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Table of Contents
ORIGINAL ARTICLE  
Year : 2013  |  Volume : 16  |  Issue : 3  |  Page : 169-177
Epidural catheterization in cardiac surgery: The 2012 risk assessment


Department of Anesthesiology, McGill University, Montreal, Canada and University of Pisa, Pisa, Italy

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Date of Submission05-Nov-2012
Date of Acceptance12-Mar-2013
Date of Web Publication29-Jun-2013
 

   Abstract 

Aims and Objectives: The risk assessment of epidural hematoma due to catheter placement in patients undergoing cardiac surgery is essential since its benefits have to be weighed against risks, such as the risk of paraplegia. We determined the risk of the catheter-related epidural hematoma in cardiac surgery based on the cases reported in the literature up to September 2012. Materials and Methods: We included all reported cases of epidural catheter placement for cardiac surgery in web and in literature from 1966 to September 2012. Risks of other medical and non-medical activities were retrieved from recent reviews or national statistical reports. Results: Based on our analysis the risk of catheter-related epidural hematoma is 1 in 5493 with a 95% confidence interval (CI) of 1/970-1/31114. The risk of catheter-related epidural hematoma in cardiac surgery is similar to the risk in the general surgery population at 1 in 6,628 (95% CI 1/1,170-1/37,552). Conclusions: The present risk calculation does not justify not offering epidural analgesia as part of a multimodal analgesia protocol in cardiac surgery.

Keywords: Epidural anesthesia, Epidural catheter, Epidural hematoma, High thoracic anesthesia, Risk assessment

How to cite this article:
Hemmerling TM, Cyr S, Terrasini N. Epidural catheterization in cardiac surgery: The 2012 risk assessment. Ann Card Anaesth 2013;16:169-77

How to cite this URL:
Hemmerling TM, Cyr S, Terrasini N. Epidural catheterization in cardiac surgery: The 2012 risk assessment. Ann Card Anaesth [serial online] 2013 [cited 2018 Dec 14];16:169-77. Available from: http://www.annals.in/text.asp?2013/16/3/169/114237

This article is accompanied by an invited commentary by Prof. Howard Barkan



   Introduction Top


The risk-benefit ratio of medical procedures needs to be known in order to make the best choice in routine clinical practice. In cardiac surgery, epidural analgesia has been performed for many years; [1] however, its use is often limited by the fear of an increased risk of epidural hematoma because of ongoing and intraoperative anticoagulation therapy. Since epidural catheterization is a controversial technique and a strongly debated practice, it is crucial to update the risk benefit-ratio of epidural catheterization in the cardiac surgery. In a recent review, Royse [2] describes the benefits and risks related to high thoracic epidural analgesia and concludes that "epidural use in cardiac surgery is no more dangerous than in non-cardiac surgery." In 2007, Bracco and Hemmerling determined the risk of catheter-related epidural hematoma in cardiac surgery, searching databases from 1966 to March 2007. [3] The calculated risk was 1 epidural hematoma for 12000 epidural catheterization. The aim of this article is to update the risk of catheter-related epidural hematoma in the cardiac surgery using the databases from 1966 to September 2012.


   Materials and Methods Top


Risk assessment was calculated as follows: The number of epidural hematoma cases/number of epidural catheter placements for cardiac surgery as described in the literature. Medline, SciSearch, Embase, Google and Google Scholar were searched to select publications presenting patients who received epidural anesthesia/analgesia while undergoing cardiac surgery. The search criteria were: ([epidural anesthesia] OR [epidural catheter] OR [loco-regional anesthesia] OR [epidural) AND ([cardiac surgery] OR [coronary artery bypass grafting] OR [aortic valve surgery] OR [mitral valve surgery]), without any restrictions for language or type of study. Databases were explored from 1966 to September 2012: The authors read titles and abstracts of retrieved articles (around 3000), and full paper copy were obtained for all studies not eliminated for irrelevance to the subject. The compiled publication list includes: Conference abstracts, randomized control trials, retrospective and prospective studies, and meta-analysis. The number of patients undergoing cardiac surgery who received epidural catheterization was retrieved; attention was paid to not count patients twice. After that, the total number of cases (which represents the denominator of our function) was calculated summing cases from 1966 to September 2012 (16,477 patients). The numerator was calculated adding cases of epidural hematoma after epidural catheterization in cardiac surgery, occurred from 1966 to 2012 (3 cases). The risk of catheter-related epidural hematoma was compared with several different risks, such as: The risk of catheter-related epidural hematoma in non-cardiac surgery, the risk of breast or prostate cancer, and the risk of road traffic injury. The percentages of risk used for comparison were extrapolated from the large trials, meta-analysis or national statistics reports. The Wilson method was used to calculate 95% two-sided confidence interval (CI) of a single proportion. [4] The comparison between 2 proportions was carried out using the same method. [5]


