Esophagectomy epidural

[sevo00]

At what level do you all usually place your thoracic epidurals for an esophagectomy?

Using 0.0625% bupi what rate do you usually run it at?

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[drmwvr]

At what level do you all usually place your thoracic epidurals for an esophagectomy?

Using 0.0625% bupi what rate do you usually run it at?

T 8-10 ...20 ml bolus of .25% on induction, start the gtt (will fentanyl) at 10 for the case and 8 for the ward.

 

[Greenbayslacker]

Does this mean in the insertion site is T8-T10, or the catheter tip is approximately at T8-T10?

 

[abolt18]

We don't do any regional for them per the surgeon. But I'd think T6-8 range for insertion would be ideal for complete coverage.

 

[dabears505]

20 cc of .25?

 

[Silo004]

At what level do you all usually place your thoracic epidurals for an esophagectomy?

Using 0.0625% bupi what rate do you usually run it at?

I would use opioid only for these. But T6-T8 sounds about right.

 

[Maz777]

What is the esophagectomy approach? 3-hole? Ivor-Lewis? Transhiatal? Lap-assisted/thoracoscopic?

All depends on the surgical approach. Every surgeon is different. If a thoracotomy is involved, best to aim for that dermatome for your thoracic epidural. It's important to avoid postop hypotension on these patients due to the anastomotic leak rate. Neuraxial opioids will be your friend.

 

[deleted1111114]

 

[drmwvr]

Does this mean in the insertion site is T8-T10, or the catheter tip is approximately at T8-T10?

The former.

 

[fakin' the funk]

Uh…haven’t done an epidural for an esophagectomy in years. Our surgeons do minimally invasive Ivor Lewis so just laparoscopy ports and VATS ports and chest tube - the largest incision of which is 8-10cm. Exparel intercostals.

 

[fakin' the funk]

And yes, if your surgeons are doing open would target where the thoracotomy is (usually 6th or 7th ICS) +\- chest tubes.

 

[Katheudontas parateroumen]

Sorry, very basic question here... what is the exact importance of getting the T6 vs low Thoracic vs lumbar? I get that we are trying to be as exact as possible with which nerve roots get analgesia but would just a basic lumbar epidural with more volume do just as well? Or does it cause more motor weakness etc? Sorry, don't do that much regional anymore.

 

[Urzuz]

Sorry, very basic question here... what is the exact importance of getting the T6 vs low Thoracic vs lumbar? I get that we are trying to be as exact as possible with which nerve roots get analgesia but would just a basic lumbar epidural with more volume do just as well? Or does it cause more motor weakness etc? Sorry, don't do that much regional anymore.

It’s challenging to anesthetize nerve roots that are far away from where the epidural tip lies. Let’s say your epidural tip is at L3. There is no safe rate you could run your epidural at to catch the T5-6 nerve roots that may be involved in the surgery. You risk LAST and unnecessary side effects of the epidural (eg: patient has quadriceps weakness after having a thoracic surgery).

The band of anesthesia spreads both above and below the dermatome where your epidural tip lies based on the rate you run, and usually (due to gravity) covers more dermatome levels below where the tip lies versus above.

Generally you want the tip of the epidural to lie somewhere in the middle dermatome that is involved surgically, or maybe a little higher. Let’s say your patient will have a big laparotomy incision involving dermatomes T6 to T12. I would opt to place the epidural at probably T8-9. That would ensure that I’m able to anesthetize at least the two levels above and the three levels below where the epidural is. Of course, we don’t control where the tip goes when you thread it into the space. I try to account for this by only threading the catheter in 4ish cm and then spending a long time securing it. Usually I spend more time securing the catheter than I do placing it.

 

[Orin]

In general I believe that thoracic epidurals need to cover the mid-low thoracic dermatomes to help with respiratory dynamics. Those higher incisions will be better covered with other agents, and much less painful than the T6-8 subcostal issues.

The thoracic epidurals float up readily while the lumbar epidurals we can get to sink down with volume. Err lower or higher depending on your fears.

 

[Katheudontas parateroumen]

It’s challenging to anesthetize nerve roots that are far away from where the epidural tip lies. Let’s say your epidural tip is at L3. There is no safe rate you could run your epidural at to catch the T5-6 nerve roots that may be involved in the surgery. You risk LAST and unnecessary side effects of the epidural (eg: patient has quadriceps weakness after having a thoracic surgery).

