1. Table 1 Patient demographics & operative details
Postoperative coagulation profiles following liver resection and the use of epidural anaesthesia
L. Kelliher, C. Jones, A. Fletcher, M. Dickinson, M. Scott, N. Quiney
Royal Surrey county NHS Foundation Trust, Guildford, UK
RESULTS
INTRODUCTION
The use of epidural anaesthesia and analgesia for open liver resection is an established practice [1]. A recent review on this subject highlighted concerns over the safety of epidural usage in this context with regard to the coagulopathy often seen following this type of surgery and the potentially increased risk of epidural haematoma formation [2]. The aim of this study was to characterise the coagulation abnormalities that occur following liver resection.
METHODOLOGY
The study was conducted between March 2011 and May of 105 patients assessed for suitability were followed-up.
All patients received a standardised anaesthetic induction. Anaesthesia was maintained with sevoflurane, together with intravenous remifentanil, phenylephrine (to maintain mean arterial blood pressure above 55 mmHg) and glyceryl trinitrate (to maintain central venous pressure at
0–2 mmHg).
A thoracic epidural (between T6 & T10) was placed in all patients and commenced at the start of the operation. It was subsequently managed by the acute pain and anaesthetic teams. Surgery was performed by 1 of 3 consultant hepatobiliary surgeons. Perioperative fluid was witheld until after the liver resection was completed.
Blood samples were taken pre-operatively, immediately postoperatively and on postoperative days one, two, three and four and analysed for platelet count, INR and APTTR.
Figure 1. Mean peri-operative values for Platelet count following liver resection
Figure 2. Mean peri-operative values for INR & APTTR following liver resection
CONCLUSIONS
The findings of this study are consistent with earlier work conducted in our department [3] and indicate that the post-operative coagulopathy is most profound between days two and three following surgery. Despite this there were no complications and the majority of patients had their epidural catheters removed by day four. This study contributes further evidence that, properly managed, the use of epidural anaesthesia for liver resection is safe.
Table 1 Patient demographics & operative details
Number of patients 92
Age *
63.7 (12.3)
Sex (% Male)
60.4
ASA Grade*
2.1
P-POSUM
Physiological score *
16.6 (3.5)
Operative severity score *
18.3 (4.4)
Number of patients receiving operation type
Major Resection
(>3 segments) 33
Minor Resection 58
Median blood loss (ml) 1
341 ( )
Number of patients requiring blood products
Blood 10
FFP 4
Platelets 1
Cryoprecipitate 2
Post-operative day of epidural removal *
2.9 (1.1)
*Mean values (SD) and 1Median (interquartile range). ASA, American Society of Anesthesiologists; P-POSSUM, Portsmouth modification of the Physiological and Operative Severity Score for the EnUmeration of Mortality and morbidity.
REFERENCES
1. Page A, Rostad B, Staley CA, et al. Epidural analgesia in hepatic resection. Journal of the American College of Surgeons 2008; 206:
2. Tzimas P, Prout J, Papadopoulos G, Mallett SV. Epidural anaesthesia and analgesia for liver resection. Anaesthesia 2013; 68:
3. Patel A, Quiney N, Fawcett W. Perioperative coagulation changes following hepatic resection surgery and consequent thoracic epidural risk. European Journal of Anesthesiology 2006;23:88A-335
ETHICS
Ethics approval sought and granted by Surrey Research & Ethics Committee
ISRCTN