Thoracic Epidural for Postoperative Pain Control after Video-Assisted Thoracoscopic Surgery (VATS) Lobectomy in a Patient with Mild Hemophilia A

    

    

    Figure 2:  PTT (sec) during admission.
    
    

After confirmation of the normalization of the factor VIII activity level, an epidural was then placed using a 17-gauge Tuohy needle at the T6-7 inter space via a paramedian approach. Epidural insertion was completed with a trace amount of bleeding at the insertion site of the skin. No blood was seen in the needle or catheter. Aspiration of the catheter was negative for blood. A test dose of 3ml of 1.5% lidocaine with 1: 200,000 of epinephrine was given and found to be negative for signs of intravascular or intrathecal injection.

The patient underwent uncomplicated VATS lobectomy and was admitted to the surgical intensive care unit postoperatively. The hematology service assisted with the management of his hemophilia postoperatively using the above protocol. The patient’s dose of recombinant factor was decreased to 2000 units every 12 hours on postoperative day 3 by the hematology service because his factor VIII activity level was consistently greater than 150%. The patient’s factor VIII activity levels ranged from 129% to 388% throughout epidural catheter dwell time using this protocol and subsequent modification based upon the factor VIII activity levels.

The patient’s postoperative course was uncomplicated, and pain control was achieved using an epidural infusion of 0.125% bupivacaine and intravenous hydromorphone PCA (0.2mg, 6 minute lockout, no 4 hour limit). Pain control was assessed using the visual analog scale (VAS). The patient’s pain scores ranged 1 to 2 out of 10 on VAS while at rest and with deep breathing, but increased to 8 out of 10 while coughing on postoperative day 1. The epidural infusion was subsequently increased from 8ml/hr to 10ml/hr with improvement of patient’s pain on coughing to 6 out of 10 on VAS. The patient reported a tolerable level of pain control which permitted him to comfortably participate with the postoperative pulmonary hygiene therapy (ambulation, coughing, and incentive spirometry).

The chest tube was removed on postoperative day 3. The patient’s epidural catheter was removed on postoperative day 4 immediately following a dose of recombinant factor VIII. It was felt that the safest time for removal was immediately following a dose when factor levels are at a maximum.

The patient remained in hospital for 2 additional days following epidural catheter removal. He continued to receive recombinant factor VIII as prescribed by his hematologist during this time. The epidural insertion site was monitored after catheter removal and showed no signs of bleeding or hematoma formation. Follow up with the patient was performed via phone call 2 days after discharge. He had no signs of bleeding or hematoma at the epidural insertion site, and no signs or symptoms of epidural hematoma formation.

Discussion

Hemophilia A is a deficiency of clotting factor VIII, with severity based on the native factor VIII activity level. Patients with severe hemophilia A have a factor VIII activity that is less than 1%, those with moderate disease have activity between 1% and 4%, and those with mild disease have activity between 5% to 50% [6]. All coagulation disorders require careful coordination of care between surgeon, anesthesiologist, and hematologist in the perioperative period to minimize the risk of bleeding and reduce the need for blood transfusions.

A literature review of Pub Med revealed several case reports of lumbar epidural placement in patients with hemophilia A, as well as a literature review by Choi and Brull published in 2009. Their review of PubMed, MEDLINE, and EMBASE included 30 articles on neuraxial techniques in patients with clotting disorders published from January 1975 to October 2008. In their review, no thoracic epidural placement in a patient with hemophilia A was found [7]. However, lumbar epidural placement was deemed safe if correction of coagulation factor(s) to normal level(s) had occurred and was maintained [7].

Currently, there are no guidelines that sufficiently include all neuraxial techniques in patients with clotting disorders. The United Kingdom Haemophilia Centre Doctors’ Organization (UKHCDO) guidelines published in 2006 and the Australian Haemophilia Centre Directors’ Organization (AHCDO) position statement published in 2009 both state that epidural anesthesia for the management of labor pains is not contraindicated if a patient’s coagulation factors are maintained in the normal range during the duration of catheter placement [8,9]. The scarcity of reports, reviews, and guidelines makes setting goal values for perioperative coagulation studies difficult. Most guidelines emphasize the importance of maintaining a normal value of the deficient coagulation factor(s) as opposed to following traditional INR and PTT values [7-9] (Table 1). The minimum accepted factor values vary by report, but usually is stated to be 50% of normal [6-9]. A minimum factor VIII level of 60% of normal was chosen in this case in an effort to provide an added margin of safety.

  

    
Date/Time:
    
INR
    
PTT (s)
    
Factor VIII
    
Comments:
  
  

    
Baseline Values
    
1
    
42
    
20%
    

  
  

    
11/13/15 at 0631
    
1
    
29.2
    
182%
    
After first dose of Factor VIII prior to insertion of the    epidural
  
  

    
11/13/15 at 1159
    

    
32.5
    
129%
    
Prior to Factor VIII
  
  

    
11/13/15 at 1230
    

    
24.4
    
388%
    
After Factor VIII
  
  

    
11/13/15 at 2015
    

    
31
    
146%
    
Prior to Factor VIII
  
  

    
11/13/15 at 2113
    

    
28.7
    
304%
    
After Factor VIII
  
  

    
11/14/15 at 0419
    

    
33.6
    
202%
    
Prior to Factor VIII
  
  

    
11/14/15 at 0514
    

    
31.4
    
300%
    
After Factor VIII
  
  

    
11/14/15 at 2016
    

    
34.3
    
207%
    
Prior to Factor VIII
  
  

    
11/14/15 at 2051
    

    
31.4
    
355%
    
After Factor VIII
  
  

    
11/15/15 at 0348
    

    
37.4
    
221%
    
Prior to Factor VIII
  
  

    
11/15/15 at 0434
    

    
34.6
    
326%
    
After Factor VIII
  
  

    
11/15/15 at 1122
    

    
35.4
    
216%
    
Prior to Factor VIII
  
  

    
11/15/15 at 1211
    

    
31.9
    
338%
    
Dosing changed to twice a day
  
  

    
11/15/15 at 2308
    

    

    
166%
    
Prior to Factor VIII
  
  

    
11/16/15 at 0001
    

    

    
207%
    
After Factor VIII
  
  

    
11/17/15 at 1124
    

    

    

    
Epidural removed
  
  

    
11/18/15 at 336
    

    
34.6
    

    
Prior to discharge
  

Table 1: PT/INR and Factor VIII activity levels at baseline, following initial dose, and during maintenance phase of therapy while epidural was in place.