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Retroperitoneal haematoma in a patient with continuous psoas compartment block and enoxaparin administration for total knee replacement

2009; Elsevier BV; Volume: 103; Issue: 2 Linguagem: Inglês

10.1093/bja/aep189

1471-6771

Mario Dauri, S. Faria, Ludovica Celidonio, Umberto Tarantino, Eleonora Fabbi, Alessandro Sabato,

Spinal Hematomas and Complications

Editor—Psoas haematoma has been previously reported,1Aveline C Bonnet F Delayed retroperitoneal haematoma after failed lumbar plexus block.Br J Anaesth. 2004; 93: 589-591Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar, 2Klein SM D’Ercole F Greengrass RA Warner DS Enoxaparin associated with psoas hematoma and lumbar plexopathy after lumbar plexus block.Anesthesiology. 1997; 87: 1576-1579Crossref PubMed Scopus (119) Google Scholar, 3Weller RS Gerancher JC Crews JC Wade KL Extensive retroperitoneal hematoma without neurologic deficit in two patients who underwent lumbar plexus block and were later anticoagulated.Anesthesiology. 2003; 98: 581-585Crossref PubMed Scopus (121) Google Scholar but the overall incidence of this rare complication is not clear. We describe a retroperitoneal haematoma without lumbar neuropathy after continuous psoas compartment block (CPCB), in a 77-yr-old man who underwent total knee replacement (TKR) and was treated with enoxaparin for a deep venous thrombosis (DVT). For the surgery, the anaesthetist performed an L2–3 spinal block injecting ropivacaine 5 mg ml−1 (2.5 ml) and a CPCB using the Winnie and colleagues’4Winnie AP Ramamurthy S Durani Z Radonjic R Plexus blocks for lower extremity surgery: new answers to old problems.Anesthesiol Rev. 1974; 1: 11-16Google Scholar landmarks. This required several attempts before obtaining quadriceps femoris contractions, and continuous aspiration for blood was negative. A total of ropivacaine 5 mg ml−1 (25 ml) and clonidine 30 µg were injected through the needle and the catheter, and an infusion of ropivacaine 2 mg ml−1 at 8 ml h−1 rate was begun for postoperative analgesia. The surgery was uneventful with the patient awake, using standard monitoring. The first dose of enoxaparin 4000 UI was given 10 h after perineural catheter placement. On the first postoperative day (POD), a Doppler study showed thrombosis of the right tibial posterior vein. Elastic-compressive stockings had been worn by the patient and enoxaparin 4000 UI was given twice a day. The perineural catheter was removed on the second POD, 12 h after the last enoxaparin dose, and the subsequent dose was administered 3 h after the catheter removal. On the fourth POD, the patient complained of left iliac fossa pain without sensory-motor deficit. The patient’s condition was stable and a computed tomography (CT) scan diagnosed a 15×12 cm haematoma of the left psoas muscle (Fig. 1). Laboratory exam: leucocyte count 14.3×103, erythrocyte 2.9×106, Hb 8.6 g dl−1, and Ht 26%. All the other biochemical measurements were within the normal range. The patient was continuously monitored, enoxaparin was discontinued, and antibiotic therapy was prescribed. By the fifth POD, the general condition was stable, the CT with contrast scan of abdomen and pelvis re-confirmed the haematoma, and a full blood count reported erythrocyte 2.15×106, Hb 6.4 g dl−1, and Ht 19%. Four units of concentrate red blood cells were transfused. Over the following days, the patient’s general condition was improving and psoas haematoma was progressively reducing. Enoxaparin 4000 UI once a day was recommenced on the 18th POD for treatment of the DVT. The patient was discharged on the 25th POD and a CT scan performed 2 weeks after hospital discharge showed almost complete resorption of the haematoma. Other authors reported renal subcapsular5Aida S Takahashi H Shimoji K Renal subcapsular hematoma after lumbar plexus block.Anesthesiology. 1996; 84: 452-455Crossref PubMed Scopus (118) Google Scholar or psoas haematoma1Aveline C Bonnet F Delayed retroperitoneal haematoma after failed lumbar plexus block.Br J Anaesth. 2004; 93: 589-591Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar 2Klein SM D’Ercole F Greengrass RA Warner DS Enoxaparin associated with psoas hematoma and lumbar plexopathy after lumbar plexus block.Anesthesiology. 1997; 87: 1576-1579Crossref PubMed Scopus (119) Google Scholar after several attempts at placing a PCB block. Both Winnie and colleagues4Winnie AP Ramamurthy S Durani Z Radonjic R Plexus blocks for lower extremity surgery: new answers to old problems.Anesthesiol Rev. 1974; 1: 11-16Google Scholar and Chayen and colleagues6Chayen D Nathan H Chayen M The psoas compartment block.Anesthesiology. 1976; 45: 95-99Crossref PubMed Scopus (210) Google Scholar described needle insertion at fixed distance from iliac crest line and the vertebral column. Capdevila and colleagues7Capdevila X Macaire P Dadure C et al.Continuous psoas compartment block for postoperative analgesia after total hip arthroplasty: new landmarks, technical guidelines, and clinical evaluation.Anesth Analg. 2002; 94: 1606-1613Crossref PubMed Google Scholar proposed a point ‘1 cm cephalad from the point at the junction of the lateral third and medial two-thirds of a line between the spinous process of L4 and a line parallel to the spinal column passing through the posterior superior iliac spine’. Since these landmarks take in consideration the anatomical dimension of the individual patient, they may be more precise and thus avoid multiple attempts at placement, but this hypothesis has not been studied. Although CPCB offers a more complete block of the thigh and knee,8Touray ST de Leeuw MA Zuurmond WW Perez RS Psoas compartment block for lower extremity surgery: a meta-analysis.Br J Anaesth. 2008; 101: 750-760Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar no clinical evidence on better analgesia is reported in comparison with continuous femoral nerve block after major knee surgery. We suggest that it be a more reasonable and less risky analgesia technique than CPCB after major knee surgery.