Case ReportCase Report of a Massive Thigh Hematoma afterAdductor Canal Block in a Morbidly Obese WomanAnticoagulated with Apixaban

Katherine L. Koniuch , Bradley Harris, Michael J. Buys, and AdamW.Meier

University of Utah Department of Anesthesiology, USA

Correspondence should be addressed to Katherine L. Koniuch; kate.koniuch@hsc.utah.edu

Received 30 April 2018; Accepted 2 August 2018; Published 13 August 2018

Academic Editor: Ehab Farag

Copyright © 2018 Katherine L. Koniuch et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Hematoma formation after peripheral nerve block placement is a rare event. We report a case of a morbidly obese patient whowas anticoagulated with apixaban and developed a massive thigh hematoma after an ultrasound-guided adductor canal block.Despite continuous visualization of the block needle, an unrecognized vascular injury occurred leading to a 14-cm hematomain the anterolateral thigh. Morbid obesity warrants additional risk consideration when placing nerve blocks in an anticoagulatedpatient. In addition, early recognition and expert consultation are both important in the management of block-related hematomas.

1. Introduction

Peripheral nerve blocks provide effective postoperative anal-gesia for extremity surgeries [1] and have been associatedwithfew complications [2]. Inmorbidly obese patients taking anti-coagulants near the time of surgery, there may be increasedrisk of bleeding or hematoma formation which should beconsidered based on the 2018 American Society of RegionalAnesthesia (ASRA) guidelines for Regional Anesthesia in thePatient Receiving Antithrombotic or Thrombolytic Therapy[3]. In this case report, we describe a morbidly obese patienttaking apixaban whose postoperative course was compli-cated by a massive thigh hematoma that developed after anadductor canal block. We detail the factors that may havecontributed to this complication, how it could have beenavoided, and how the hematoma was managed.

2. Case Description

The patient involved provided written consent for reportingof this case.

A 63-year-old woman with medical history of supermorbid obesity (BMI 54) and atrial fibrillation for whichshe was anticoagulated with apixaban presented for an open

reduction internal fixation (ORIF) of an ankle fracture.Significant medical history included diabetes mellitus type2, obstructive sleep apnea, chronic obstructive pulmonarydisease, and diastolic heart failure. The patient’s last dose ofapixaban was 48 hours prior to surgery. Other than moderateanemia (hemoglobin 8.8 g/dL), all laboratory studies, includ-ing a coagulation profile, were normal.

Prior to surgery, the patient was offered a sciatic nervecatheter and an adductor canal block as part of a multimodalpostoperative analgesia strategy. Because of hermany, seriousmedical conditions, we concluded that a peripheral nerveblock offered the best opportunity to provide satisfactorypostoperative analgesia. Specifically, we were concerned thatthe postoperative pain management primarily with opioidmedications would pose increased cardiopulmonary risk tothe patient. We were careful to explain the risks associatedwith peripheral nerve blocks, including the risk of bleedingand hematoma formation, and verbal consent was obtained.

The surgery was performed under general anesthesia andher intraoperative course was uncomplicated. Upon arrivalto the recovery room, our acute pain service was contactedto evaluate her for peripheral nerve blockade. We positionedthe patient in the lateral decubitus position and placed asciatic nerve catheter. Though technically challenging due

HindawiCase Reports in AnesthesiologyVolume 2018, Article ID 7653202, 4 pageshttps://doi.org/10.1155/2018/7653202

2 Case Reports in Anesthesiology

to body habitus, this sciatic nerve block was performedsuccessfully and without any complication. The patient wasthen positioned supine for the adductor canal block. The legwas externally rotated and the knee slightly flexed for opti-mal positioning. A high-frequency linear array ultrasoundtransducer was applied to the mid-thigh in short-axis and theadductor canal was identified. Imaging was again challenginggiven the patient’s habitus, but with firm compression of theultrasound transducer, the important anatomical structureswere clearly identified. The superficial femoral artery (SFA)was visualized dorsal to the sartorius muscle and a hypere-choic structure anterolateral to the artery was identified asthe adductor canal and saphenous nerve [4, 5]. The skinadjacent to the probe was cleansed with a chlorhexidine andalcohol solution. A 20-gauge × 4-inch beveled, echogenicneedle was inserted using an in-plane technique. The needlewas visualized continuously as it coursed between the vastusmedialis and sartorius toward the adductor canal. The needlewas positioned lateral to the SFAwithin the canal and a bolusof 20 ml of 0.25% bupivacaine with 5 mcg/ml epinephrinewas administered with negative heme aspiration checks afterevery 5 ml injection. Spread of local anesthetic within theadductor canal was clearly observed under ultrasound visu-alization. There was no evidence of intravascular injectionof epinephrine while monitoring the patient. Upon needlewithdrawal, brisk bleeding was noted at the skin insertionsite but with direct manual pressure for approximately 60seconds, bleeding ceased completely.