   Results Top


From 1966 to September 2012, 16,477 patients undergoing cardiac surgery were found who received only epidural or epidural plus general anesthesia (GA). The risk of catheter-related epidural hematoma was 3 cases out of 16,477 patients, or 1/5,493, with a 95% CI of 1/970-1/31,114. This population also included some pediatric patients. The type of surgery and the number of the patients derived from articles from April 2007 to September 2012 are shown in [Table 1]. Previous articles were presented in the study by Bracco and Hemmerling. [3] Only two cases of catheter-related epidural hematoma are described in the literature from April 2007 to September 2012. The 1 st one occurred in 2010 and reported by the UK Medical Protection Society. [6] A 70-year-old woman underwent coronary artery bypass grafting revision surgery 6 years after she received a triple coronary artery bypass grafting. An epidural catheter was placed on the day of surgery without incident and general anesthesia was induced. In the morning of the day after surgery, the patient showed neurological symptoms noticed by a nurse. She underwent a neurological examination revealing an intense motor and sensory deficit at the T6 level bilaterally; then hours later, her spine was examined using a Computed Tomography scan. A large hematoma was found in the epidural space; an emergency laminectomy and evacuation of hematoma were performed in the evening, about 12 h after the 1 st symptom appeared. The patient remained paraplegic. The 2 nd case of catheter-related epidural hematoma happened in 2011. [11] On the day of surgery, after induction of general anesthesia, an epidural catheter was placed. The patient, a 55-year-old man scheduled for the mitral valve replacement and tricuspid valvuloplasty, had stopped warfarin 7 days before surgery. Pre-operative blood exam revealed a normal coagulation profile and normal platelet count. At the end of surgery, International Normalized Ratio (INR) and Activated Partial Thromboplastin Time (aPTT) were 1.52 and 42.2 s, respectively, and his platelet count was 77,000/mm 3 . A flaccid paraplegia appeared 16 h after the end of surgery; at that time, his coagulation profile was still altered (aPTT 53.3 s, INR 1.30). An emergency magnetic resonance imaging showed an epidural hematoma at the T5-T6 level, a laminectomy, within 6 h since the onset of the symptoms was performed to remove the hematoma. This patient had a good overall recovery and presented only slight dysuria 6 months after laminectomy. The third case of catheter-related epidural hematoma was reported earlier by Bracco and Hemmerling; it occurred in 1995 and was reported in 2004. [76] The epidural catheter was placed on the day of surgery in a 60-year-old man who underwent coronary artery bypass grafting surgery. He had no health problems other than the ischemic heart disease. The epidural catheter placement at T12/L1 was uneventful as well as the surgery; heparinization was reversed, and the patient received 4 units of fresh frozen plasma and 6 units of platelets The morning after surgery around 7 am, a nurse noticed that the man could move his arms but not his legs, and it was ascribed to the sleepy state of the patient. Around 11 am, the patient could not move his legs, even though he was extubated since 3 h; the catheter was removed. At 16 h, magnetic resonance imaging (MRI) scan revealed a spinal hematoma from T5 to T10, and 4 h later it was evacuated through a laminectomy. The surgery started around 13 h after the first symptom of neurological deficits were noticed. The patient was paralyzed in his legs, and he did not recover after surgery. Several cases of neurological complications occurring in patients with an epidural catheter placed for cardiac surgery are described in the literature. Arora et al., reported a case of pneumocephalus after epidural anesthesia. [9] The patient, a 68-year-old hypertensive, diabetic, and an obese male was admitted for coronary artery bypass surgery. After uneventful epidural catheter insertion, the test dose was administered (2 ml of 2% lidocaine). Immediately, the patient reported severe headache, and then generalized tonic-clonic seizures developed. The patient regained consciousness 10 min later after control of seizures. The MRI showed air in the basal cisterns and subarachnoid spaces. The patient refused to undergo surgery and underwent successful coronary angioplasty 2 days later. The authors concluded that the complications were due to the puncture of the dura-mater.
Table 1: The articles included for the current risk assessment. Only articles from April 2007 to September 2012 are included. The previous articles were published earlier by Bracco and Hemmerling[3]