The band of anesthesia spreads both above and below the dermatome where your epidural tip lies based on the rate you run, and usually (due to gravity) covers more dermatome levels below where the tip lies versus above.

Generally you want the tip of the epidural to lie somewhere in the middle dermatome that is involved surgically, or maybe a little higher. Let’s say your patient will have a big laparotomy incision involving dermatomes T6 to T12. I would opt to place the epidural at probably T8-9. That would ensure that I’m able to anesthetize at least the two levels above and the three levels below where the epidural is. Of course, we don’t control where the tip goes when you thread it into the space. I try to account for this by only threading the catheter in 4ish cm and then spending a long time securing it. Usually I spend more time securing the catheter than I do placing it.

Ah of course, makes sense

 

[woopedazz]

If laparotomy --> T7/T8 (left) paramedian approach --> test dose lignocaine pre induction --> loading dose + opioid pre incision --> boluses of plain throughout.

If thoracotomy, and no laparotomy --> paravertebral is fine.

0.0625% ... Why bother?

 

[OptionOffense]

I would use opioid only for these.

What concentration of Fentanyl would you use and how much per hour? Ive always wanted to try opioid only. Sounds like MOney. I bet you get high satisfaction scores with that.

 

[Maz777]

What concentration of Fentanyl would you use and how much per hour? Ive always wanted to try opioid only. Sounds like MOney. I bet you get high satisfaction scores with that.

You might as well just forgo the epidural and start a postop IV fentanyl infusion (if you aren't going to give any local anesthetic and choose a lipophilic opioid). TIC.

 

[Silo004]

What concentration of Fentanyl would you use and how much per hour? Ive always wanted to try opioid only. Sounds like MOney. I bet you get high satisfaction scores with that.

I forget. Used to do them in residency. Same as OB without local?? Theory was that LA would lead to hypotension jeopardizing the anastomosis. Also hydrophobic nature of fentanyl means it will theoretically stay in place and not suppress respiratory drive. Would not use fentanyl gtt in these patients. They need to breathe and given possible respiratory complications, don't want to complicate that picture further.

 

[OptionOffense]

You might as well just forgo the epidural and start a postop IV fentanyl infusion (if you aren't going to give any local anesthetic and choose a lipophilic opioid). TIC.

Why do that when you can infuse it right into the epidural space.

 

[Maz777]

Why do that when you can infuse it right into the epidural space.

How does a lipophilic opioid disperse neuraxially? Is it similar to a hydrophilic opioid like morphine? Hint, it doesn't stay in the epidural space. It rapidly diffuses out and into the plasma. There's no point in doing a fentanyl-only epidural infusion in any patient because it makes zero sense. Might as well start a fentanyl PCA with a basal rate. Would achieve the exact same thing as a fentanyl-only epidural.

 

[OptionOffense]

How does a lipophilic opioid disperse neuraxially? Is it similar to a hydrophilic opioid like morphine? Hint, it doesn't stay in the epidural space. It rapidly diffuses out and into the plasma. There's no point in doing a fentanyl-only epidural infusion in any patient because it makes zero sense. Might as well start a fentanyl PCA with a basal rate. Would achieve the exact same thing as a fentanyl-only epidural.

I agree that the plasma concentrations are similar when injected epidurally vs intravenously but isn't there a rich concentration of opioid receptors in the spinal cord that it attaches to to give additional benefits?

 

[nimbus]

You might as well just forgo the epidural and start a postop IV fentanyl infusion (if you aren't going to give any local anesthetic and choose a lipophilic opioid). TIC.

In residency we used 0.0625% bupiv + dilaudid 20mcg/ ml running 6-8ml/hr for thoracotomies. We’d occasionally get hypotension but it otherwise worked very well.

 

[drmwvr]

20 cc of .25?

Yep...We're talking about a straight ahead Ivor Lewis? A 3-4 hour slog at our shop. Top of the thoracotomy around T6 T7 bottom of the laparotomy around T10. Works great...up checking their phone in pacu. Start the infusion right after the bolus.

