Delayed Epidural Catheter Removal: The Impact of Postoperative Coagulopathy

Abstract

A retrospective analysis of 413 patients who received postoperative epidural analgesia under a standardized protocol found that 84 (20%) had a duration of epidural catheterization of greater than four days. The most common reasons were significant pain (n=64, 15%) and coagulopathy (n=26, 6%). Risk factor analysis for coagulopathy showed an odds ratio of 10.1 (95% confidence interval 4.2-24.5) for prolonged epidural catheterization among patients undergoing hepatectomy. Magnetic resonance imaging, performed in four patients with clinical signs suggestive of epidural haematoma, was negative for a space-occupying lesion in all cases. Eleven patients developed fever and clinical signs suggestive of epidural catheter-related infection, necessitating early catheter removal. Sixteen patients had persistent lower limb weakness at 24 hours after catheter removal. The signs soon resolved in all except two, one of whom had neuropathy related to intraoperative positioning and the other preoperative weakness. Accidental epidural catheter dislodgement occurred in 29 patients (7%) and is potentially hazardous if coagulopathy is unresolved. The riskbenefit ratio and factors complicating catheter removal, especially coagulopathy, should be considered when deciding whether to use epidural techniques.

Abnormal coagulation profile after hepatic resection: the effect of chronic hepatic disease and implications for epidural analgesia

“…In a retrospective study of 413 patients, 20% of patients had delayed catheter removal postsurgery; 30% of the delayed removal was attributed to coagulopathy, and the main risk for coagulopathy was hepatic resection [6].…”

“…However, the use of epidural analgesia postoperatively is limited in these patients by a decrease in coagulation factors, even in patients with a normal coagulation profile prior to surgery [4,5]. This may result in delayed removal of the epidural catheter, epidural hematomas, and abscesses [6].…”

“…Most studies to date on changes in the perioperative coagulation profile during hepatic surgery and epidural analgesia have not reported on chronic hepatic disease, defined as hepatic diseases of greater than 6 months' duration [5][6][7][8][9], or are limited by patient populations being restricted to healthy donors for donor hepatectomies [10][11][12][13]. However, patients with chronic hepatic diseases frequently require hepatic surgery, and hence are subject to the risks of abnormal postoperative coagulation profiles on epidural analgesia.…”

Live donor hepatectomy for liver transplantation in Egypt: Lessons learned

“…[7–10] Alternatively, a hypercoagulable profile can also result from diminished hepatic synthesis of anticoagulants, extensive tissue trauma and acute phase response. [1112]…”

Intestinal transplantation: The anesthesia perspective

“…The catheter may be kept for a longer time due to persistent pain or transient coagulopathy [38]. The incidence of epidural hematoma is 1:26,000 [39] and the risk of epidural abscess is 0.014% [40].…”