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The risk of catheter-related epidural hematoma in cardiac surgery is comparable to the risk of epidural hematoma after use of epidural catheters for general surgery. [77],[78] In Germany, Volk et al., estimated an incidence of epidural hematoma of 1:6,628 in general surgical population from 2008 to 2009. [78] For this report, a relative risk reduction of 17% favoring general surgery (not significant) was calculated between the risk of epidural hematoma after catheterization in the cardiac surgery (1/5,493) and in general surgery (1/6,628).The mortality for heart disease in the United States is 10 times higher than the risk of epidural hematoma after epidural anesthesia/analgesia for cardiac surgery. [79] The risk of catheter-related epidural hematoma in cardiac surgery is 100 times lower than the risk of acute renal failure after coronary artery bypass grafting surgery, [80] and the risk of sternal wound infection. [81] The risk of catheter-related epidural hematoma in cardiac surgery is 1,000 times lower than the frequency of prescribing errors in hospitals (errors/admissions). [82] Patients undergoing cardiac surgery with an epidural catheter in place have a risk to develop an epidural hematoma comparable to the risk of women developing breast cancer (women/year), [83] or prostate cancer (men/year), [83] and to the risk of dying by car traffic accident (deaths/population) [Figure 1]. [84]
Figure 1: Risk comparison. Risk of catheter-related epidural hematoma of some medical complications of some nonmedical activities. Risk is expressed as proportion (diamond) and its 2-sided 95% confidence interval (lines). (a) Data from [Bateman, 2012, Anesth Analg, Epub ahead of print]. (b) Data from (Volk, 2012, Eur J Anaesthesiol 29 (4): 170-176). (c) Data from (Osta, 2010, Br J Anaesth 104 (4): 429-432). (d) Data from (Martinelli, 2009, Ren Fail 31 (8): 633-640). (e) Data from (Lu, 2003, European Journal of Cardio-Thoracic Surgery 23 (6): 943-949). (f) Data form (Heart Disease-Centers for Disease Control and Prevention, 2009, http://www. cdc.gov/nchs/fastats/heart.htm). (g) Data from (Lewis, 2009, Drug Saf 32 (5): 379-389). (h) Data from (The Serious Hazards of Transfusion [SHOT] Steering Group, 2012, http://www.shotuk.org/wp-content/uploads/2012/07/SHOT-Summary_FinalWebVersion 2012_06_261.pdf). (i) Data from [US National Cancer Institute, 2009, http://seer.cancer.gov/statfacts/]. (j) Data from (WHO-World report on road traffic injury prevention, 2002, http://www.who.int/violence_injury_prevention/publications/ road_traffic/world_report/chapter 2.pdf). (k) Data from (Unintentional injury deaths, 2009, http://www.cdc.gov/nchs/fastats/acc-inj.htm)

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   Discussion Top


Knowing the risk related to medical procedures is extremely beneficial in the clinical practice; it permits to correctly evaluate the risk-benefit ratio and to obtain an informed consent before performing the procedures. Two recent meta-analyses have shown that the use of epidural analgesia/anesthesia in patients undergoing cardiac surgery improves the outcome by decreasing the incidence of acute renal failure, the incidence of post-operative supraventricular arrhythmias, the time on mechanical ventilation, and respiratory complications. [85],[86] The composite endpoint of mortality and myocardial infarction are decreased by the use of epidural anesthesia in cardiac surgery. [86] Epidural anesthesia/analgesia can be an vital intervention in a multimodal strategy.

Awake cardiac surgery is a new minimally invasive anesthesia technique, and it might be an option for high-risk patients with severe lung disease; avoiding intubation and mechanical ventilation might be able to reduce the risk of morbidity and mortality. [20],[33],[42],[44],[52],[53] The present article demonstrates that the risk of catheter-related epidural hematoma in cardiac surgery is not zero; however, a risk that is comparable to the risk of dying in a car accident, [87] which is a hazard commonly accepted [Figure 1].

As previously studied by Ho et al., we decided to consider all studies about 'epidural in cardiac surgery, even if no reports about epidural hematoma and/or neurological injuries were present. [88] In 2006, Ruppen et al., [89] calculated the incidence of epidural hematoma and neurological injury in patients with epidural anesthesia/analgesia undergoing cardiac surgery, selecting 12 studies from1966 to February 2005, which met their search criteria. Only articles reporting at least 100 cardiovascular or thoracic surgery patients and numerical data about hematoma and neurological injuries were selected for the meta-analysis. They found 4971, 4108, and 5026 cases of cardiac, thoracic, and vascular surgery, respectively. No cases of epidural hematoma were found, therefore, according to Hanley and Lippman-Hand's mathematical model, the maximum risk of epidural hematoma in cardiac surgery was determined as 1 out of 1700 (0.06%). In the same year, Ruppen et al., [90] also described the incidence of epidural hematoma, infection and neurologic injury in obstetric patients with epidural analgesia/anesthesia, searching articles from 1966 to 2005; all the articles including at least 200 obstetric patients and numerical data about epidural catheterization related adverse outcomes were included in the study. A risk of 1 epidural hematoma in 183,000 cases was found (0.0005%). Christie and McCabe described 3 cases of epidural hematoma in 8,100 patients (0.04%), who underwent significant surgery between January 2000 and December 2005 in their hospital. [91] One out of 3 hematoma was due to coagulopathy caused by a dose of low molecular weight heparin 9 hours after a complicated insertion of epidural catheter. Authors suggested that adverse neurological outcome and severity of the neurological deficit after epidural hematoma was related to diagnostic delays. The increased risk compared to the 2007 assessment by Bracco and Hemmerling, [3] might be due to a decrease in the number of cases we used to determine the denominator. Since epidural analgesia/anesthesia is no longer a novelty in cardiac anesthesia, less case studies or series are reported; the number of actual thoracic epidurals may be much higher after cardiac surgery as not all routine epidurals are reported and therefore, the actual risk may be even lower.

