Bleeding during epidural analgesia: case report

BACKGROUND: Bleeding at the puncture site during neuraxial blocks is a potentially dangerous complication, and its risk is significantly increased in patients receiving antithrombotic therapy. CLINICAL CASE DESCRIPTION: Patient S. (aged 60 years) was admitted to the department of vascular surgery (Vladivostok). He was diagnosed with Leriches syndrome, for which he took 100 mg of aspirin and 75 mg of clopidogrel. On January 12, 2022, combined spinal-epidural anesthesia was performed, and the epidural space was punctured on the fourth attempt. However, massive bleeding was observed from the puncture site. Intraoperatively, before the great vessels were clamped, 100 units/kg of heparin (8000 units) was administered. After the operation, the epidural puncture site was revised: the sticker was soaked with hemorrhagic discharge and removed, and a new sticker was applied. On January 12, 2022, nadroparin calcium 9500 IU anti-Xa/ml 0.3 mL was given two times a day in the ICU. On the same day, intensive bleeding was noted in the area where the epidural catheter was located. This was treated locally with cold and two doses of fresh frozen plasma. On January 13, 2022, magnetic resonance imaging of the lumbar spine showed the spinal cord without displacement and compression, the puncture area had no signs of bleeding, the epidural catheter was removed, and the patient was discharged for outpatient treatment on day 7. CONCLUSION: To reduce bleeding risk in neuraxial blockade, the recommendations for preparing for surgery patients receiving anticoagulant and antiplatelet therapy must be followed, and the pharmacokinetics of antithrombotic drugs must be taken into account. If puncture and catheterization of the epidural space are technically difficult, manipulation should be abandoned.