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Incidence and Risk Factors of Coagulation Profile Derangement After Liver Surgery: Implications for the Use of Epidural Analgesia—A Retrospective Cohort Study

Jacquenod, Pierre*; Wallon, Grégoire MD*; Gazon, Mathieu MD*; Darnis, Benjamin MD; Pradat, Pierre PhD; Virlogeux, Victor MD, PhD; Farges, Olivier MD, PhD§; Aubrun, Frédéric MD, PhD*

doi: 10.1213/ANE.0000000000002457
Research Report: PDF Only

BACKGROUND: Hepatic surgery is a major abdominal surgery. Epidural analgesia may decrease the incidence of postoperative morbidities. Hemostatic disorders frequently occur after hepatic resection. Insertion or withdrawal (whether accidental or not) of an epidural catheter during coagulopathic state may cause an epidural hematoma. The aim of the study is to determine the incidence of coagulopathy after hepatectomy, interfering with epidural catheter removal, and to identify the risk factors related to coagulopathy.

METHODS: We performed a retrospective review of a prospective, multicenter, observational database including patients over 18 years old with a history of liver resection. Main collected data were the following: age, preexisting cirrhosis, Child-Pugh class, preoperative and postoperative coagulation profiles, extent of liver resection, blood loss, blood products transfused during surgery. International normalized ratio (INR) ≥1.5 and/or platelet count <80,000/mm3 defined coagulopathy according to the neuraxial anesthesia guidelines. A logistic regression analysis was performed to assess the association between selected factors and a coagulopathic state after hepatic resection.

RESULTS: One thousand three hundred seventy-one patients were assessed. Seven hundred fifty-nine patients had data available about postoperative coagulopathy, which was observed in 53.5% [95% confidence interval, 50.0–57.1]. Maximum derangement in INR occurred on the first postoperative day, and platelet count reached a trough peak on postoperative days 2 and 3. In the multivariable analysis, preexisting hepatic cirrhosis (odds ratio [OR] = 2.49 [1.38–4.51]; P = .003), preoperative INR ≥1.3 (OR = 2.39 [1.10–5.17]; P = .027), preoperative platelet count <150 G/L (OR = 3.03 [1.77–5.20]; P = .004), major hepatectomy (OR = 2.96 [2.07–4.23]; P < .001), and estimated intraoperative blood loss ≥1000 mL (OR = 1.85 [1.08–3.18]; P = .025) were associated with postoperative coagulopathy.

CONCLUSIONS: Coagulopathy is frequent (53.5% [95% confidence interval, 50.0–57.1]) after liver resection. Epidural analgesia seems safe in patients undergoing minor hepatic resection without preexisting hepatic cirrhosis, showing a normal preoperative INR and platelet count.

From the *Department of Anesthesiology and Critical Care, Department of Digestive, Hepato-biliary and Liver Transplantation Surgery, and Department of Hepatology, Clinical Research Center, Croix-Rousse University Hospital, Hospices Civils de Lyon (HCL), Lyon, France; and §Department of Hepato-biliary and Pancreatic Surgery, Beaujon University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Clichy, France.

Accepted for publication July 28, 2017.

Trial registry number: 2011 French Hospital Clinical Research Program AOM11060.

Funding: None.

Conflicts of Interest: See Disclosures at the end of the article.

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Reprints will not be available from the authors.

Address correspondence to Pierre Jacquenod, Department of Anesthesiology and Critical Care, Croix-Rousse University Hospital, 15 rue St Amour, 69003 Lyon, France. Address e-mail to

© 2018 International Anesthesia Research Society
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