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  • Thoracic Epidural Anesthesia and Prophylactic Three Times Daily Unfractionated Heparin Within an Enhanced Recovery After Surgery Pathway for Colorectal Surgery

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Regional Anesthesia and Acute Pain: Original Article
Thoracic Epidural Anesthesia and Prophylactic Three Times Daily Unfractionated Heparin Within an Enhanced Recovery After Surgery Pathway for Colorectal Surgery
  1. Alexander B. Stone, BA*,
  2. Michael C. Grant, MD*,
  3. Brandyn D. Lau, MPH†,
  4. Deborah B. Hobson, BSN†,
  5. Michael B. Streiff, MD‡,
  6. Elliot R. Haut, MD†,
  7. Christopher L. Wu, MD* and
  8. Elizabeth C. Wick, MD§
  1. *Department of Anesthesiology and Critical Care Medicine
  2. †Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD
  3. ‡Department of Hematology, The Johns Hopkins Medical Institutions, Baltimore, MD
  4. §Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA
  1. correspondence: Alexander B. Stone, BA, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, 1800 Orleans St, Sheikh Zayed Tower 8120J, Baltimore, MD 21287 (e-mail: astone25{at}jhmi.edu).

Abstract

Background and Objectives Venous thromboembolism (VTE) is a common cause of preventable harm. Perioperative thoracic epidural analgesia (TEA) presents a challenge to optimal VTE prophylaxis. Our primary aim was to characterize missed doses of VTE prophylaxis associated with epidural catheter placement and removal. Our secondary aim was to measure the effect of an enhanced recovery after surgery (ERAS) pathway on the rate of TEA-associated missed VTE prophylaxis.

Methods We retrospectively reviewed a prospectively collected database of 1264 colorectal surgery patients at a single academic center. Missed preoperative doses between TEA patients and non-TEA patients were compared. Missed postoperative unfractionated heparin (UFH) doses associated with epidural removal were compared before and after implementation of an ERAS program. Other data collected included demographic data, surgical indication, and thrombohemorrhagic complications.

Results Of the 445 TEA patients, 12.6% missed their preoperative heparin doses compared with 8.4% of patients without epidurals (P = 0.017). Of the TEA patients prescribed 3 times daily UFH, 22.5% missed one or more doses associated with epidural removal. The percent of patients missing at least one dose of UFH on epidural removal dropped from 28.1% before ERAS to 17.9% after the ERAS program (P = 0.023). Seven patients developed VTEs. There were zero epidural hematomas.

Conclusions Thoracic epidural analgesia was associated with a 1.5-fold increased risk of missed dose of preoperative VTE prophylaxis, which was not affected by implementation of an ERAS program. The implementation of an ERAS program reduced missed doses associated with epidural removal. This study highlights the challenge posed by providing VTE prophylaxis in the setting of perioperative neuraxial analgesia.

https://doi.org/10.1097/AAP.0000000000000542

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    Footnotes

    • Alexander B. Stone and Michael C. Grant contributed equally to this work.

      The authors declare no conflict of interest.

      Disclosure: B.D.L., E.R.H., M.B.S., are supported by a contract (CE-12-11-4489) from the Patient-Centered Outcomes Research Institute (PCORI) entitled “Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information Technology.” B.D.L. is supported by the Institute for Excellence in Education Berkheimer Faculty Education Scholar Grant and a contract (AD-1306-03980) from the PatientCentered Outcomes Research Institute (PCORI) entitled “Patient Centered Approaches to Collect Sexual Orientation/Gender Identity Information in the Emergency Department.” M.B.S. has received research funding from Bristol Myers Squibb, honoraria for CME lectures from Sanofi-Aventis and consulted for Sanofi-Aventis, Eisai, Daiichi-Sankyo, Boehringer-Ingelheimand Janssen HealthCare and has given expert witness testimony in various medical malpractice cases. E.R.H. was the Primary Investigator of a Mentored Clinician Scientist Development Award K08 1K08HS017952-01 from the AHRQ entitled “Does Screening Variability Make DVT an Unreliable Quality Measure of Trauma Care?” E.R.H. receives royalties from Lippincott, Williams, & Wilkins for a book, “Avoiding Common ICU Errors” and consulting fees from VHA.

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