The online version of this article (https://doi.org/10.1186/s13741-017-0070-7) contains supplementary material, which is available to authorized users.
Epidural anaesthesia and analgesia are indicated for oesophageal surgery. A rare but serious complication is spinal haematoma, which can occur on insertion, manipulation or withdrawal of catheters. Evidence and guidelines are vague regarding which tests are appropriate and how to interpret their results. We aimed to describe how routine coagulation test results change during oesophagectomy’s perioperative course.
Following ethical approval, we retrospectively identified patients who had undergone oesophagectomy between 2002 and 2012. Blood test results and details of operations, haemorrhage and complications were recorded and analysed with Excel and R. A literature search was conducted using the PubMed terms ‘epidural’ AND ‘coagulation’ AND English language. Relevant articles published in 2000 and after were included.
Three hundred and seven patients received a thoracic epidural infusion with bupivacaine and morphine while 51 received an intravenous morphine infusion. Tests taken preoperatively and before the planned withdrawal of the epidural catheter demonstrated increases in all three measures: aPTT (activated partial thromboplastin time), PT-INR (prothrombin international normalised ratio) and platelet count (Plc). Postoperative thrombocytopenia was almost non-existent while aPTT or PT-INR was elevated above the reference range in 129/307 patients: aPTT was elevated in 116/307 while PT-INR was elevated in 32/307. This is too small a sample to allow meaningful estimation of risk of spinal haematoma: it may be as high as 2.3%. The literature search returned 275 articles, of which 57 were relevant. Twenty-one concerned the natural history of postoperative coagulation; 16, the incidence of and risk factors for spinal haematoma; and 5, evaluation of specific blood tests. Postoperative coagulation is characterised by thrombocytosis and transient moderately abnormal routine coagulation test results. Viscoelastic tests are not validated in the stable postoperative setting.
Screening for coagulopathy before removal of epidural catheters is of unclear benefit since elevated aPTT and PT-INR are usual and may not indicate hypocoagulation. A thorough clinical assessment is important. We nevertheless recommend caution when being presented with elevated routine tests of coagulation before withdrawing an epidural catheter: viscoelastic haemostatic tests may have a role in testing before withdrawal of epidural catheters but they are so far not validated. Future research should include advanced coagulation analysis as soon as a patient is unfortunate enough to have a spinal haematoma.
Additional file 1: Graphical representation of epidemiological, quality and other laboratory data. Stars indicate significant differences between pre- and postoperative results as tested using Student’s t test (P < 0.05). aPTT, activated partial prothrombin time. PT-INR, prothrombin time international normalised ratio. Plc, platelet count. EPI, epidural analgesia. IV-PCA, intravenous patient-controlled analgesia with morphine. (TIFF 1498 kb)13741_2017_70_MOESM1_ESM.tiff
Additional file 2: Summaries of the individual articles included in the literature search (Vandermeulen et al. 1994; Sandhu et al. 2000; Greaves 1997; Liu and Mulroy 1998; Horlocker 2003; Moen and Irestedt 2008; Singh et al. 2009; Davies 2007; Shontz et al. 2009; Cwik 2012; Ladha et al. 2013; Okuda and Kitajima 2001; Schulz-Stubner et al. 2005; Tyagi and Bhattacharya 2002; Unic-Stojanovic et al. 2012). (PDF 99 kb)
Additional file 3: Raw data presented as a tabulated text file (.txt). Patients’ ages and the dates of operation have been removed to preserve anonymity. (TXT 91 kb)13741_2017_70_MOESM3_ESM.txt
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- Pre- to postoperative coagulation profile of 307 patients undergoing oesophageal resection with epidural blockade over a 10-year period in a single hospital: implications for the risk of spinal haematoma
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