Bilateral paravertebral block vs thoracic epidural

[MERICA]

I am scheduled for a big abdominal case- a cytoreductive surgery and HIPEC. There will be a lot of fluid shifts and likely pressor support due to the massive inflammatory response. Regional techniques will be helpful for postoperative pain, but will only add to fluid needs. I was talking to my attending and the question came up: Should we perform bilateral paravertebral catheters or a single thoracic epidural catheter. I understand a unilateral PVB would be superior to a TEB in terms of sympathectomy for unilateral surgery (ie thoracotomy), but how would a bilatateral PVB's be superior to a single TEC in terms of sympathetic blockade- and ultimately fluid resuscitation needs?

Patient- relatively young patient, easy airway, healthy heart, unfortunate abdominal carcinomatosis scheduled for CRS/HIPEC- lots of abdominal contents being taken out- essentially an abdominal exenteration.
Plan:
Preop- PO gabapentin/tylenol, bilateral thoracic PVC or TEC
Induction- lidocaine, fentanyl, propofol, rocuronium RSI, dexamethasone for PONV
Airway- ETT
Access- RIJ double lumen CVC, 1 PIV (from preop)
Monitors- radial A-line, LIDCO for SVV guidance of resuscitation, nitro gtt to keep CVP low during hepatic resection to reduce blood loss.
Maintenance- Isoflurane, ketamine gtt, rocuronium for muscle relaxation
Post op- hook up the E-Pump to the the PVC's/TEC, ondansetron PONV
Note the low opioid technique. There is a big push at my institution for decreasing opioids to improve peristalsis and decrease hospital LOS.

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[Arch Guillotti]

Thoracic epidural and skip the ketamine infusion.

 

[bigdan]

We did TONS of PVNB during residency; they were the epitome of "60% of the time, they work all the time". You just never knew which were gonna work. I suppose you could make a case for placing the PVNB with US (which we never did), and you'd have a better chance of truly being in the epidural space.

I'd vote for the epidural, too. Agree with doing ketamine.

The low opiate thing is an interesting idea; at our residency's cancer hospital, we had a couple of attendings that were big on avoiding opiates for these big cancer whacks, since there is literature they may increase cancer metastasis.

I like your plan.

 

[kazuma]

I would want a thoracic epidural as well.

 

[BLADEMDA]

Thoracic epidural or bilateral Subcostal tap and regular tap with Exparel plus decadron. I'd skip the bilateral PVNB for abdomjnal surgery.

To all the doubters out there I've performed more than a dozen major abdomjnal cases using Subcostal/tap with Exparel and decadron with excellent results.

 

[Noyac]

I agree with the thoracic epidural approach others have mentioned here. However, I would be extremely cautious with dosing during the case. You will be chasing BPs the entire case. I like Blade's Tap block approach as well and with exparel this should give some good duration.

I'd also ditch the ketamine infusion. That's for people with a long history of pain or on large doses of narcs pre-op IMO. As long as your epidural works, the pain should be addressed well.

 

[BLADEMDA]

Anaesthesia. 2011 Jun;66(6):465-71. doi: 10.1111/j.1365-2044.2011.06700.x. Epub 2011 Apr 4.
Comparison of analgesic efficacy of subcostal transversus abdominis plane blocks with epidural analgesia following upper abdominal surgery.
Niraj G1, Kelkar A, Jeyapalan I, Graff-Baker P, Williams O, Darbar A, Maheshwaran A, Powell R.
Author information

• 1Department of Anaesthesia and Pain Management, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK. [email protected]

Abstract
Subcostal transversus abdominis plane (TAP) catheters have been reported to be an effective method of providing analgesia after upper abdominal surgery. We compared their analgesic efficacy with that of epidural analgesia after major upper abdominal surgery in a randomised controlled trial. Adult patients undergoing elective open hepatobiliary or renal surgery were randomly allocated to receive subcostal TAP catheters (n=29) or epidural analgesia (n=33), in addition to a standard postoperative analgesic regimen comprising of regular paracetamol and tramadol as required. The TAP group patients received bilateral subcostal TAP catheters and 1 mg.kg(-1) bupivacaine 0.375% bilaterally every 8 h. The epidural group patients received an infusion of bupivacaine 0.125% with fentanyl 2 μg.ml(-1) . The primary outcome measure was visual analogue pain scores during coughing at 8, 24, 48 and 72 h after surgery. We found no significant differences in median (IQR [range]) visual analogue scores during coughing at 8 h between the TAP group (4.0 (2.3-6.0 [0-7.5])) and epidural group (4.0 (2.5-5.3) [0-8.5])) and at 72 h (2.0 (0.8-4.0 [0-5]) and 2.5 (1.0-5.0 [0-6]), respectively). Tramadol consumption was significantly greater in the TAP group (p=0.002). Subcostal TAP catheter boluses may be an effective alternative to epidural infusions for providing postoperative analgesia after upper abdominal surgery.