 

[Hoya11]

I agree that the plasma concentrations are similar when injected epidurally vs intravenously but isn't there a rich concentration of opioid receptors in the spinal cord that it attaches to to give additional benefits?

an interesting question, but my understanding is that there is no evidence of any analgesic advantage of neuraxial opioids vs systemic opioids

 

[Katheudontas parateroumen]

Epidural opioids are certainly more potent, no? 3-4 mg duramorph epidural is much more efficacious than 3-4mg morphine IV.

 

[Hoya11]

Epidural opioids are certainly more potent, no? 3-4 mg duramorph epidural is much more efficacious than 3-4mg morphine IV.

potency is irrelevant, which provides the better analgesia for the side effects?

would you rather have an epidural started on you and get 3mg morphine? or an IV and get 6mg?

IMO there is no ANALGESIC benefit to neuraxial opioids vs IV

 

[nimbus]

potency is irrelevant, which provides the better analgesia for the side effects?

would you rather have an epidural started on you and get 3mg morphine? or an IV and get 6mg?

IMO there is no ANALGESIC benefit to neuraxial opioids vs IV

We used to do intrathecal opioids for big pelvic whacks, cystectomies, exenterations etc. Those patients would be awake, bright eyed, and conversant in PACU with a pain score of 0/10. That was not achievable with IV opioids. Our PACU nurses were very impressed. We’ve now moved on to body wall blocks (due to occasional hypotension with IT opioids) but even those are not as consistently effective as IT opioids were. Purely in terms of pain control, I think we’ve taken a step back.

If there is no difference, why do people still put morphine in csection spinals?

 

[abolt18]

Edit: I can't read good.

 

[nimbus]

3mg epidural hydromorphone???? That's a pretty fat dose. I've never given more than 1mg. Usually do 0.5-0.8mg

He said duramorph (pf morphine), not hydromorphone.

 

[abolt18]

He said duramorph (pf morphine), not hydromorphone.

Ha! I skimmed while making lunch and just caught the 'D' drug.

 

[deleted875186]

Wow, a lot of hate on neuraxial opioids. Surprising.

They are more potent than IV, less side effects, different area of action as there are many opioid receptors in the spinal cord, and make the ED50 of local anesthetic needed for sensory block much less.

If I have a thoracic epidural, I give 50 mcg fentanyl along with some local at the start of the case, and the other 50mcg bolus at the end. Alternatively can give a 0.2-0.6 mg or so bolus of hydromorphone at the start, patient will wake up super comfortable, but always a risk of over narcotizing. Opioid only epidural works very well. No data to back this up with studies, but I 100% believe neuraxial opioids are far superior. Never understood giving IV opioids when you have an epidural unless pain is in a different body part or something.

 

[OptionOffense]

. Opioid only epidural works very well.

Thanks. I knew my eyes weren't playing tricks on me

 

[Hoya11]

We used to do intrathecal opioids for big pelvic whacks, cystectomies, exenterations etc. Those patients would be awake, bright eyed, and conversant in PACU with a pain score of 0/10. That was not achievable with IV opioids. Our PACU nurses were very impressed. We’ve now moved on to body wall blocks (due to occasional hypotension with IT opioids) but even those are not as consistently effective as IT opioids were. Purely in terms of pain control, I think we’ve taken a step back.

If there is no difference, why do people still put morphine in csection spinals?

i have not had that experience and apparently neither has anyone who has published literature..

they give IT duramorph for convenience in avoiding the PCA, not because its superior in any way

 

[Southpaw]

We used to do intrathecal opioids for big pelvic whacks, cystectomies, exenterations etc. Those patients would be awake, bright eyed, and conversant in PACU with a pain score of 0/10. That was not achievable with IV opioids. Our PACU nurses were very impressed. We’ve now moved on to body wall blocks (due to occasional hypotension with IT opioids) but even those are not as consistently effective as IT opioids were. Purely in terms of pain control, I think we’ve taken a step back.

If there is no difference, why do people still put morphine in csection spinals?

We still do for big pelvic cases. They do great. As do most CS who get IT duramorph. Not the case for those who don’t.

 

[woopedazz]

Morphine IT/epidural bolus makes sense in terms of its PK for post-op analgesia.

