Journal of Anesthesia

, Volume 29, Issue 3, pp 367–372 | Cite as

Coagulation profile changes and safety of epidural analgesia after hepatectomy: a retrospective study

  • Kelly G. Elterman
  • Zhiling XiongEmail author
Original Article



We aimed to review post-hepatectomy coagulation profile changes, to assess outcomes of epidural catheter placement in post-hepatectomy patients, and to make justifications regarding use of epidural analgesia in patients undergoing hepatectomy.


We performed a retrospective study of 141 patients undergoing liver resection at Brigham and Women’s Hospital between January 1, 2007 and December 31, 2011. All patients were between 21 and 85 years old, with ASA physical status classification of II or III, and Child-Pugh scores ≤6. Patients undergoing laparoscopy or resection of less than three hepatic segments were excluded. We examined pre-operative hematocrit, platelet count, coagulation studies, and liver function tests, and trended values for 7 post-operative days. We examined frequency of epidural placement, use of peri-operative anticoagulation, and incidence of epidural-related complications.


We demonstrated statistically significant decreases in hematocrit and platelet counts, as well as statistically significant increases in prothrombin time and international normalized ratio (INR) values. Thirty-two percent of patients required vitamin K or fresh frozen plasma to achieve an INR ≤1.3. No patient required platelet transfusion to achieve platelets ≥100,000 prior to catheter removal. Changes in post-operative partial thromboplastin time were not significant. Epidural catheters were placed in 90 % of liver resections performed at our institution. We noted no epidural hematomas, even in the 7 % of patients in whom the epidural catheter was inadvertently removed before coagulation criteria were met. The latter group was monitored with hourly neurologic exams for 24 h.


Epidural analgesia may be safely used in patients undergoing major hepatic resection, providing that they have normal pre-operative coagulation and catheters are removed only when resection-induced perioperative coagulopathy has resolved or has been corrected.


Hepatectomy Coagulopathy Epidural anesthesia 



The Authors would like to acknowledge Xiaoxia Liu, MS, a statistician, who provided data analysis and graph making, and James Bell, our graphic designer, who helped create and edit the figures.

Conflict of interest

No author has financial interests to disclose.


