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Intra-operative crises05 / 21

Leg weakness with a thoracic epidural56-year-old man, 78 kg, day 4 after open right hemicolectomy

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Know this first

  • Motor block should fade within about 2 h of stopping the infusion; if not, think haematoma, abscess or catheter migration.
  • Risk factors for neuraxial infection: immunosuppression, diabetes, systemic infection, long catheter time.
  • MRI first; CT if MRI isn't immediately available.
  • Best recovery if decompression is within 8–12 h of symptom onset.

The patient

56-year-old man, 78 kg, day 4 after open right hemicolectomy, with a T9–10 epidural infusion running. Renal transplant 6 years ago. Takes tacrolimus, mycophenolate, prednisolone 5 mg daily. Since this morning: back pain, fever 38.6 °C and weakness of both legs. Enoxaparin 40 mg daily, last dose 10 hours ago. Vitals: BP 136/80, HR 104, SpO2 96% on air, RR 18.

The examiner asks

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  1. Consider

    The ward calls about his legs. What concerns you?

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    • A 56-year-old immunosuppressed transplant patient, 4 days of epidural, now fever, back pain and weak legs. Patient
    • New weakness is never just the epidural; I assume something is compressing his cord. Disease
    • Abscess fits best: fever, immunosuppression and 4 days with a catheter in.
    • Haematoma stays on the list; he's on enoxaparin with the catheter in place.
    • Ischaemia of the cord is the third cause I keep in mind.
    • The clock runs: recovery is best if he's decompressed within 8–12 hours of onset. Stem trigger

  2. Prepare

    How do you assess him?

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    • Stop his epidural infusion now; a drug block should wear off within about 2 hours. (Disease)
    • Power, sensory level, bladder and bowel, and the catheter site for pus or tenderness.
    • Blood cultures before any antibiotic, plus blood count, CRP and clotting.
    • Urgent MRI of his thoracic spine; CT if MRI isn't available at once.
    • Neuro checks every hour while we wait, written down each time.

  3. Crisis

    MRI shows a dorsal epidural collection at T8–T10 compressing the cord. His power is getting worse. Your next steps?

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    • Epidural abscess compressing his cord: neurosurgery now, for decompression inside the 8–12-hour window. (Crisis)
    • Catheter out at 12 hours after his last enoxaparin; that's 2 hours from now.
    • Next enoxaparin no sooner than 4 hours after removal, timed with the surgeon.
    • Catheter tip and pus sent for culture.
    • IV antibiotics covering staphylococci, the commonest skin organism in epidural infection.
    • On prednisolone 5 mg, he takes his usual dose; he needs no extra steroid cover.

  4. Plan

    What else do you do?

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    • Hourly neuro checks after surgery, with a clear threshold to call neurosurgery back. (After surgery)
    • The transplant team reviews his immunosuppression and kidney function during the infection.
    • I tell him and his family the abscess came from his epidural, and document every neuro check.
    • Reported as a serious incident; we review why his catheter stayed 4 days despite immunosuppression.
    • Long epidural catheters carry more abscess risk in immunocompromised patients like him.

Fatal mistakes

  • Putting his leg weakness down to the epidural block.
  • Delaying his MRI.
  • No neurosurgical referral.

Checked against: Miller 10e · Barash 9e · Surviving Sepsis Campaign: international guidelines for sepsis and septic shock (2021)

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