2024 FSA Podium and Poster Abstracts
P047: PROLONG THORACIC EPIDURAL CATHETER FOLLOWING PANCREATICODUODENECTOMY: RISK AND BENEFITS OF CATHETER SAFETY AND PATIENT OUTCOMES
Kevin P Dazen, MD1; Christopher P Emerson, MD1; Sean Quinn, MD2; 1Jackson Memorial Hospital/University of Miami Health System; 2Miami Bruce W. Carter Veterans Affairs Hospital
Introduction/Background: Thoracic epidural analgesia is an effective plan for postoperative pain in patients undergoing pancreaticoduodenectomy. Epidural analgesia is associated with improved pulmonary mechanics, earlier return of bowel function, and early ambulation. Guidelines for practitioners in epidural management and discontinuation of catheters exist specifically for risk of bleeding and infection. Oncology patients are at higher risk of postoperative venothromboembolic (VTE) events, thus chemothrombophrophylaxis is indicated in the postoperative period. Holding chemothrombophylaxis, and in some instances confirming coagulation lab values, prevent epidural hematomas. The risk of epidural abscess formation increases with prolonged catheter duration.
Methods: The presented patient is a 78-year-old male with a pertinent past medical history of colon adenocarcinoma, non-small cell lung cancer, prior deep vein thrombosis (DVT), and lymphoma, who underwent pancreaticoduodenectomy for pancreatic adenocarcinoma with general anesthesia and preprocedural placement of thoracic epidural catheter. The procedure was complicated by gallbladder adhesion to the hepatic capsule. Anesthetic management was complicated by hypotension requiring low dose phenylephrine infusion. Catheter removal occurred on postoperative day (POD) 7 due to unforeseen issues with the patient’s coagulation studies and concern for holding chemothrombophylaxis.
Results: Postoperatively in the surgical intensive care unit, labs showed prolonged PTT and PT/INR and elevated liver function tests. The evening of surgery, 5000 units of heparin was initiated 3 times daily. The subsequent 6 days the patient labs continued with prolonged PTT and INR without evidence of blood dyscrasia. Per current guidelines, the catheter could not be removed until INR < 1.5 and PTT < 40. Given the risk of VTE, the surgical team could not hold heparin doses. On POD 6 the patient received vitamin K 1mg IV with minimal change in coagulation studies. Factor X, Factor VII, anti-factor Xa and Vitamin K levels were sent for laboratory analysis and heparin dose was held but evening heparin dose was given. The morning of POD 7, PTT and INR were acceptable for removal of the catheter. The patient did not have any fevers, signs of infection, or signs of bleeding post-catheter removal.
Discussion/Conclusion: While thoracic epidural analgesia has been shown to have superior outcomes for a multitude of complications following pancreaticoduodenectomy, patients who become coagulopathic present significant obstacles to catheter removal. While ASA guidelines attempt to ensure a normal coagulation profile based on the half-lives of anticoagulants, the lab tests for PTT and PT/INR evaluations were meant to guide anticoagulant therapy not to evaluate in-vivo coagulability. There are not currently guidelines for other laboratory evaluations to aid neuraxial anesthesia management.
Patients with a high probability of developing VTE perioperatively should be started on chemothromboprophalxis immediately. Patients who are at increased risk of developing a DVT, holding chemothromboprophalxis long enough for coagulation values to normalize may pose a greater threat than benefit.
As such, this case illustrates a situation in which an anesthesia provider may be required to venture beyond current ASA guidelines for neuraxial anesthesia in this subset of patients.