 

[Noyac]

No surprise there.

 

[psychbender]

You had me at ketamine infusion. Seriously, though, if you do not use the epidural throughout the case, and are using minimal opioids, then the infusion should buy you some much needed analgesia, and help post-op, since the epidural will cover most but not all of the pain. We did intra- and post-op ketamine infusions on all major spines in residency, and I often added bolus ketamine to big abdominal whacks with good anecdoctal response. With regards to bilateral PVCs vs CTE, I would vote CTE. Its less time, fewer sticks in the back, lower chance of PTX, better chance of actually placing the catheter where you want it, better chance of the catheter remaining where you want it. Now, in light of the minimal opioid approach, have you discussed dosing the epidural with dilaudid at the start to further decrease analgesics requirements intra and immediately post-op? With some epidural dilaudid, you can get away with giving less gas to cover the sympathetic response to surgical stimuli, which can allow you to run the epidural without having to fight severe hypotension you would get if you tried to run it with a MAC of gas onboard.

 

[sleepallday]

I am a big fan of TAP catheters and do plenty of them. But generally place them only when an epidural is not an option. From what I've seen the analgesia from an epidural is superior to to TAP. You have to remember that TAP blocks only cover somatic pain. Epidurals will cover both somatic and visceral pain. Also, love the ketamine infusion. Lots of data to support low dose intraop ketamine infusion improving postop pain. If you want to improve postop pain even more, continue ketamine for a couple days postop and add an around the clock NSAID.

 

[BLADEMDA]

I am a big fan of TAP catheters and do plenty of them. But generally place them only when an epidural is not an option. From what I've seen the analgesia from an epidural is superior to to TAP. You have to remember that TAP blocks only cover somatic pain. Epidurals will cover both somatic and visceral pain. Also, love the ketamine infusion. Lots of data to support low dose intraop ketamine infusion improving postop pain. If you want to improve postop pain even more, continue ketamine for a couple days postop and add an around the clock NSAID.

No thanks. I like to use low dose Ketamine only when needed and definitely NOT postop.

A Thoracic Epidural offers superior pain control compared to a Bilteral subcostal Tap/Tap but the pain control is still very, very good. Here are the advantages of a Subcostal TAP:

1. Easier to do, Higher success rate
2. Use Exparel so no Catheter needed
3. Surgeon can start LMWH whenever he sees fit
4. No hypotension or bradycardia (a real issue with thoracic epidurals)
5. No Rounding or pulling out the catheter

So, for my practice the EXPAREL Subcostal TAp/Tap is a clear winner over a thoracic epidural.

 

[Noyac]

No thanks. I like to use low dose Ketamine only when needed and definitely NOT postop.

A Thoracic Epidural offers superior pain control compared to a Bilteral subcostal Tap/Tap but the pain control is still very, very good. Here are the advantages of a Subcostal TAP:

1. Easier to do, Higher success rate
2. Use Exparel so no Catheter needed
3. Surgeon can start LMWH whenever he sees fit
4. No hypotension or bradycardia (a real issue with thoracic epidurals)
5. No Rounding or pulling out the catheter

So, for my practice the EXPAREL Subcostal TAp/Tap is a clear winner over a thoracic epidural.

For sure, ketamine is only for those "special" cases. That's why it's called SPECIAL K. And not a good idea for post-op. Not because it doesn't work or that is isn't a benefit but because it confuses the situation too much. Some pts get up and ambulate with it and some are vegetables. Sure, you can adjust to effect but any confusion and it will be blamed on you. KISS baby.

