title: Thoracic Epidural Anesthesia and Prophylactic Three Times Daily Unfractionated Heparin Within an Enhanced Recovery After Surgery Pathway for Colorectal Surgery.
abstract: OBJECTIVE
  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.
authors.affiliation: From the *Department of Anesthesiology and Critical Care Medicine, †Department of Surgery, and ‡Department of Hematology, The Johns Hopkins Medical Institutions, Baltimore, MD; and §Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA.
authors.forename: Alexander B
authors.initials: AB
authors.lastname: Stone
authors.forename: Michael C
authors.initials: MC
authors.lastname: Grant
authors.forename: Brandyn D
authors.initials: BD
authors.lastname: Lau
authors.forename: Deborah B
authors.initials: DB
authors.lastname: Hobson
authors.forename: Michael B
authors.initials: MB
authors.lastname: Streiff
authors.forename: Elliot R
authors.initials: ER
authors.lastname: Haut
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Wu
authors.forename: Elizabeth C
authors.initials: EC
authors.lastname: Wick
mesh_terms: D000046:Academic Medical Centers; D015360:Analgesia, Epidural / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D000767:Anesthesia, Epidural / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects; D015142:Baltimore; D002408:Catheters, Indwelling; D003106:Colon / Q000601:surgery*; D016208:Databases, Factual; D020878:Device Removal; D013505:Digestive System Surgical Procedures / Q000009:adverse effects / Q000534:rehabilitation*; D004334:Drug Administration Schedule; D004434:Early Ambulation / Q000009:adverse effects / Q000379:methods*; D006493:Heparin / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D015397:Program Evaluation; D012007:Rectum / Q000601:surgery*; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D054556:Venous Thromboembolism / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*
chemical_list: D000925:Anticoagulants; D006493:Heparin