In the literature, several cases of idiopathic epidural hematoma are reported. [92] Cases of spontaneous epidural hematoma without an epidural catheter after cardiac surgery are also described. [93],[94],[95],[96] Hayashi et al., reported a 71-year-old women, who underwent mitral valvoplasty with CPB. [95] Surgery lasted around 4 h uneventfully, and she was not previously treated with any anticoagulant therapy. One hour after surgery, paraplegia was noted, an epidural hematoma compressing the spinal cord at the C7-T4 level was revealed on MR imaging. A conservative approach was chosen because the paraplegia was not progressive. The authors stated that the epidural hematoma etiology was not evident. The woman had a good overall outcome.

There are several considerations of using an epidural technique in cardiac surgery which should be mentioned despite no scientific risk assessment available in the literature. An epidural technique necessitates a considerable effort in establishing an infrastructure, which allows safe conduct of epidural analgesia. If the epidural is placed the day before surgery, then substantial logistical issues need to be resolved: When exactly is the catheter inserted, how long and where should the patient be admitted and monitored before being transferred to the general cardiac surgery ward. If the epidural catheter is inserted on the day of surgery, this adds time to the induction time; however, this is an issue, which is not specific for epidural techniques in cardiac surgery only and therefore, not different from the use of epidural techniques in general surgery. Since the insertion of an epidural catheter for cardiac surgery should be reserved to expert hands, the time added for insertion should be within the range of 5-15 min. There needs to be a "culture" where the potential of case cancellation due to a bloody tap is accepted as a rare, but unavoidable complication. The user, together with all health-care providers, should have a protocol for this rare complication in place: Cancellation with venous tap or arterial tap only? (The differentiation is easy by drawing blood for a blood gas). Based on the literature and the senior author's own experience, the probability of a bloody tap is approximately 1 in 1000 cases - however, there is no scientific data published. More and more patients are on aggressive antiplatelet therapy: Diligent protocoling of the type and dosage of antiplatelet drugs before surgery and their cessation is important for safe insertion of an epidural catheter in cardiac surgery. Even more important is the establishment of a protocol for post-operative anticoagulation especially in valve surgery. The physiological benefits of thoracic epidural analgesia are greatest in the first 48 h after surgery. They include early extubation, reduced respiratory complications and cardiac dysrhythmias, as well as better analgesia. [97] Therefore, it is important to have 24-48 h of post-operative period before the start of anticoagulant treatment. The removal of the epidural catheter needs to be preceded by a normal coagulation profile. Protocols need to be in place: What to do when an abnormal coagulation profile is detected with an epidural catheter in place? In addition, there needs to be a diligent protocol for repetitive - short intervals of neurological assessment after surgery of these patients to detect possible neurological complications early enough. The combination of TEA and early or immediate extubation are the safest choice to allow neurological diagnosis. However, this is true for any epidural technique in any patient for any surgery: If the patient stays intubated after surgery, then neurological deficits might be masked by the level of sedation of the patient to respond to commands for neurological assessment. Performing epidural techniques in cardiac surgery in a center with no immediate access to MRI scanning of the spine cannot be recommended. From the moment the clinical diagnosis or suspicion is raised, there should be no delay to confirm the diagnosis via MRI. The literature has shown that recovery from epidural hematoma in the cardiac surgery can be complete only if the established time interval between detection and surgery (approximately within 8 h) is respected.

Limitations of the current risk analysis are related to our decision of not considering differences among the studies we used as source. Different times of catheter placement, different perioperative heparinization protocols, and different puncture levels are not taken into account. It would be impossible because of the limited number of patients undergoing cardiac surgery with epidural analgesia/anesthesia and even lesser number [3] of cases of epidural hematoma described in the literature.

In conclusion, evaluating the risk-benefit ratio of using thoracic epidural anesthesia in cardiac surgery shows that the risk of catheter-related epidural hematoma is 1/5,493, with a 95% CI of 1/970-1/31,114.

 
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Correspondence Address:
Thomas M Hemmerling
Montreal General Hospital, C 10-153, 1650 Cedar Avenue, Montreal, H3G 1A4, Canada

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DOI: 10.4103/0971-9784.114237

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