As far as the 5 points you mention Blade:
1) really? How much easier can it be than an epidural? Sort of kidding here cuz I hear that TAP blocks are simple but I don't do them mostly cuz they are inferior to the epidural. Maybe one day you can show how.
2) no comment
3) we start LMWH post-op with TEA. no issues on our part.
4) hypotension can be a bitch. But easily remedied if you no how. Intra-op you are in control but it makes for some work on occasion. In PACU, it can be annoying. I give 30mg IM ephedrine just before arrival and haven't had much issue with the hypotension from that point on. Once on the floor they seem to be pretty darn good and most importantly pain free therefore, I get no calls which may be different with a TAP block when the pt isn't completely pain free.
5) rounding and pulling catheters is a good point. Timing with LMWH is key. This would be a nice addition.

 

[Oggg]

I get called for epidurals causing hypotension, hypertension, inadequate pain control, sedation, agitation, tachycardia, numbness, motor block of legs... You name it, the nurses will call, because they have no idea what an epidural is. If you do TAP blocks, all calls go to the primary or the surgeon because TAPs have essentially no side effects and after you inject you never have to see the pt again.

That being said, a mid or low thoracic epidural isn't that hard, should provide 100% pain relief for any abdominal surgery, and a small dose phenylephrine infusion fixes the hypotension.

How about bilateral quadratus lumborum blocks?

 

[nap$ter]

For sure, ketamine is only for those "special" cases. That's why it's called SPECIAL K. And not a good idea for post-op. Not because it doesn't work or that is isn't a benefit but because it confuses the situation too much. Some pts get up and ambulate with it and some are vegetables. Sure, you can adjust to effect but any confusion and it will be blamed on you. KISS baby.

As far as the 5 points you mention Blade:
1) really? How much easier can it be than an epidural? Sort of kidding here cuz I hear that TAP blocks are simple but I don't do them mostly cuz they are inferior to the epidural. Maybe one day you can show how.
2) no comment
3) we start LMWH post-op with TEA. no issues on our part.
4) hypotension can be a bitch. But easily remedied if you no how. Intra-op you are in control but it makes for some work on occasion. In PACU, it can be annoying. I give 30mg IM ephedrine just before arrival and haven't had much issue with the hypotension from that point on. Once on the floor they seem to be pretty darn good and most importantly pain free therefore, I get no calls which may be different with a TAP block when the pt isn't completely pain free.
5) rounding and pulling catheters is a good point. Timing with LMWH is key. This would be a nice addition.

i also vote TEP, no ketamine. i also like ephedrine - i use 50mg IM about one hour prior to extubation; try to wean the neo off. we do a lot of HIPECs - they can really suck up the fluid and you have to make sure the preload is ok before pacu.

i almost never get called about epidurals - our nurses are savvy.

we don't do LMWH and epidurals. our surgeon uses SQ heparin.

 

[MERICA]

Update on the HIPEC case from last week:
The case lasted 9 hours. (partial hepatectomy, splenectomy, bowel resection, peritoneal stripping, hysterectomy/BSO, and one hell of an incision)
Pain Control:
The parevertebral catheters worked great. I bolused them with high volumes of 1/8% bupiv every hour until the E-Pumps became available. The patient did not need pressors until the chemo portion several hours later- so hypotension was not really a problem with this approach, surprisingly. However, a HIPEC later in the week did not have as much success in block coverage. I will try a thoracic epidural for the next one. The patient did not receive any opioids in the OR. I am a fan of the PO meds in preop and ketamine drip (turned off 45 min before case ending)- as the patient was extubated in the OR, followed commands, and had a pain score of ZERO. The patient got hydromorphone PCA (ordered by the surgeons) on the floor. The PCA requirements were astoundingly low. The patient was walking on the floor the NEXT MORNING.
Volume Management:
Using the Lidco or FloTrac for fluid management is CRUCIAL. There were multiple times with hypotension- and a pressor was used instead of fluids based on SVV. In the past, they would have been flooded with fluids based on the clinical context. The patient only needed 5 liters of crystalloid intraop- which is pretty amazing with such fluid shifting during a huge open belly case. Albumin was not needed as it was normal in preop. No products needed- 1 liter EBL, but we also didn't hemodilute the patient.

