PMID- 28079734
OWN - NLM
STAT- MEDLINE
DCOM- 20180917
LR  - 20190109
IS  - 1532-8651 (Electronic)
IS  - 1098-7339 (Linking)
VI  - 42
IP  - 2
DP  - 2017 Mar/Apr
TI  - Thoracic Epidural Anesthesia and Prophylactic Three Times Daily Unfractionated 
      Heparin Within an Enhanced Recovery After Surgery Pathway for Colorectal Surgery.
PG  - 197-203
LID - 10.1097/AAP.0000000000000542 [doi]
AB  - 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.
FAU - Stone, Alexander B
AU  - Stone AB
AD  - From the *Department of Anesthesiology and Critical Care Medicine, daggerDepartment of 
      Surgery, and double daggerDepartment of Hematology, The Johns Hopkins Medical Institutions, 
      Baltimore, MD; and  section signDepartment of Surgery, University of California San Francisco 
      School of Medicine, San Francisco, CA.
FAU - Grant, Michael C
AU  - Grant MC
FAU - Lau, Brandyn D
AU  - Lau BD
FAU - Hobson, Deborah B
AU  - Hobson DB
FAU - Streiff, Michael B
AU  - Streiff MB
FAU - Haut, Elliot R
AU  - Haut ER
FAU - Wu, Christopher L
AU  - Wu CL
FAU - Wick, Elizabeth C
AU  - Wick EC
LA  - eng
PT  - Journal Article
PT  - Observational Study
PL  - England
TA  - Reg Anesth Pain Med
JT  - Regional anesthesia and pain medicine
JID - 9804508
RN  - 0 (Anticoagulants)
RN  - 9005-49-6 (Heparin)
SB  - IM
MH  - Academic Medical Centers
MH  - Analgesia, Epidural/adverse effects/instrumentation/*methods
MH  - Anesthesia, Epidural/adverse effects/instrumentation/*methods
MH  - Anticoagulants/*administration & dosage/adverse effects
MH  - Baltimore
MH  - Catheters, Indwelling
MH  - Colon/*surgery
MH  - Databases, Factual
MH  - Device Removal
MH  - Digestive System Surgical Procedures/adverse effects/*rehabilitation
MH  - Drug Administration Schedule
MH  - Early Ambulation/adverse effects/*methods
MH  - Heparin/*administration & dosage/adverse effects
MH  - Humans
MH  - Program Evaluation
MH  - Rectum/*surgery
MH  - Retrospective Studies
MH  - Risk Factors
MH  - Time Factors
MH  - Treatment Outcome
MH  - Venous Thromboembolism/diagnosis/etiology/*prevention & control
EDAT- 2017/01/13 06:00
MHDA- 2018/09/18 06:00
CRDT- 2017/01/13 06:00
PHST- 2017/01/13 06:00 [pubmed]
PHST- 2018/09/18 06:00 [medline]
PHST- 2017/01/13 06:00 [entrez]
AID - 10.1097/AAP.0000000000000542 [doi]
PST - ppublish
SO  - Reg Anesth Pain Med. 2017 Mar/Apr;42(2):197-203. doi: 
      10.1097/AAP.0000000000000542.