Acute Coronary Syndrome in a Patient With a Thoracic Epidural Catheter

Abstract

Thoracic epidural catheters are often used for acute perioperative pain management in complex and extensive thoracic and abdominal surgeries. There are important clinical considerations when managing an indwelling thoracic epidural catheter postoperatively, especially to prevent catastrophic bleeding complications such as thoracic epidural hematomas in unique scenarios where anticoagulation is employed concomitantly. The timing of catheter removal, timing of postoperative anticoagulation to prevent thromboembolic events or to maintain cardiac stent patency, and adequate neurologic monitoring to identify hemorrhagic consequences can be challenging for the physician anesthesiologist and acute pain medicine physician. Perioperative acute coronary syndrome (ACS) is a complication that can occur after major surgery. The contemporary treatment options for acute coronary syndrome involve cardiothoracic surgery or percutaneous coronary intervention (PCI), followed by administration of potent fibrinolytic agents or anticoagulants. The use of anticoagulants complicates the management of thoracic epidural catheters and can increase the risk of a thoracic epidural hematoma. Prompt diagnosis of a thoracic epidural hematoma in this setting through adequate monitoring, detailed neurological exam, or MRI is paramount to facilitate emergent surgical decompression and to prevent catastrophic and irreversible neurological deficits. This chapter presents a case of a surgical patient with an indwelling thoracic epidural catheter postoperatively who had an episode of ACS treated with PCI and subsequent dual antiplatelet therapy. The patient developed an epidural hematoma and underwent surgical decompression. The chapter reviews the literature and discusses diagnosis, management, treatment options, and prognosis.