Shortly after the blocks were performed, the patientreported complete resolution of her ankle pain and wastransferred to her hospital room. Approximately 6 hoursafter surgery, the patient reported new anterior thigh painon the operative leg, which was treated by her nurse withintravenous hydromorphone. Roughly 13 hours after surgery,the patient’s nurse finally contacted the orthopedic surgeryteam due to unmanageable mid-thigh pain. The orthope-dics team initially believed the pain was due to tourniquetcompression pain which occurred during surgery. Uponfurther physical examination, a hematoma was noted inthe anterolateral mid-thigh. Vital signs were within normalranges and distal pulses were intact. A CT scan with contrastwas ordered and revealed a 14-cm hematoma in the rightthigh (Figure 1). Lab studies showed a drop in hemoglobinfrom 8.8 g/dL preoperatively to 6.9 g/dL the morning ofpostoperative day (POD) 1. Coagulation studies at that timewere within normal limits including partial thromboplastintime, prothrombin time, and international normalized ration,as well as platelet count. The patient’s primary medicineservice transfused 1 unit of packed red blood cells, whichimproved her hemoglobin to 7.6 g/dL.

Interventional radiologywas consulted on themorning ofPOD 1 formanagement recommendations for the hematoma.A CT angiogram was performed revealing active extravasa-tion from a small superficial branch of the SFA (Figure 2).Embolization with coil and gel foam was performed andcompressive dressings were used to apply direct pressure.Throughout the day, the patient’s hemoglobin remainedstable and the hematoma showed no evidence of furtherexpansion.

Figure 1: CT of the patient’s right thigh showing the superficialfemoral artery (A) and 5 × 14 cm hematoma (B).

Figure 2: CT angiogram of the patient’s right thigh showing thesuperficial femoral artery (A) and active extravasation from a smallbranch of the SFA (B).

OnPOD2, further consultation from the vascular surgeryand interventional radiology teams was sought for possiblehematoma evacuation versus drain placement given themassive size. Vascular surgery recommended conservativemanagement with application of direct pressure. Interven-tional radiology, however, recommended placement of adrain within the hematoma. A pigtail catheter was placed andfluid cultures were obtained. Minimal output from the drainwas observed, so beginning on POD 3, tissue plasminogen

Case Reports in Anesthesiology 3

activator (TPA) was administered through the catheter dailyto facilitate hematoma drainage. Follow-up ultrasound onPOD 6 showed a persistent hematoma despite TPA admin-istration. Hematoma cultures resulted negative for infection.On POD 7, she was discharged to a rehabilitation facilitywith the drain in place and care team instructions to flush5-10ml saline twice daily until evaluation with interventionalradiology one week later.

On POD 14, the drain was inadvertently pulled outrequiring a return visit to interventional radiology and drainreplacement. OnPOD 19, the hematoma cavity had decreasedto an acceptable size so the drain was removed. One weeklater, on POD 26, she returned to interventional radiologydue to increased pain and swelling at the hematoma site. Arecurrent fluid collection was noted on ultrasound exami-nation so the drain was replaced a third time and aspiratedfluid was sent for culture, which grew staphylococcus aureus.She was treated for hematoma superinfection with a five-day course of levofloxacin and when she returned twoweeks later, the abscess had resolved and the drain wasremoved.

3. Discussion

This case demonstrates important points regarding regionalanesthesia in an anticoagulated, morbidly obese patient.First, morbid obesity represents an additional risk factorwhen considering a superficial peripheral nerve block onan anticoagulated patient. Second, there is a paucity of casereports detailing the complication of hematoma formationdue to a peripheral nerve block. Third, the subsequentmanagement of the hematoma after peripheral nerve block isnot well reported in the literature and presents a considerablechallenge, especially in patients with multiple comorbidities.

Peripheral nerve blocks can provide excellent analgesiafor patients having ankle surgery [6]. In a morbidly obesepatient, a nerve block may significantly reduce the needfor opioid administration [7, 8]. This can provide greatbenefit for patients at risk for postoperative opioid-inducedhypoventilation. When considering the risks and benefits ofa nerve block for our patient, opioid reduction was a clearbenefit. Throughout her hospital course, she never receivedopioids for ankle pain while nerve blocks were in effect. Thuswe believe there was a clear analgesic benefit to regionalanesthesia.

For this patient, however, the risk of bleeding due toher anticoagulation status was also concerning. Althoughvascular injuries resulting from peripheral nerve blocks arerare complications [2, 7, 9, 10], this case demonstrates thesignificant morbidity that may occur. The recently updated(2018) ASRA guidelines recommend “management basedon site compressibility, vascularity, and consequences ofbleeding.” [3] While an adductor canal block is consideredto be superficial, we feel it is more appropriately categorizedas a deep block in a morbidly obese patient because com-pressibility is more difficult if inadvertent vascular puncturewere to occur. In addition, given the potential for massivebleeding into the thigh, additional consideration shouldbe made for procedures on the upper leg. Anticoagulation

recommendations for deep peripheral blocks are the sameas neuraxial techniques—the ASRA guidelines recommendwaiting 72 hours after the last dose of apixaban for blockplacement [3]. Although it had only been 48 hours sinceour patient’s last dose, we felt the benefit of opioid reductionwould outweigh the risk of vascular injury or significantbleeding.