  1. 1.
    Wrighton LJ, O’Bosky KR, Namm JP, Senthil M. Postoperative management after hepatic resection. J Gastrointest Oncol. 2012;3:41–7.PubMedCentralPubMedGoogle Scholar
  2. 2.
    Jarnagin WR, Gonen M, Fong Y, DeMatteo RP, Ben-Porat L, Little S, Corvera C, Weber S, Blumgart LH. Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade. Ann Surg. 2002;236:397–406.PubMedCentralPubMedCrossRefGoogle Scholar
  3. 3.
    Ryan WH, Hummel BW, McClelland RN. Reduction in the morbidity and mortality of major hepatic resection. Experience with 52 patients. Am J Surg. 1982;144:740–3.PubMedCrossRefGoogle Scholar
  4. 4.
    Ballantyne JC, Carr DB, de Ferranti S, Suarez T, Lau J, Chalmers TC, Angelillo IF, Mosteller F. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg. 1998;86:598–612.PubMedGoogle Scholar
  5. 5.
    Matot I, Scheinin O, Eid A, Jurim O. Epidural anesthesia and analgesia in liver resection. Anesth Analg. 2002;95:1179–81.PubMedCrossRefGoogle Scholar
  6. 6.
    Shontz R, Karuparthy V, Temple R, Brennan TJ. Prevalence and risk factors predisposing to coagulopathy in patients receiving epidural analgesia for hepatic surgery. Reg Anesth Pain Med. 2009;34:308–11.PubMedCrossRefGoogle Scholar
  7. 7.
    Weinberg L, Scurrah N, Gunning K, McNicol L. Postoperative changes in prothrombin time following hepatic resection: implications for perioperative analgesia. Anaesth Intensiv Care. 2006;34:438–43.Google Scholar
  8. 8.
    Choi SJ, Gwak MS, Ko JS, Lee H, Yang M, Lee SM, Kim GS, Kim MH. The changes in coagulation profile and epidural catheter safety for living liver donors: a report on 6 years of our experience. Liver Transplant. 2007;13:62–70.CrossRefGoogle Scholar
  9. 9.
    Schulick R. Hepatobiliary anatomy. In: Mulholland M, Lillemoe K, Doherty G, Maier R, Upchurch Jr G, editors. Greenfield’s surgery scientific principles and practice. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 892–909.Google Scholar
  10. 10.
    Suc B, Panis Y, Belghiti J, Fekete F. ‘Natural history’ of hepatectomy. Br J Surg. 1992;79:39–42.PubMedCrossRefGoogle Scholar
  11. 11.
    Yuan FS, Ng SY, Ho KY, Lee SY, Chung AY, Poopalalingam R. Abnormal coagulation profile after hepatic resection: the effect of chronic hepatic disease and implications for epidural analgesia. J Clin Anesth. 2012;24:398–403.PubMedCrossRefGoogle Scholar
  12. 12.
    Kim YK, Shin WJ, Song JG, Jun IG, Kim HY, Seong SH, Sang BH, Hwang GS. Factors associated with changes in coagulation profiles after living donor hepatectomy. Transplant Proc. 2010;42:2430–5.PubMedCrossRefGoogle Scholar
  13. 13.
    Siniscalchi A, Begliomini B, De Pietri L, Braglia V, Gazzi M, Masetti M, Di Benedetto F, Pinna AD, Miller CM, Pasetto A. Increased prothrombin time and platelet counts in living donor right hepatectomy: implications for epidural anesthesia. Liver Transplant. 2004;10:1144–9.CrossRefGoogle Scholar
  14. 14.
    Stamenkovic DM, Jankovic ZB, Toogood GJ, Lodge JP, Bellamy MC. Epidural analgesia and liver resection: postoperative coagulation disorders and epidural catheter removal. Minerva Anestesiol. 2011;77:671–9.PubMedGoogle Scholar
  15. 15.
    Horlocker TT. Regional anaesthesia in the patient receiving antithrombotic and antiplatelet therapy. Br J Anaesth. 2011;107(Suppl 1):i96–106.PubMedCrossRefGoogle Scholar
  16. 16.
    Lim HJ, Koay CK, Lee LS. Postoperative coagulopathy after liver resection—implications for epidural analgesia. Anaesth Intensive Care. 2006;34:118–9.PubMedGoogle Scholar
  17. 17.
    Tsui SL, Yong BH, Ng KF, Yuen TS, Li CC, Chui KY. Delayed epidural catheter removal: the impact of postoperative coagulopathy. Anaesth Intensive Care. 2004;32:630–6.PubMedGoogle Scholar
  18. 18.
    Barton JS, Riha GM, Differding JA, Underwood SJ, Curren JL, Sheppard BC, Pommier RF, Orloff SL, Schreiber MA, Billingsley KG. Coagulopathy after a liver resection: is it over diagnosed and over treated? HPB. 2013;15(11):865–71.PubMedCrossRefGoogle Scholar
  19. 19.
    Fazakas J, Toth S, Fule B, Smudla A, Mándli T, Radnai M, Doros A, Nemes B, Kóbori L. Epidural anesthesia? No, of course. Transplant Proc. 2008;40:1216–7.PubMedCrossRefGoogle Scholar
  20. 20.
    Tzimas P, Prout J, Papadopoulos G, Mallett SV. Epidural anaesthesia and analgesia for liver resection. Anaesthesia. 2013;68:628–35.PubMedCrossRefGoogle Scholar
  21. 21.
    Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK, Kopp SL, Benzon HT, Brown DL, Heit JA, Mulroy MF, Rosenquist RW, Tryba M, Yuan CS. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010;35:64–101.PubMedCrossRefGoogle Scholar

Copyright information

© Japanese Society of Anesthesiologists 2014

Authors and Affiliations

  1. 1.Department of Anesthesiology, Perioperative and Pain MedicineBrigham and Women’s HospitalBostonUSA
  2. 2.Harvard Medical SchoolBostonUSA

Personalised recommendations