Estimating the Incidence of Suspected Epidural Hematoma and the Hidden Imaging Cost of Epidural Catheterization

Abstract

Introduction Hematoma associated with epidural catheterization is rare, but the diagnosis might be suspected relatively frequently. We sought to estimate the incidence of suspected epidural hematoma after epidural catheterization, and to determine the associated cost of excluding or diagnosing an epidural hematoma through radiologic imaging. Methods We conducted an electronic retrospective chart review of 43,200 patient charts using 4 distinct search strategies and cost analysis, all from a single academic institution from 2001 through 2009. Charts were reviewed for use of radiological imaging studies to identify patients with suspected and confirmed epidural hematomas. Costs for imaging to exclude or confirm the diagnosis were related to the entire cohort. Results In our analysis, over a 9-year period that included 43,200 epidural catheterizations, 102 patients (1:430) underwent further imaging studies to exclude or confirm the presence of an epidural hematoma—revealing 6 confirmed cases and an overall incidence (per 10,000 epidural blocks) of epidural hematoma of 1.38 (95% CI 0, 0.002). Among our patients, 207 imaging studies, primarily lumbar spine MRI, were performed. Integrating Medicare cost expenditure data, the estimated additional cost over a 9-year period for imaging and hospital charges related to identifying epidural hematomas nets to approximately $232,000 or an additional $5.37 per epidural. Discussion About 1 in 430 epidural catheterization patients will be suspected to have an epidural hematoma. The cost of excluding the diagnosis, when suspected, is relatively low when allocated across all epidural catheterization patients.

Residual Enoxaparin Activity, Anti-Xa Levels, and Concerns About the American Society of Regional Anesthesia and Pain Medicine Anticoagulation Guidelines

“…While we did not specifically investigate prophylactic dosing regimens, it is also conceivable that residual anticoagulant activity could exist 12 hours following twice-daily dosing strategies, because at this time interval anti-Xa levels have been previously reported to be approximately 50% of peak levels. 8 Given the low incidence of symptomatic epidural hematomas (1.38 per 10,000 epidural blocks; 95% confidence interval, 0-0.002), 21 an increase in the occurrence of this adverse event, secondary to residual enoxaparin activity, could easily go unrecognized and might be challenging to detect in prospective studies. However, the incidence of epidural hematoma formation was recently found to be increased in the setting of abnormal coagulation parameters.…”

A Checklist for Performing Regional Nerve Blocks

“…This FDA recommendation notes that epidural hematoma with significant nerve injury remains a problem despite previous ASRA Guidelines for anticoagulation management. [22][23][24] This step also includes a suggestion to review drug allergies (based on common practice). The original proposal included a review of medical history and DNR status, which were removed based on feedback from the surveys.…”

Nationwide incidence of serious complications of epidural analgesia in the United States

“…The inci-dence of spinal hematoma in non-obstetric EA found in our study (18.5 per 100,000) is consistent with studies including large sample size, which have reported incidences of spinal hematoma in the range of 11-19 per 100,000 catheterizations. 6,12,33,34,36 Our estimates may be more precise (as reflected by the narrow CIs) probably because of our larger sample size. Of note, after excluding patients undergoing vascular procedures, the incidence of spinal hematoma in non-obstetric patients was 14.7 9 10 À5 (95% CI, 12.7 9 10 À5 to 17.0 9 10 À5 ).…”