Thoracic Epidural for Decortication

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

Metalblade

Full Member
10+ Year Member
Joined
Jul 6, 2010
Messages
94
Reaction score
4
Wondering how you guys feel about placing thoracic epidurals in patients who have empyemas and are undergoing decortications? Do you avoid completely? Do you go by white count/symptoms?

Members don't see this ad.
 
Not worth it for a few reasons. One, it just isn't that uncomfortable postop. (Disclaimer, I've never had one).
Two, if it's not that uncomfortable then not worth the infectious risk. Ther are more but that's enough for me to not place them.
 
Members don't see this ad :)
A reasonable chance of puss coming out of the chest tube at some point...... No needle from me. No worth the risk for me , even for PVB.
 
We do them as VATS, and usually surgeon does percutaneous intercostal blocks while watching the local spread on camera. you can see the local tracking along the nerve, and seems to work pretty well...
 
What if the procedure is a thoracotomy? I've seen thoracotomies done for empyemas when the surgeon felt the pleural peel needed to be removed manually. Thanks for the responses so far.
 
Personally I have done thoracic epidurals for thoracotomies for empyema. I do recognize it's somewhat controversial, so I would qualify that in general antibiotics should be in place and the patient should not be acutely septic.
 
I agree. If the pt is on antibiotics prior to placement then I would place it.
 
I recently did a thoracotomy for an empyema. Took out a rib for it. I didn't quite know how to feel as I've seen them done very successfully via VATS. Ouch!
Def. give'em an epidural, PVB or intercostal if on abx. These patients need to be able to take breaths post-op to avoid atelectasis and other respiratory insults.
 
I'd do a para vertebral with a white count. Patient is getting antibiotics. I might not place a PVB catheter but would certainly repeat in 12-24 hours.


Sent from my iPad using Tapatalk
 
One of our surgeons now does these as local/MAC cases with the scope. Took me a while a while to wrap my head around that one but I gotta say it works amazingly well. I agree with others that if the plan is thoracotomy and pt has been on ABX with no sign of disseminated infxn/sepsis I would place one.
 
I'd do a para vertebral with a white count. Patient is getting antibiotics. I might not place a PVB catheter but would certainly repeat in 12-24 hours.


Sent from my iPad using Tapatalk

Do you guys know of any good papers you can point me towards for paravertebral catheters/ single shot vs epidural for thoracotomy or vats.....

I ask because , If paravertebral is even close to as good, why even bother with what the wbc count and abx status is?

Thanks
 
I've been doing para vertebrals since 1990. Didn't have ultrasound then and it was all by feel and landmarks. Now ultrasound makes it so easy. Why would you even do an epidural? No risk of sympathetic-block-induced hypotension. Only unilateral blockade. Excellent pain relief because it gets the ligaments near the head of the rib that are ripped by the retractor and which cannot be blocked with intercostal nerve block.

I learned from an old Royal Navy anesthesiologist who had perfected the art of para vertebral blocks. He might have published a case report or review article. His name was Richard Wyatt.

Eason MJ, Wyatt R. Paravertebral thoracic block - a reappraisal. Anaesthesia 1979; 34: 638–42.


Sent from my iPad using Tapatalk
 
Top