Managing a Patient with a Suspected Epidural Haematoma

1. Epidural haematomas or abscesses are rare but catastrophic.  Early evacuation (within 12 hours of initial presentation) is required to maximise the chance of recovery, so it is essential to take seriously any concerns over neurological deficit during or immediately after an epidural infusion.
2. The pain team should be contacted if it is within their working hours and will be able to give advice.  Outside of their working hours the responsibility for pain issues falls to the on-call anaesthetic trainee, who can turn to their on-call consultant for further advice as necessary Useful Contact Details within OUH.
3. Provide alternative analgesia while epidural infusion is off.  A morphine PCA ( Starting a PCA) is likely to be most appropriate.  Use bolus only: do not add a background as this could increase the risk of opioid toxicity in view of the persisting opioid effects of the fentanyl in the epidural infusate.
4. Repeat the Bromage Score ( Bromage Score - to Assess Leg Weakness with Epidural) every 30 minutes and formally reassess the patient at 2 hours.

 In most cases the motor block will have completely resolved, indicating a patient’s sensitivity to the 0.1% bupivacaine.  The options are now:

a) restart the epidural infusion at a lower rate to see if analgesia can be re-established without leg weakness

b) accept that leg weakness is likely if the epidural is restarted but that good epidural analgesia is necessary for recovery

c) abandon the epidural and continue with intravenous PCA ( Starting a PCA).

 The patient is likely to have a view particularly if they found the leg weakness distressing, so discuss the options with them and come to a joint conclusion.  Document the improved Bromage Score (Bromage Score - to Assess Leg Weakness with Epidural ) in the notes and the discussion with the patient.  If option b) is chosen and leg weakness recurs it is important to stop the epidural again in 12 to 24 hours to ensure that motor function continues to return to normal.

 If there has NOT been resolution of motor function, start to organise an urgent MRI scan ( Arranging an MRI for a Suspected Epidural Haematoma) which can take time to arrange. 

Review the patient again at 3 hours (as the bupivacaine should have worn off completely by then): 

 If there has been improvement and the patient no longer has leg weakness, stand the MRI scan down as it is no longer needed, and consider options a,b or c as above. 

 If there has still been no improvement, go ahead with the urgent MRI scan ( Arranging an MRI for a Suspected Epidural Haematoma).

         5. The risk of epidural abscess increases after 3 days, so our trust policy is that patients cannot continue with epidural analgesia after 4 days.  There are very rare exceptions to this where the pain team only decide to continue until day 5.