Superficial arterial hemorrhage after epidural catheter removal

      This case pertains to a parturient with a large-volume superficial arterial hemorrhage at the removal site of her epidural catheter, and the subsequent local injection of epinephrine that provided hemostasis. A 26-year-old female presented for anesthesia for a cesarean delivery. While previously healthy, her pregnancy was complicated by severe hyperemesis gravidarum, requiring hospitalization and a laparoscopic cholecystectomy at 25 weeks’ gestational age. Despite a lack of complications or excessive blood loss, her abdominal symptoms continued, necessitating hospitalization until delivery. At 32+1 weeks’ gestational age, she was scheduled for a cesarean delivery due to preeclampsia with severe features which included hypertension, liver transaminases double the normal limit, severe right upper-quadrant pain, and headache. She was deemed eligible for neuraxial anesthesia as >12 h had elapsed since her last prophylactic dose of enoxaparin (40 mg subcutaneously once daily). Laboratory tests on the morning of delivery showed a hemoglobin of 101 g/L and a platelet count of 195 × 109/L. Coagulation studies were not performed prior to delivery given no history of coagulopathy and in accordance with the American Society of Anesthesiologists Guidelines for Obstetric Anesthesia.
      • Practice Guidelines for Obstetric Anesthesia
      An updated report by the American Society of Anesthesiologists Task Force on obstetric anesthesia and the Society for Obstetric Anesthesia and Perinatology.
      She was given a combined spinal-epidural (CSE) anesthetic after a single midline insertion at the L3/4 level using a 18-gauge Tuohy epidural needle and a 27-gauge Pencan spinal needle (B. Braun Medical Inc., Bethlehem, PA, USA). A 20-gauge closed-end, side-fenestrated epidural catheter was threaded 5 cm into the epidural space and aspiration was negative for blood. The cesarean delivery was uncomplicated, reporting an estimated blood loss of 550 mL, and the epidural catheter was removed intact without any bleeding.
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