 

[nap$ter]

Update on the HIPEC case from last week:
The case lasted 9 hours. (partial hepatectomy, splenectomy, bowel resection, peritoneal stripping, hysterectomy/BSO, and one hell of an incision)
Pain Control:
The parevertebral catheters worked great. I bolused them with high volumes of 1/8% bupiv every hour until the E-Pumps became available. The patient did not need pressors until the chemo portion several hours later- so hypotension was not really a problem with this approach, surprisingly. However, a HIPEC later in the week did not have as much success in block coverage. I will try a thoracic epidural for the next one. The patient did not receive any opioids in the OR. I am a fan of the PO meds in preop and ketamine drip (turned off 45 min before case ending)- as the patient was extubated in the OR, followed commands, and had a pain score of ZERO. The patient got hydromorphone PCA (ordered by the surgeons) on the floor. The PCA requirements were astoundingly low. The patient was walking on the floor the NEXT MORNING.
Volume Management:
Using the Lidco or FloTrac for fluid management is CRUCIAL. There were multiple times with hypotension- and a pressor was used instead of fluids based on SVV. In the past, they would have been flooded with fluids based on the clinical context. The patient only needed 5 liters of crystalloid intraop- which is pretty amazing with such fluid shifting during a huge open belly case. Albumin was not needed as it was normal in preop. No products needed- 1 liter EBL, but we also didn't hemodilute the patient.

thanks for the update - sounds like a well done case.

personally i find lidco/flotrac unnecessary. aline SPV, CVP, and traditional preload assessment is adequate given relatively normal cardiac function

 

[OB1🤙]

What level(s) did you place the catheters? Multiple per side or just one?

 

[deleted9493]

CO monitors are fine but in cases like this, usually only tell you what you already know. Bookwalter retraction, arms deep in the abdomen, liver eversion are the common events that you can expect hypotension with. You just need to know how you're going to treat it when it happens. Fluid restriction is clearly better for the liver and bowel resection crowd, so that would be my strategy as well--lean on pressors as much as you are able until closing and slowly resuscitate once the hands are out of the abdomen.

In kids I will use the epidural routinely for the case. In adults, it just has that potential to become a hassle. The aforementioned hypotensive patient suddenly has two possible reasons for hypotension--low SVR and low preload, confounding the picture.

 

[nap$ter]

CO monitors are fine but in cases like this, usually only tell you what you already know. Bookwalter retraction, arms deep in the abdomen, liver eversion are the common events that you can expect hypotension with. You just need to know how you're going to treat it when it happens. Fluid restriction is clearly better for the liver and bowel resection crowd, so that would be my strategy as well--lean on pressors as much as you are able until closing and slowly resuscitate once the hands are out of the abdomen.

In kids I will use the epidural routinely for the case. In adults, it just has that potential to become a hassle. The aforementioned hypotensive patient suddenly has two possible reasons for hypotension--low SVR and low preload, confounding the picture.

i almost alway use the epidural. the SVR is already dropped from the volatile, and the epidural just adds to the reduction a bit. i'm going to be shooting for a normal SVR c pressor anyhow...

SVR is constant once the epidural gtt and pressor are started - just don't bolus the epidural...

 

[dhb]

just don't bolus the epidural...

This is a key point when doing a case with an epidural infusion: cut back the volatile and don't bolus the epidural

 

[Planktonmd]

I am not sure why anyone would want to do 2 procedures that are of questionable value to replace one procedure that is known to work (provided you know what you are doing)

 

[BLADEMDA]

I recently did a major open exploratory laparotomy on an 85 year old female. Preoperatively I placed a bilateral Subcostal tap and standard tap (as described by Hebbard) using Exparel with decadron. The patient was pain free (zero out of 10) for 46 hours. No phone calls about hypotension, no catheter to pull or round on and no issueswith anticoagulation

I have no doubt the thoracic epidural is the gold standard here but a long BD tap block is definitely worth consideration here and is technically quite easy to perform.

 

[BLADEMDA]

http://onlinelibrary.wiley.com/doi/10.1111/anae.12103/full

 

[deleted171991]

http://onlinelibrary.wiley.com/doi/10.1111/anae.12103/full

This reminds me that Anesthesiology does not publish case reports (like this one) anymore.