Elective open operations Emergency open operations Membership of the Vascular Anaesthesia Society of Great Britain and Ireland (VASGBI) Volume of cases done by anaesthetists Use of epidural anaesthesia Blood loss in open operations Temperature Monitoring and vasoactive drugs Destination after surgery Mechanical ventilation after surgery

The anaesthetist >> Use of epidural anaesthesia

Use of epidural anaesthesia	Use of epidurals with agents that affect coagulation
Removal of epidural catheters

Use of epidural anaesthesia

92% of elective admission patients received an epidural catheter as part of the anaesthetic technique.

An epidural catheter was inserted in 92% (345/377) of elective patients having an open operation. The question was unanswered in 57 cases. An epidural catheter was inserted in 73% (57/78) of emergency unruptured open aneurysm repairs. The question was unanswered in nine patients. In emergency ruptured aneurysm patients, an epidural catheter was inserted in 8% (11/133) of cases. Four were answered as unknown and 32 questions were unanswered.

Use of epidurals with agents that affect coagulation

Including the patients who underwent endovascular repair, a total of 465 patients received an epidural catheter. Anaesthetists were asked whether the epidural catheter had been inserted when the patient had received drugs that might impair coagulation.

Table 15. Preoperative epidural catheter insertion by whether patients received aspirin in the seven days before surgery
Aspirin in patients who received an epidural	Total	%
Yes	168	38
No	274	62
Sub-total	442
Unknown	19
Not answered	4
Total	465

Nine patients had received subcutaneous unfractionated heparin in the six hours before surgery, 448 had not.

Table 16. Fractionated heparin in patients who received an epidural
Fractionated heparin in patients who received an epidural	Total	%
Yes	61	14
No	390	86
Sub-total	451
Unknown	7
Not answered	7
Total	465

It would appear that anaesthetists do not think there is much risk associated with placing epidural catheters when the patient has been taking aspirin (Table 15).

The finding that 14% of patients had an epidural catheter placed within 12 hours of receiving fractionated heparin is worrying (Table 16). The consensus is that this practice exposes the patient to a significant risk of developing an epidural haematoma and the morbidity associated with this complication of treatment.

Removal of epidural catheters

In 16% of patients undergoing elective open repair the anaesthetist could not report when the epidural catheter was removed.

For the 345 patients undergoing elective open repair in whom an epidural catheter was inserted, no answer at all was given in seven cases to the question asking when the epidural catheter was removed. Of the 338 responses, in 55 cases (16%) the anaesthetist reported that they did not know when the epidural catheter was removed. If an anaesthetist inserts an epidural catheter it is their responsibility to ensure that the management of the catheter and of the epidural analgesia is safe. Some anaesthetists will want to exercise that responsibility personally until the catheter is removed. Others will wish to delegate that responsibility to a properly organised acute pain team. The finding that the anaesthetist was often unable to retrieve from the patient’s notes the date when the epidural catheter was removed suggests, at the least, failure in documentation of the care given to the patient. This would cause an anaesthetist considerable difficulty if there were a problem with the epidural catheter resulting in a complaint or medico-legal correspondence. More worryingly, this failure may be a symptom of problems with the supervision of epidural analgesia and the delivery of safe clinical care. Clinicians should ensure that hospitals have robust systems in place for the postoperative care of epidural catheters, that demonstrate who is responsible for the care of the epidural catheter and for the accompanying appropriate documentation.