LETTERS TO EDITOR Year : 2023  |  Volume : 24  |  Issue : 1  |  Page : 78-79  

Communication is the key – Let's not forget it!!

Rashmi Syal1, Priyanka Sethi2, Manbir Kaur2, Pradeep Kumar Bhatia2
1 Department of Anesthesiology and Critical Care, Dr. SN Medical College, Jodhpur, Rajasthan, India
2 Department of Anesthesiology and Critical Care, All India Institute of Medical Science, Jodhpur, Rajasthan, India

Date of Submission18-Feb-2022Date of Decision15-May-2022Date of Acceptance15-Sep-2022Date of Web Publication24-May-2023

Correspondence Address:
Dr. Rashmi Syal
Department of Anesthesiology and Critical Care, Dr. SN Medical College, Jodhpur, Rajasthan
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/TheIAForum.TheIAForum_28_22

How to cite this article:
Syal R, Sethi P, Kaur M, Bhatia PK. Communication is the key – Let's not forget it!!. Indian Anaesth Forum 2023;24:78-9

Sir,

Anticoagulation and bleeding disorders are considered to be the risk factors for hematoma formation after neuraxial blocks. To prevent such complications and to deliver maximum benefit to the patient, strong communication between an anesthesiologist and a surgeon is the key. We hereby present a case which highlights the significance of a proper communication for the best patient outcome.

A 30-year-old man with a carcinoma gallbladder was scheduled to undergo radical cholecystectomy. Proper written and informed consent was taken from the patient before taking him to operation theatre. Prior to the induction of general anesthesia, an epidural catheter (20 gauge) was inserted uneventfully at the T8–T9 interspace using the loss-of-resistance technique. The surgery went uneventful, and in the postoperative period, a continuous epidural infusion of 0.2% ropivacaine (6 ml/h) was administered. As per our institutional protocol, prophylactic dose of enoxaparin (40 mg) was started and the removal of epidural catheter was planned for day 3 after holding enoxaparin for 12 h.[1] The patient was followed 12 hourly, and on the 1st postoperative day, the patient's analgesia was satisfactory. On the 2nd postoperative day, the patient became dyspneic and saturation dropped to 90%, pulmonary embolism was suspected, and emergency computed tomography (CT) angiography was done, which confirmed the diagnosis. With quick advice from a pulmonologist, the enoxaparin dose was increased to 0.6 mg bd without intimating to an anesthesiologist on call.

As per ASRA guidelines, a minimum 24-h time should be elapsed between the last dose of enoxaparin and catheter removal. Since a repeat dose was already given, the epidural catheter could not be removed and a decision was taken to continue the therapeutic dose of enoxaparin with catheter in situ. The patient was being followed regularly and the catheter site was also being checked for any swelling. On day 4, when the patient went for CT chest and abdomen, his epidural catheter got displaced and it was removed by the duty doctor on the spot without informing to an anesthesiologist. During our rounds, we found out that this incident happened around 4 h after the last dose, and by this time, the next dose was also given. The patient did not develop any symptom and neurological examination was normal. Warning symptoms were informed to the patient and his relatives. Also, he was regularly followed for his symptoms and MRI suite was intimated about urgent need if any.

The patient did not complain of low backache and neurological deficit and was followed for 96 hours after this incident.

Epidural anesthesia can be employed for patients who may need prophylactic anticoagulant therapy in the perioperative period. However, this case was a rare one where therapeutic dose was started in the emergency due to postoperative pulmonary embolism. As the thoracic vertebral canal is narrower and has profuse vasculature owing to radicular arteries (C5–T2) and Adamkiewicz's artery (T9–T12), the fear of epidural hematoma was greater.[2] We were fortunate enough that the incident of accidental removal happened around 4 h after the last dose. Since the clearance half time of enoxaparin is 3–4 h,[3] more than half of the dose would have been already metabolized before the accidental dislodgement of the catheter.

Our case highlights the need for proper communication between the surgical team and the anesthesiologist. Communication of surgical team and concerned anesthesiologists at the point of suspicion of pulmonary embolism could have made them aware of the possible consequences. Formulation of a written further plan regarding the epidural catheter and its proper communication to all the involved team (anesthesiologist, surgeon, pulmonologist, etc.) must have avoided the further event (removal of the catheter by the surgeon).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

  References 
1.Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, Benzon HT. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American society of regional anesthesia and pain medicine evidence-based guidelines (Fourth Edition). Reg Anesth Pain Med 2018;43:263-309.  
    2.Kreppel D, Antoniadis G, Seeling W. Spinal hematoma: A literature survey with meta-analysis of 613 patients. Neurosurg Rev 2003;26:1-49.  
    3.Bara L, Samama M. Pharmacokinetics of low molecular weight heparins. Acta Chir Scand Suppl 1988;543:65-72.