Epidural Hematoma Following Lumbar Epidural Anesthesia: A case report / 대한마취과학회지

Epidural hematoma associated with epidural anesthesia is rare. We describe a case of a epidural hematoma after continuous epidural anesthesia and analgesia for arthroscopic patella shaving. Anesthesia was indudced with 8 ml lidocaine, 2.0% with epinephrine, 1:200,000 and surgery proceeded. When additional boluses of bupivacaine were administered later, aspiration of the epidural catheter still yielded no blood. At the end of the operation, an epidural infusion of 0.125% bupivacaine was done 2 ml/hr by two-day infusor. In the third postoperative day, the patient suffered from acute myocardial infarction and then heparin was infused. In the fourth postoperative day, she complained lumbar back pain and developed depressed dorsiflexion (Grade II) of great toe in left foot during the infusion of heparin. Sagittal MRI showed posterior thickened epidural hematoma along the segments of T12-L4. Despite the delayed laminectomy and decompression, which was performed six days after her initial operation, she had a good postoperative response, followed by a complete neurological recovery.

In Vitro Aprotinin Enhanced Anticoagulation Synergistically to Heparinized Blood on Thromboelastography / 대한마취과학회지

BACKGROUND: Aprotinin is a potent, nonspecific broad serine protease inhibitor. It's inhibitory effects on intrinsic pathway of coagulation cascade can augment anticoagulation by heparin. This study designed to demonstrate augmented anticoagulation of aprotinin to heparin contaminated blood on thromboelastography(TEG). METHODS: This study designed into two phases for 21 healthy volunteers undergoing elective opeation. The first phase study, it was for looking at TEG differences between blood treated with aprotinin 200 KIU and blood treated with heparin 0.05 unit and 0.1 unit per blood 1 ml. The second phase study was for looking at anticoagulation of aprotinin added by heparin 0.05 unit and 0.1 unit per blood 1 ml and their reversal added by optimal dose of protamine sulfate. RESULTS: The aprotinin treated blood showed only a prolonged reaction time. Blood treated with incremental dose of heparin showed longer reaction time and smaller alpha angle than TEGs of native blood. Aprotinin added to the heparin contaminated blood showed much longer reaction time and much less alpha angle when compared with TEGs of aprotinin or heparin treated blood. Depressed TEG pattern by the heparin and aprotinin mixture reversed back to the TEGs of blood treated with aprotinin when optimal dose of protamine added. CONCLUSIONS: Those results suggest that aprotinin administered in open cardiac surgery can augment the remained anticoagulation effect due to heparin even after first dose fo protamine after weaning of cardiopulmonary bypass. This is of clinically improtance to distinguish heparin related coagulopathy from heparin non related coagulopathy by thromboelastography.

Acute Pulmonary Hypertension Associated with Protamine Neutralization of Systemic Heparinization during Open Heart Surgery / 대한마취과학회지

Protamine sulfate, a strong polycationic polypeptide, combined with acidic heparin to form a neutral salt, eliminates the anticoagulating properties of heparin. Heparin reversal with protamine after cardiopulmonary bypass may complicate with adverse hemodynamic effects including systemic hypotension, decreased cardiac output, changes in systemic and pulmonary vascular resistances, anaphylaxis and noncardiogenic pulmonary edema. We recently observed a case of severe pulmonary vasoconstriction with right ventricular failure after protamine administration in 37-year-old woman with mitral stenosis who underwent mitral valvuloplasty. After uneventful termination of cardiopulmonary bypass, administration of protamine was associated with sudden elevation of pulmonary arterial pressure with profound right ventricular distension and systemic hypotension by which heparin-protamine reaction is suspected. After intravenous epinephrine infusion and cardiac massage, these changes were reversed. Although the mechanism of this protamine-heparin induced response is unclear, complement activation and thromboxane release may play a role in the development of pulmonary vasoconstriction.