Midline approach for TEP

[okayplayer]

After doing paramedian approach for most of my training for thoracic epidurals I have started going midline initially for all but really high thoracic epidurals. In my hands at least I find my first pass success rate is way higher midline.

Anyone else favor midline approach for mid to low thoracic epidurals?

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[Arch Guillotti]

How high do you consider "really high"? I always go paramedian since that is how I was trained. Since I do few of these I stick with what works for me.

 

[okayplayer]

How high do you consider "really high"? I always go paramedian since that is how I was trained. Since I do few of these I stick with what works for me.

T4 or so (ie. for a thoracotomy).

 

[WholeLottaGame7]

After doing paramedian approach for most of my training for thoracic epidurals I have started going midline initially for all but really high thoracic epidurals. In my hands at least I find my first pass success rate is way higher midline.

Anyone else favor midline approach for mid to low thoracic epidurals?

T10-T12 I'll usually go midline, higher than that and I always go paramedian. If they're young-ish and have particularly nice spaces higher up, sometimes I'll go midline but typically no.

So, lower - yes, mid - occasionally.

 

[Noyac]

I would usually go paramedian for all my TEA but when I was in the pain clinic I always went midline. I would do ESI's up to C 6/7 this way. Therefore, one day I just switched to midline for everything and haven't really looked back.

 

[pgg]

Anyone else favor midline approach for mid to low thoracic epidurals?

Yes. I don't do many, but I start midline. It's been a couple years since I needed to try again with a paramedian approach.

 

[Jay K]

midline

 

[psychbender]

In training, I rarely did paramedian for any epidurals, so I stick to midline. So far, I haven't found a patient that necessitated a change in approach (probably just low n).

 

[Noyac]

In training, I rarely did paramedian for any epidurals, so I stick to midline. So far, I haven't found a patient that necessitated a change in approach (probably just low n).

The ones I find necessitating the paramedian approach are the elderly. And they may be thin which is frustrating cuz you look at them and think slam dunk. But like I said I haven't done it in awhile, maybe one or two paramedian a year.

 

[psychbender]

The ones I find necessitating the paramedian approach are the elderly. And they may be thin which is frustrating cuz you look at them and think slam dunk. But like I said I haven't done it in awhile, maybe one or two paramedian a year.

When I had the occasion, I still went midline on those patients. Now, I don't get to practice and find patients who prove me wrong, as my CT surgeons are in love with exparel.

 

[Noyac]

Are they " in love" with it cuz it works well or cuz they can bill for it?
Where are they putting it, intercostal?

 

[sevoflurane]

Right from the manufacturer of exparel:

"EXPAREL Phase 3 Clinical Trial in Intercostal Nerve Block Does Not Meet Primary Endpoint...
The study did not achieve its primary endpoint of a reduction of cumulative pain scores over 72 hours."

http://investor.pacira.com/phoenix.zhtml?c=220759&p=irol-newsArticle&ID=1843862&highlight

 

[sevoflurane]

+1 for midline.

Hanging drop for cervicals.

 

[epidural man]

Paramedian.

Take a look at a spine model - then make your decission.

We are rock solid in the mid thoracic area in the midline. You guys that get an epidural at T8 using midline - good on ya.

The people that do them often and have a high success rate generally do them paramedian.

Where I did my fellowship, we had to round on on the epidural patients (routinely 15-25 TEA in the hospital). Everyone at that hospital placed them paramedian. They were an epidural machine.

However, now using exparel for TAP and rectus sheath, and pectus and serratus blocks higher up, I'm not sure an epidural is needed that often.

Off the subject, we did two cases of on open chole with a rectus sheath and serratus block. It worked both times phenomenally well.

 

[psychbender]

Are they " in love" with it cuz it works well or cuz they can bill for it?
Where are they putting it, intercostal?

I work in the military system, so billing is not an issue. They inject intercostal, and are getting about 48 hours of decent pain relief from that. Considering where I trained, we usually pulled the epidural within 48 hours, the duration of analgesia is the same, although I still argue that a properly placed thoracic epidural offered superior pain relief. Thoracic epidurals used to be done more commonly here before I arrived, but I get the sense that the surgeons stopped asking for them because they were tired of: 1) waiting to start because the staff doing the case had an SRNA or was covering CRNAs who would take forever repeatedly impaling patients, 2) dealing with hypotension and their patients getting more fluid post-op, and 3) the anesthesiologists themselves didn't like to have to round on the patients afterwards. The willingness to hand these cases and procedures off to the nurses, and the lack of interest in anything outside of the operating room are some of the issues that I have with the other members of my department.