Fentanyl bolus for rapid onset is great too, but I'd argue there is a very limited role for fentanyl bolus via epi at the end of cases... If you want to fudge the PACU requirements, sure, be my guest. But I don't see how that helps the patient. I'm not a fan.

 

[deleted875186]

Morphine IT/epidural bolus makes sense in terms of its PK for post-op analgesia.

Fentanyl bolus for rapid onset is great too, but I'd argue there is a very limited role for fentanyl bolus via epi at the end of cases... If you want to fudge the PACU requirements, sure, be my guest. But I don't see how that helps the patient. I'm not a fan.

I give a fentanyl bolus along with a local bolus at the end of the case, lowers the ED50 of local needed for pain relief, less hypotension than giving a dense local bolus, and will typically last one hour into PACU, by which time the infusion is running and gives some time. Less risk of over narcotizing and having issues, could give a fairly big dose of fentanyl and not goin got get burned.

 

[epidural man]

Sorry, very basic question here... what is the exact importance of getting the T6 vs low Thoracic vs lumbar? I get that we are trying to be as exact as possible with which nerve roots get analgesia but would just a basic lumbar epidural with more volume do just as well? Or does it cause more motor weakness etc? Sorry, don't do that much regional anymore.

The goal of a thoracic epidural is to provide both static and dynamic pain control. Systemic opioids do a good job at static pain control, but are really bad at helping with dynamic pain control.

So the REAL goal is to allow your patient to get up and MOVE, so systemic opioids are very poor at accomplishing this early on.

So with mobility as the goal, a low lying thoracic or lumbar epidural doesn't work. You have to use such high volumes that you will likely take out the hip flexors (and possibly lower systems) AND you will make them hypotensive from the large volume of local anesthetic.

A well placed thoracic epidural (and I would shoot for T6 in this case) will accomplish your goal beautifully. However, to keep them from getting hypotensive, your really should run low concentration of local (20th percent, or 0.05% surprisingly works about 80% of the time). However, with a low concentration, you need to run it with an opioid for the synergistic effect. Keep volume low (6ml/hr, sometimes even less).

But neuraxial opioids scare people. Here is some data for your.

rate of respiratory depression with PCA: ~1%
rate of respiratory depression with neuraxial fentanyl: ~1%
rate of respiratory depression with neuraxial morphine: ~1%
rate of respiratory depression with neuraxial hyrdomorphone: 0% (This was shown in a large trial down at that orthopedic hospital of special services - something like that.)

If the 0.05% doesn't work well enough, increase it to 0.01%. If that doesn't work, don't' increase it anymore, you will just get hypotension without increase in analgesia. Just add toradol.

Most of the time, you don't even need a foley with a thoracic epidural. If they can't pee, put it in. I think you will need to put it back in about 1-5% of the time.

 

[Ronin786]

The goal of a thoracic epidural is to provide both static and dynamic pain control. Systemic opioids do a good job at static pain control, but are really bad at helping with dynamic pain control.

So the REAL goal is to allow your patient to get up and MOVE, so systemic opioids are very poor at accomplishing this early on.

So with mobility as the goal, a low lying thoracic or lumbar epidural doesn't work. You have to use such high volumes that you will likely take out the hip flexors (and possibly lower systems) AND you will make them hypotensive from the large volume of local anesthetic.

A well placed thoracic epidural (and I would shoot for T6 in this case) will accomplish your goal beautifully. However, to keep them from getting hypotensive, your really should run low concentration of local (20th percent, or 0.05% surprisingly works about 80% of the time). However, with a low concentration, you need to run it with an opioid for the synergistic effect. Keep volume low (6ml/hr, sometimes even less).

But neuraxial opioids scare people. Here is some data for your.

rate of respiratory depression with PCA: ~1%
rate of respiratory depression with neuraxial fentanyl: ~1%
rate of respiratory depression with neuraxial morphine: ~1%
rate of respiratory depression with neuraxial hyrdomorphone: 0% (This was shown in a large trial down at that orthopedic hospital of special services - something like that.)

If the 0.05% doesn't work well enough, increase it to 0.01%. If that doesn't work, don't' increase it anymore, you will just get hypotension without increase in analgesia. Just add toradol.

Most of the time, you don't even need a foley with a thoracic epidural. If they can't pee, put it in. I think you will need to put it back in about 1-5% of the time.

Name checks out