last dose is administered before placing an epidural catheter, and two hours after a dose before removing the catheter. Having said that, the guidelines say that 8 hours is preferred, but they refuse to make this a standard because of the scant data to suggest an increased risk of epidural hematoma in patients receiving anti-coagulant medication.
Expert Witness Response E-008119
I place 6 or more epidurals a week. There are clear guidelines on subcutaneous heparin dosing, as well as neuraxial blockade, that would apply in a situation like that described above. If the dosage of anticoagulant given to this patient was accurately detailed in the records, then a minimum of 4 hours wait from administration to the placement of an epidural should be observed. Just as important is the delay in identification of the problem. Flaccid paralysis is not caused by dilute local anesthetics used for postoperative pain, and doctors should have taken a more aggressive diagnostic approach as soon as it was discovered. This delay directly increases the risk of permanent paralysis.