Prevalence and Risk Factors Predisposing to Coagulopathy in Patients Receiving Epidural Analgesia for Hepatic Surgery

Abstract

Patients undergoing liver resection may have marginal preoperative liver function, extensive intraoperative blood loss, and perioperative hepatic dysfunction. We evaluated the prevalence and types of coagulopathic conditions that occur in patients with epidural catheters undergoing hepatic resection. A retrospective chart review was conducted of all patients undergoing hepatic surgery who received epidural analgesia between June 1995 and September 2003 at our institution. Forty-nine surgical cases had an epidural catheter placed preoperatively. Data were collected included age, weight, American Society of Anesthesiologists physical status; preoperative partial thromboplastin time (PTT), international normalized ratio (INR), and platelet count (PLT); estimated blood loss (EBL); and volume of hepatic resection. Forty-nine cases received an epidural catheter before hepatic resection. Preoperative PTT, INR, and PLTs were within reference ranges in 47 of 49 patients. Twenty-three (47%) of 49 patients were coagulopathic in the postoperative period. The most common abnormality was an INR greater than 1.4 in 16 patients. Nine patients had a PLT of less than 100,000/microL, and 4 patients had a PTT of greater than 40 secs. Patients who developed a hemostatic abnormality were likely to have greater median EBL (400 vs 1400 mL; Mann-Whitney = 100.5, P = 0.0004) and have a greater median volume of liver resected (166 vs 1688 cm; Mann-Whitney = 57.0, P = 0.0004). There was no causal relationship to preoperative laboratory values, age, weight, or American Society of Anesthesiologists classification. A high prevalence of hemostatic abnormalities in patients undergoing major hepatic resection while receiving epidural analgesia occurred. Important considerations may include discussion with the surgical team, measuring coagulation, and heightened clinical monitoring in the postoperative period.