Co-existing liver disease increases the risk of postoperative thrombocytopenia in patients undergoing hepatic resection: implications for the risk of epidural hematoma associated with the removal of an epidural catheter

Takita, Kensuke; Uchida, Yoshiyuki; Hase, Tetsutaro; Kamiyama, Toshiya; Morimoto, Yuji

doi:10.1007/s00540-013-1776-4

Cited by 9 publications

(10 citation statements)

References 14 publications

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“…In hyperthyroidism the cystatin C level will increase and the creatinine level decrease without corresponding changes in GFR". factor deficiencies, but also imbalance between production and destruction of platelets, resulting in thrombocytopenia [73]. Reductions in both pro-and anti-coagulant factors seem to be able to balance each other, and platelet dysfunction is compensated, at least in part, by a concomitant increase in the von Willebrand factor [34,72].…”

Section: Estimate Glomerular Filtration Rate (Egfr) In Elderly Patienmentioning

confidence: 99%

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Reducing risk of spinal haematoma from spinal and epidural pain procedures

Breivik

Norum

Fenger-Eriksen

et al. 2018

Scandinavian Journal of Pain

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Abstract Background and aims: Central neuraxial blocks (CNB: epidural, spinal and their combinations) and other spinal pain procedures can cause serious harm to the spinal cord in patients on antihaemostatic drugs or who have other risk-factors for bleeding in the spinal canal. The purpose of this narrative review is to provide a practise advisory on how to reduce risk of spinal cord injury from spinal haematoma (SH) during CNBs and other spinal pain procedures. Scandinavian guidelines from 2010 are part of the background for this practise advisory. Methods: We searched recent guidelines, PubMed (MEDLINE), SCOPUS and EMBASE for new and relevant randomised controlled trials (RCT), case-reports and original articles concerning benefits of neuraxial blocks, risks of SH due to anti-haemostatic drugs, patient-related risk factors, especially renal impairment with delayed excretion of antihaemostatic drugs, and specific risk factors related to the neuraxial pain procedures. Results and recommendations: Epidural and spinal analgesic techniques, as well as their combination provide superior analgesia and reduce the risk of postoperative and obstetric morbidity and mortality. Spinal pain procedure can be highly effective for cancer patients, less so for chronic non-cancer patients. We did not identify any RCT with SH as outcome. We evaluated risks and recommend precautions for SH when patients are treated with antiplatelet, anticoagulant, or fibrinolytic drugs, when patients’ comorbidities may increase risks, and when procedure-specific risk factors are present. Inserting and withdrawing epidural catheters appear to have similar risks for initiating a SH. Invasive neuraxial pain procedures, e.g. spinal cord stimulation, have higher risks of bleeding than traditional neuraxial blocks. We recommend robust monitoring routines and treatment protocol to ensure early diagnosis and effective treatment of SH should this rare but potentially serious complication occur. Conclusions: When neuraxial analgesia is considered for a patient on anti-haemostatic medication, with patient-related, or procedure-related risk factors, the balance of benefits against risks of bleeding is decisive; when CNB are offered exclusively to patients who will have a reduction of postoperative morbidity and mortality, then a higher risk of bleeding may be accepted. Robust routines should ensure appropriate discontinuation of anti-haemostatic drugs and early detection and treatment of SH. Implications: There is an on-going development of drugs for prevention of thromboembolic events following surgery and childbirth. The present practise advisory provides up-to-date knowledge and experts’ experiences so that patients who will greatly benefit from neuraxial pain procedures and have increased risk of bleeding can safely benefit from these procedures. There are always individual factors for the clinician to evaluate and consider. Increasingly it is necessary for the anaesthesia and analgesia provider to collaborate with specialists in haemostasis. Surgeons and obstetricians must be equally well prepared to collaborate for the best outcome for their patients suffering from acute or chronic pain. Optimal pain management is a prerequisite for enhanced recovery after surgery, but there is a multitude of additional concerns, such as early mobilisation, early oral feeding and ileus prevention that surgeons and anaesthesia providers need to optimise for the best outcome and least risk of complications.

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Section: Estimate Glomerular Filtration Rate (Egfr) In Elderly Patienmentioning

confidence: 99%

“…Liver resection is followed by a decline in PLT and a rise in INR during the first postoperative days, despite normal values preoperatively [73,74]. Platelet transfusion should be considered at PLT <50 × 10 9 /L.…”

Section: Recommendationsmentioning

confidence: 99%

Reducing risk of spinal haematoma from spinal and epidural pain procedures

Breivik

Norum

Fenger-Eriksen

et al. 2018

Scandinavian Journal of Pain

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“…In our patient collective, neuraxial anesthesia was performed in accordance with the actual guidelines precluding patients with impaired coagulation or existing use of anticoagulants or antiplatelet drugs within certain time intervals prior surgery. Moreover, changes in coagulation profile including thrombocytopenia are frequently observed after liver resection due to perioperative blood loss or impairments of liver function [ 8 , 26 , 27 ]. Concerns about the risk of epidural hematoma or prolonged duration of indwelling catheters caused by coagulation derangements have been raised in this regard.…”

Section: Discussionmentioning

confidence: 99%

“…On the other hand, thoracic epidural anesthesia itself can cause complications. Especially in cirrhotic patients with impaired coagulation or in patients undergoing expanded liver resection, thoracic epidural anesthesia bears the risk of bleeding and epidural hematoma [ 8 – 10 ]. Only few studies investigated effects of thoracic epidural anesthesia on hospital length of stay and postoperative complications in patients undergoing liver surgery — and they revealed contrasting results [ 11 – 15 ].…”

