Abstract Background and objectives Neuraxial hematoma is a rare complication of the epidural technique which is commonly used for high quality postoperative pain relief. In case of urgent initiation of multiple antithrombotic therapy, the optimal timing of epidural catheter removal and need for treatment modification may be quite challenging. There are no specific guidelines and published reports are scarce. Case report We present the uneventful removal of an indwelling epidural catheter in a patient who was put on emergency triple antithrombotic treatment with Low Molecular Weight Heparin (LMWH), aspirin and clopidogrel in the immediate postoperative period, due to acute coronary syndrome. In order to define the optimal conditions and timing for catheter removal, so as to reduce the risk of complications, various laboratory tests were conducted 3 hours after aspirin/clopidogrel intake. Standard coagulation tests revealed normal platelet count, normal prothrombin time and normal activated partial thromboplastin time, while Platelet Function Analysis (PFA-200) revealed abnormal values (increased COL/EPI and COL/ADP values, both indicating inhibition of platelet function). The anti-Xa level, estimated 4 hours after LMWH administration, was within therapeutic range. At the same time, Rotational Thromboelastometry (ROTEM) showed a relatively satisfactory coagulation status overall. The epidural catheter was removed 26 hours after the last dual antiplatelet dose and the next dose was given 2 hours after removal. Enoxaparin was withheld for 24 hours and was resumed after 6 hours. Neurologic checks were performed regularly for alarming signs and symptoms suggesting development of an epidural hematoma. No complications occurred. Conclusion Point-of-care coagulation and platelet function monitoring may provide a helpful guidance in order to define the optimal timing for catheter removal, so as to reduce the risk of complications. A case-specific management plan based on a multidisciplinary approach is also important.

Resumo Justificativa e objetivos: A previsão de laringoscopia difícil se baseia em testes que avaliam as características anatômicas da face e pescoço. Nosso objetivo foi identificar os testes mais precisos e propor modelo preditivo multivariado. Método: Estudo observacional prospectivo incluiu 1134 pacientes e avaliou no pré-operatório: Distância Tireomentoniana (DTM), Distância Esternomentoniana (DEM), razão Altura-Distância Tireomentoniana (A/DTM), Circunferência Cervical (CC), razão Circunferência Cervical-Distância Tireomentoniana (CC/DTM), Distância Hiomentoniana com a cabeça na Posição Neutra (DHM-PN) e em Extensão Máxima (DHM-EM), razão Distância Hiomentoniana com Cabeça em Extensão Máxima/Distância Hiomentoniana na posição Neutra (DHME/DHMN), Classe Mallampati (CML), Teste da Mordida do Lábio Superior (TMLS), Abertura da Boca (AB) e Extensão da Cabeça (EC). Grau Cormack-Lehane ≥ 3 foi definido como Laringoscopia Difícil. A sensibilidade, especificidade, valores preditivos positivo e negativo foram avaliados para todos os testes. A análise multivariada com regressão logística foi usada para criar modelos preditivos. Resultados: Um modelo incorporando CML, TMLS, EC, DHM-EM e CC/DTM demonstrou alta precisão prognóstica (x2(5) = 109,12, p < 0,001, AUC = 0,86, p < 0,001). A sensibilidade, especificidade e valor preditivo negativo foram 82,3%, 74,8% e 97,4%, respectivamente. Um segundo modelo incluindo duas medidas que não necessitavam da cooperação do paciente (CC/DTM e DHM-EM) demonstrou bom desempenho prognóstico (x2 (2) = 63,5; p < 0,001; AUC = 0,77, p < 0,001). Entre os testes individuais, EC teve a maior sensibilidade (78,5%) e valor preditivo negativo (96%). Conclusões: O modelo de cinco variáveis incorporando CML, TMLS, EC, DHM-EM e CC/DTM mostrou valor preditivo satisfatoriamente alto para laringoscopia difícil. Um modelo que incluísse CC/DTM e DHM-EM poderia ser útil em pacientes com incapacidade. O preditor individual mais preciso foi EC.

Abstract Background and objectives: The prediction of difficult laryngoscopy is based on tests that assess anatomic characteristics of face and neck. We aimed to identify the most accurate tests and propose a multivariate predictive model. Methods: This prospective observational study included 1134 patients. Thyromental Distance (TMD), Sternomental Distance (STMD), Ratio of Height-to-Thyromental Distance (R-H/TMD), Neck Circumference (NC), Ratio of Neck Circumference-to-Thyromental Distance (R-NC/TMD), Hyomental Distance with head in Neutral Position (HMD-NP) and at Maximal Extension (HMD-HE), Ratio of Hyomental Distance at Maximal head extension-to-hyomental distance in neutral position (R-HMD), Mallampati Class (MLC), Upper Lip Bite Test (ULBT), Mouth Opening (MO) and Head Extension (HE) were assessed preoperatively. A Cormack-Lehane Grade ≥ 3 was defined as Difficult Laryngoscopy. Sensitivity, specificity, positive and negative predictive values were assessed for all tests. Multivariate analysis with logistic regression was used to create the predictive models. Results: A model incorporating MLC, ULBT, HE, HMD-HE and R-NC/TMD showed high prognostic accuracy; x2(5) = 109.12, p < 0.001, AUC = 0.86, p < 0.001). Its sensitivity, specificity and negative predictive value were 82.3%, 74.8% and 97.4%, respectively. A second model including two measurements not requiring patient's cooperation (R-NC/TMD and HMD-HE) exhibited good prognostic performance; x2(2) = 63.5, p < 0.001, AUC = 0.77, p < 0.001. Among single tests, HE had the highest sensitivity (78.5%) and negative predictive value (96%). Conclusions: A five-variable model incorporating MLC, ULBT, HE, HMD-HE and R-NC/TMD showed satisfyingly high predictive value for difficult laryngoscopy. A model including R-NC/TMD and HMD-HE could be useful in incapable patients. The most accurate single predictor was HE.