In this case, the anesthesiologist performing the adduc-tor canal block was an experienced regional anesthesi-ology fellow who had performed adductor canal blocksin this same manner many times before. A fellowship-trained regional anesthesiologist supervised the nerve blockplacement. Direct visualization of the needle and of theneurovascular structures was uninterrupted. We believe thevascular injury likely occurred when the needle passedthrough the superficial branch of SFA as the ultrasound probewas compressing it. This small branching artery was neverrecognized on ultrasound imaging. Although the vascularinjury may not have been easily avoided regardless of thepatient’s coagulation status, waiting an additional 24 hours toperform the block (72 hours after her last apixaban dose) mayhave decreased the extent of hematoma formation. While thismay havemade no difference in her clinical outcome, perhapsit can be used to better guide risk versus benefit discussionsin morbidly obese patients who are anticoagulated beforereceiving a peripheral nerve block.

Another factor that contributed to the significant mor-bidity in this case was the management of the hematomaafter it was recognized. The patient underwent multipleprocedures to drain the hematoma and required return tothe hospital for drain replacement, and ultimately her coursewas complicated by an infection of the hematoma cavity.Despite a thorough literature search, we were unable to findclear recommendations as to the management of extremityhematomas. We believe that a more conservative approachof close monitoring instead of drain placement would haveresulted in an acceptable outcome without additional proce-dures, increased cost, a prolonged hospital stay, and increasedrisk of infection.

Disclosure

Katherine L. Koniuch is first author. Bradley Harris andMichael J. Buys are coinvestigators. Adam W. Meier isprincipal investigator.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Authors’ Contributions

Katherine L. Koniuch wrote, edited, and submitted this arti-cle. Bradley Harris and Michael J. Buys helped in compilingand editing this article. AdamW. Meier helped in compiling,editing, and submitting this article.

4 Case Reports in Anesthesiology

References

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[2] T. Huo, L. Sun, S. Min et al., “Major complications of regionalanesthesia in 11 teaching hospitals of China: a prospectivesurvey of 106,569 cases,” Journal of Clinical Anesthesia, vol. 31,pp. 154–161, 2016.

[3] T. T. Horlocker, E. Vandermeuelen, S. L. Kopp, W. Gogarten, L.R. Leffert, andH. T. Benzon, “Regional Anesthesia in the PatientReceiving Antithrombotic orThrombolytic Therapy: AmericanSociety of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition),” Regional Anesthesia andPain Medicine, vol. 43, no. 3, pp. 263–309, 2018.

[4] J. Lund, M. T. Jenstrup, P. Jæger, A. M. Sørensen, and J.B. Dahl, “Continuous adductor-canal-blockade for adjuvantpost-operative analgesia after major knee surgery: Preliminaryresults,” Acta Anaesthesiologica Scandinavica, vol. 55, no. 1, pp.14–19, 2011.

[5] N. A. Hanson, C. J. Allen, L. S. Hostetter et al., “Continuousultrasound-guided adductor canal block for total knee arthro-plasty: a randomized, double-blind trial,” Anesth & Analg, vol.118, no. 6, pp. 1370–1377, 2014.

[6] P. F. White, T. Issioui, G. D. Skrivanek, J. S. Early, and C.Wakefield, “The Use of a Continuous Popliteal Sciatic NerveBlock After Surgery Involving the Foot and Ankle: Does ItImprove the Quality of Recovery?” Anesthesia & Analgesia, vol.97, no. 5, pp. 1303–1309, 2003.

[7] X. Capdevila, P. Pirat, S. Bringuier et al., “Continuous peripheralnerve blocks in hospital wards after orthopedic surgery: amulticenter prospective analysis of the quality of postoperativeanalgesia and complications in 1,416 patients,” Anesthesiology,vol. 103, no. 5, pp. 1035–1045, 2005.

[8] J. R. Soberon, C. McInnis, K. S. Bland et al., “Ultrasound-guided popliteal sciatic nerve blockade in the severely andmorbidly obese: a prospective and randomized study,” Journalof Anesthesia & Clinical Research, vol. 30, no. 3, pp. 397–404,2016.

[9] C. W. Njathi, R. L. Johnson, R. S. Laughlin, D. R. Schroeder,A. K. Jacob, and S. L. Kopp, “Complications after ContinuousPosterior Lumbar Plexus Blockade for Total Hip Arthroplasty:A Retrospective Cohort Study,” Regional Anesthesia and PainMedicine, vol. 42, no. 4, pp. 446–450, 2017.

[10] T. C. Stan, M. A. Krantz, D. L. Solomon, J. G. Poulos, andK. Chaouki, “The incidence of neurovascular complicationsfollowing axillary brachial plexus block using a transarterialapproach: A prospective study of 1,000 consecutive patients,”Regional Anesthesia, vol. 20, no. 6, pp. 486–492, 1995.

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