Section: Introductionmentioning

confidence: 99%

Effect of thoracic epidural anesthesia on postoperative outcome in major liver surgery: a retrospective cohort study

Behem

Wegner

Pinnschmidt

et al. 2023

Langenbecks Arch Surg

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Purpose Postoperative complications after major liver surgery are common. Thoracic epidural anesthesia may provide beneficial effects on postoperative outcome. We strove to compare postoperative outcomes in major liver surgery patients with and without thoracic epidural anesthesia. Methods This was a retrospective cohort study in a single university medical center. Patients undergoing elective major liver surgery between April 2012 and December 2016 were eligible for inclusion. We divided patients into two groups according to whether or not they had thoracic epidural anesthesia for major liver surgery. The primary outcome was postoperative hospital length of stay, i.e., from day of surgery until hospital discharge. Secondary outcomes included 30-day postoperative mortality and major postoperative complications. Additionally, we investigated the effect of thoracic epidural anesthesia on perioperative analgesia doses and the safety of thoracic epidural anesthesia. Results Of 328 patients included in this study, 177 (54.3%) received thoracic epidural anesthesia. There were no clinically important differences in postoperative hospital length of stay (11.0 [7.00–17.0] vs. 9.00 [7.00–14.0] days, p = 0.316, primary outcome), death (0.0 vs. 2.7%, p = 0.995), or the incidence of postoperative renal failure (0.6 vs. 0.0%, p = 0.99), sepsis (0.0 vs. 1.3%, p = 0.21), or pulmonary embolism (0.6 vs. 1.4%, p = 0.59) between patients with or without thoracic epidural anesthesia. Perioperative analgesia doses — including the intraoperative sufentanil dose (0.228 [0.170–0.332] vs. 0.405 [0.315–0.565] μg·kg−1·h−1, p < 0.0001) — were lower in patients with thoracic epidural anesthesia. No major thoracic epidural anesthesia-associated infections or bleedings occurred. Conclusion This retrospective analysis suggests that thoracic epidural anesthesia does not reduce postoperative hospital length of stay in patients undergoing major liver surgery — but it may reduce perioperative analgesia doses. Thoracic epidural anesthesia was safe in this cohort of patients undergoing major liver surgery. These findings need to be confirmed in robust clinical trials.

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“…4,6,9,[19][20][21][22] This is a consequence of preoperative liver dysfunction (reflected by the Model for End-Stage Liver Disease (MELD) score), 19 the amount of tissue resected, blood loss, and intraoperative liver ischaemia. 14,23,24 Thoracic paravertebral block (PVB) has been used with several surgical procedures [25][26][27][28][29][30][31][32][33][34][35][36] including ablation of hepatic tumors 35 and hepatectomy. 36 Previous research suggests that advantages include haemodynamic stability, 37,38 low failure rate, 39 and a negligible risk of spinal haematoma.…”

Section: Introductionmentioning

confidence: 99%

Paravertebral vs. Epidural Analgesia for Liver Surgery (PEALS): Protocol for a randomized controlled pilot study

Mizubuti

Ho²,

DuMerton³

et al. 2022

F1000Res

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Background: Perioperative thoracic epidural analgesia (TEA) is commonly used in hepatectomy patients since it is opioid-sparing and reduces cardiorespiratory complications. However, TEA has a high failure rate and is associated with potentially devastating complications (particularly spinal haematoma) and the risk is likely increased with hepatectomy. Thus, some centres favour systemic opioid-based modalities which, in turn, are associated with inferior analgesia and well-known risks/side-effects. Hence, alternative analgesic methods are desirable. Paravertebral block (PVB) has been used in liver resection with advantages including hemodynamic stability, low failure rates, and low risk of spinal haematoma. Our purpose is to conduct a blinded, pilot RCT with hepatectomy patients randomised to receive TEA or PVB for perioperative analgesia. Our hypothesis is that opioid consumption, time to first analgesic request, and pain scores will be comparable between groups, but PVB patients will require fewer perioperative vasopressors/blood products, and have fewer adverse events and a shorter hospital stay. Methods: With ethics approval, this non-inferiority, pilot RCT with a convenience sample of 50 hepatectomy patients will examine whether PVB imparts analgesia comparable to TEA but with fewer adverse effects. Primary outcomes are surrogates of analgesia for 72 h postoperatively (i.e., opioid consumption, time to first analgesic request and pain scores at rest and with coughing); Secondary outcomes are blood products/fluids administered; side effects/complications until 72 h postoperatively; length of hospital stay. The results will be used to plan a large multicentre trial comparing TEA vs. PVB in hepatectomy patients. This study has a high potential to positively impact the quality/safety of patient care. ClinicalTrials.gov registration: NCT02909322 (09-21-2016); Available at URL: https://clinicaltrials.gov/ct2/show/NCT0290932

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Co-existing liver disease increases the risk of postoperative thrombocytopenia in patients undergoing hepatic resection: implications for the risk of epidural hematoma associated with the removal of an epidural catheter

Abstract: Hepatic resection can cause postoperative thrombocytopenia that may increase the potential risk of epidural hematoma associated with catheter removal, and the presence of co-existing liver disease heightens concerns for postoperative crucial thrombocytopenia.

Cited by 9 publications

References 14 publications

Reducing risk of spinal haematoma from spinal and epidural pain procedures

Reducing risk of spinal haematoma from spinal and epidural pain procedures

Effect of thoracic epidural anesthesia on postoperative outcome in major liver surgery: a retrospective cohort study

Paravertebral vs. Epidural Analgesia for Liver Surgery (PEALS): Protocol for a randomized controlled pilot study

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