This document discusses the rare but devastating complication of epidural hematomas from neuraxial blocks. It focuses on the risk from clopidogrel, a drug that inhibits platelet aggregation. While the exact risk is unknown, guidelines recommend stopping clopidogrel 7 days before a procedure. The case report describes an 80-year-old woman who developed a T12/L1 epidural hematoma after inadvertently being given a clopidogrel dose 48 hours before her epidural was removed. Her neurology was not recovered despite a delayed diagnosis and treatment.

1. Clopidogrel & epidurals Dr John Zois

2. Epidural Haematomas Rare but devastating complication of Neuraxial blocks Irreversible Neurology if evacuation not performed within 6-12hrs post Sx Onset Exact Risk Uknown due to rarity ?1:150,000 Epidurals ?1:220,000 Spinals

3. Clopidogrel Pharmacology A Thienopyridine, increasingly used for prevention of vascular events in pts with established IHD Selectively & Irreversibly blocks Platelet P2Y12 ADP Receptor -> Inhibits PLT aggregation Max effect with 75mg dose @ 3-7/7 Bleeding time increases 2x, returns to normal @10/7 Use with aspirin for synergistic effects

4. ASRA Guidelines (American society of Regional anaesthesia) Convened 2004 to form consensus on Neuraxials & Anticoagulation Exact risk of Haematoma with antiplatelet agents is unknown No accepted lab test to determine bleeding risk Recommend 7/7 cessation of Clopidogrel, 14/7 of Ticlopidine

5. Case report BJA-Dec 2005 80y F post TKR -Pt normally on clopidogrel 75mg daily. Ceased 7/7 prior to surgery. -Deltaparin 5000SC night prior to surgery (10hrs prior) as DVT prophylaxis -Atraumatic Lumbar CSE

6. Case report D0 -Complained of lumbar back pain D1- Inadvertently administered single dose of clopidogrel Physio noted numbness + weakness of NON operated leg and attributed to epidural analgesia

7. Case report D3 -Epidural removed (48hrs post clopidogrel dose) with neurology still present. Again attributed to persistent epidural block. Neurosurg eventually consulted but 48hr delay until transfer to MRI capable centre

8. Case report MRI= T12/L1 Haematoma Neurology never recovered.

9. Discussion.. VCCAMM on Epidural haematomas - Incidence higher than initially thought Concern over frequently delayed diagnosis Need to increase cessation period of clopidogrel to 10/7 pre op? Remove Epidural immediately post inadvertent antiplatelets given delayed onset of action?