title: Rotational thromboelastometry and multiple electrode platelet aggregometry in four patients with abnormal routine coagulation studies before removal of epidural catheters after major surgery: a case series and research study.
abstract: BACKGROUND
  Routine coagulation tests have a low predictability for perioperative bleeding complications, and spinal hematoma after removal of epidural catheters is very infrequent. Thromboelastometry and point-of-care platelet aggregometry may improve hemostatic monitoring but have not been studied in the context of safety around epidural removal.
  
  
  METHODS
  Twenty patients who received an epidural catheter for major thoracoabdominal and abdominal surgery were included prospectively. In addition to routine coagulation tests, rotational thromboelastometry and multiple electrode platelet aggregometry were carried out.
  
  
  RESULTS
  A coagulation deficit was suggested by routine coagulation tests on the intended day of epidural catheter removal in four out of 20 patients. Prothrombin time-international normalized ratio was elevated to 1.5 in one patient (normal range: 0.9 to 1.2) while rotational thromboelastometry and multiple electrode platelet aggregometry parameters were within normal limits. Activated partial thromboplastin time was elevated to 47 to 50 seconds in the remaining three patients (normal range 28 to 45 seconds). Rotational thromboelastometry showed that one of the patients' results was due to heparin effect: the clotting time with the HEPTEM® activator was 154 seconds as compared to 261 seconds with INTEM. The three remaining patients with prolonged routine coagulation test results had all received over 1L of hydroxyethyl starch (Venofundin®) and thrombosis prophylaxis with low-molecular-weight heparin (enoxaparin). Rotational thromboelastometry and multiple electrode platelet aggregometrygave normal or hypercoagulative signals in most patients.
  
  
  CONCLUSIONS
  This case series is new in that it examines rotational thromboelastometry and multiple electrode platelet aggregometry postoperatively in the context of epidural analgesia and shows that they may be clinically useful. These methods should be validated before they can be used for standard patient care.
authors.affiliation: Department of Anaesthesia and Intensive Care, Skåne University Hospital, S-22185 Lund, Sweden. odt@cantab.net.
authors.forename: Owain D
authors.initials: OD
authors.lastname: Thomas
authors.forename: Anna
authors.initials: A
authors.lastname: Gustafsson
authors.forename: Ulf
authors.initials: U
authors.lastname: Schött