 

[Noyac]

Sp

Right from the manufacturer of exparel:

"EXPAREL Phase 3 Clinical Trial in Intercostal Nerve Block Does Not Meet Primary Endpoint...
The study did not achieve its primary endpoint of a reduction of cumulative pain scores over 72 hours."

http://investor.pacira.com/phoenix.zhtml?c=220759&p=irol-newsArticle&ID=1843862&highlight

spoiler!

 

[napman]

I work in the military system, so billing is not an issue. They inject intercostal, and are getting about 48 hours of decent pain relief from that. Considering where I trained, we usually pulled the epidural within 48 hours, the duration of analgesia is the same, although I still argue that a properly placed thoracic epidural offered superior pain relief. Thoracic epidurals used to be done more commonly here before I arrived, but I get the sense that the surgeons stopped asking for them because they were tired of: 1) waiting to start because the staff doing the case had an SRNA or was covering CRNAs who would take forever repeatedly impaling patients, 2) dealing with hypotension and their patients getting more fluid post-op, and 3) the anesthesiologists themselves didn't like to have to round on the patients afterwards. The willingness to hand these cases and procedures off to the nurses, and the lack of interest in anything outside of the operating room are some of the issues that I have with the other members of my department.

TEP's are losing popularity for other resions also. I know that post hoc analysis are not very reliable but TEP is going to be under great scrutiny after this study

Neuraxial block, death and serious cardiovascular morbidity in the POISE trial.
Br J Anaesth. 2013 Sep;111(3):382-90
BACKGROUND:
This post hoc analysis aimed to determine whether neuraxial block was associated with a composite of cardiovascular death, non-fatal myocardial infarction (MI) and non-fatal cardiac arrest within 30 days of randomization in POISE trial patients.
METHODS:
A total of 8351 non-cardiac surgical patients at high risk of cardiovascular complications were randomized to β-blocker or placebo. Neuraxial block was defined as spinal, lumbar or thoracic epidural anaesthesia. Logistic regression, with weighting using estimated propensity scores, was used to determine the association between neuraxial block and primary and secondary outcomes.
RESULTS:
Neuraxial block was associated with an increased risk of the primary outcome [287 (7.3%) vs 229 (5.7%); odds ratio (OR), 1.24; 95% confidence interval (CI), 1.02-1.49; P=0.03] and MI [230 (5.9%) vs 177 (4.4%); OR, 1.32; 95% CI, 1.07-1.64; P=0.009] but not stroke [23 (0.6%) vs 32 (0.8%); OR, 0.76; 95% CI, 0.44-1.33; P=0.34], death [96 (2.5%) vs 111 (2.8%); OR, 0.87; 95% CI, 0.65-1.17; P=0.37] or clinically significant hypotension [522 (13.4%) vs 484 (12.1%); OR, 1.13; 95% CI, 0.99-1.30; P=0.08]. Thoracic epidural with general anaesthesia was associated with a worse primary outcome than general anaesthesia alone [86 (12.1%) vs 119 (5.4%); OR, 2.95; 95% CI, 2.00-4.35; P<0.001].
CONCLUSIONS:
In patients at high risk of cardiovascular morbidity, neuraxial block was associated with an increased risk of adverse cardiovascular outcomes, which could be causal or because of residual confounding

 

[nap$ter]

After doing paramedian approach for most of my training for thoracic epidurals I have started going midline initially for all but really high thoracic epidurals. In my hands at least I find my first pass success rate is way higher midline.

Anyone else favor midline approach for mid to low thoracic epidurals?

nope - always start paramedian for anything above T12, and all levels for anyone over 80 yo. review a spine model - the target is bigger fromt he paramedian approach, and you avoid midline calcifications. imho if your midline thoracic success rate is higher you were doing something wrong with your paramedian approach.

 

[UBCmed09]

At my training program (Canada), we have a fairly prominent thoracics group who are almost exclusively proponents of a paramedian approach. Consequently that's how most of us approach thoracic epidurals. It's only in my final (5th) year of training now that I have settled on an initial midline approach for low thoracics (like T9 and lower). If the spaces are difficult to palpate or if I'm placing it higher I'll go paramedian.

 

[chmd]

I always go midline, but mostly because I never practiced paramedian enough in residency.

Any advice on learning paramedian approach? I've done a handful of them.

We mostly did paravertebral catheters for thoracic surgeries in training, so that's part of my excuse I guess. Those are really nice and easy to do, but I haven't carried them over to my PP group mostly because no one else does them and I don't want to offer surgeons a procedure that only 1 of 7 anesthesiologists can do. Also they are time consuming since you typically need to place 2 on the same side.