Epidural failure on patient on suboxone

[seamonkey]

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38yoF, in good health 'till trashed in a car wreck this past spring. L 1-11 rib fx, spleen out, was trach/peg, SAH....but now doing great! Trach/peg out, feels wonderfull, looks actually very good, except for ventral hernia 2/2 multiple laparotomies in the spring. Coming in for large ventral hernia repair.
She is 65". 135lbs, on no pain meds, walkie talkie, really a PS2.

however, I find out on the pre-op night-before phone call, she in on suboxone.....for "nerves". Not because of opiod dependence 2/2 her icu time, but apparently has been on it for a year. for "nerves". denies any h/o drug use. whatever. i stop the last dose of it, fwiw

yadayadayad, epidural is +/- pre-induction, and intra-op looks non-effecive with boluses. 2 attendings tell me its working. i think it isn't. gets a xyphoid to pubis slice open. she is fine on emergence (no tachycardia, no tachypnea, no hypertension) until extubation. first word is kind of a scream. all downhill from there. 15mg morphine stat do not touch her and she is dropped off in sicu semi-screaming. attendings don't want too mcuh systemic opioid for fear of overshoot and apnea. Had acute pain service resident with me for transport, and it they eventually re-placed epidural with +/- success, had to split the bag and give local epidurally and iv opiods.

what a trainwreck.

so, obviously, knowing about the suboxone ahead of time and getting her off >3 days ahead would have helped, but that was not an option in this case.

anyone else had to deal with this scenario? failed epidural, concern of pain vs apnea in a suboxone patient?

 

[periopdoc]

My take on suboxone. For elective surgery with high likelihood of moderate to severe pain, patient should be off for 5 days minimum, and a pain management plan should be arranged by the physician who is managing the suboxone. I am happy if that plan is for me to manage the perioperative opiates, but I want to be sure that there is already someone to manage the bridge off of and back onto the suboxone. If the patient hasn't been off for 5 days, I would cancel the case. If the surgeon complains I would explain that this is the equivalent to doing this case while providing no postoperative analgesia.

For emergency cases, the patient gets loaded over the course of one hour in PACU. They need one on one nursing with a nurse who understands rapid loading of opiates. The patient gets a rapidly escalating opiate dose every 2-5 minutes. Each dose is doubled from the last one until the patient is either sedated or comfortable. Total the amount of opiate used over that one hour and divide by 6. That is your incremental q5min PCA dose with no lockout. The patient goes to a monitored setting overnight.

Of course you should also maximize non-opiate therapy. Blocks, ketorolac, tylenol, clonidine, dexmed, ketamine etc.

- pod

 

[Jeff05]

management: lower thoracic (t8-11) epidural with local only. put it in the right spot and give enough local (at least 0.1 bupi equiv). maybe up to 0.25. add epidural clonidine if not working.

ketamine during the case. 0.5mg/kg up front, then low dose (5-10mg/hr ) for remainder of case. if you're nice, throw in tap block. opioid mostly not effective for this.

 

[Narcotized]

Why did the epidural fail? I can't see if you gave LA or opiods only. Shouldn't LA work in the presence of suboxone?

 

[Bertelman]

Why did the epidural fail? I can't see if you gave LA or opiods only. Shouldn't LA work in the presence of suboxone?

Ditto. Maybe it was just a failed epidural in a patient that happened to be on subox

 

[coprolalia]

I had an outpatient during residency - who didn't tell me she was on Suboxone until after the surgery was over - almost jump completely off of the OR table during a 1.0 MAC sevoflurane LMA anesthetic when she was "over" stimulated. I roc'd her, something I had only done once before with an LMA. Scared the pants off of me.

-copro

 

[Jeff05]

Jeff, can you explain why not?

http://www.med.umich.edu/anes/pdf/Bup Policy for web.pdf

scroll down to last page for flow chart. i think post-op analgesic management will be very difficult for this patient.

sub has a very high affinity for mu. you would have to give large doses of potent opioids to competitively displace it from receptors.

 

[Ferdie]

why redo the whole epidural? why not just dose it with about 4 cc or so of 0.5% rop or 2% lido to tide her over while working in some IV goodies (ketamine sounds kinda nice here, don't you think?). Should work if you had a level preop or have a level now, and I think this is still what I'd do if there's no level - dose it and check a level in 15-20 min while hitting her with some ketamine

 

[Idiopathic]

i guess i dont see why this is any different than any failed epidural? the suboxone obviously hurt your narcotic plan but good coverage from a functioning epidural would have fixed things, IMHO.

 

[mille125]

Ditto. Maybe it was just a failed epidural in a patient that happened to be on subox

this was the problem

 

[seamonkey]

the epidural failed from the start due to poor placement (by me. Hey, I'm a CA-1, not done too many of these). The pt had no dermatomes anesthetized prior to induction of GA, but my attending felt that it would kick in later, so we went ahead. Throughout the case, had 2 attendings come in and bolus it and say it looked like it was working (we were just using a post-op pain bag for boluses, still on GA throughout). So, the failure was due to not being in the epidural space. Sorry if I didn't make that clear before.

Again, I found out she was on suboxone on the night-before phone call. Told my attending, but was told we would go ahead regardless, since the epidural would cover it. Spoke with Pain Service attending preoperatively as well, who felt the suboxone should not interfere with the neuraxial anesthetic....well, obviously the point is moot if the epidural is in the wrong place. That SUCKED.

 

[Idiopathic]

yeah this is the issue. in retrospect you get started on this one early, ensure good placement and replace if you have to before going back (yes its a beat down, but dont get fooled into thinking the "postop placement" will somehow be easier in case of failure).

 

[Idiopathic]

oh and the location of the epidural space doesnt change with your CA level, have a routine, execute it, test your placement and redo it if necessary. plenty of experienced practitioners have epidural failures

if this wasnt discussed as an option, consider using lidocaine 2% 5-10 cc up front before you go back and test with ice...you should see within 5-10 minutes, and if you start to get any temperature level then you can feel confident in your placement. if it fails later so be it

 

[huktonfonix]

oh and the location of the epidural space doesnt change with your CA level, have a routine, execute it, test your placement and redo it if necessary. plenty of experienced practitioners have epidural failures

if this wasnt discussed as an option, consider using lidocaine 2% 5-10 cc up front before you go back and test with ice...you should see within 5-10 minutes, and if you start to get any temperature level then you can feel confident in your placement. if it fails later so be it

5 cc of 2% lido should be plenty to see a dermatomal level. Another trick is to test in the OR with the end of a metal laryngoscope alcohol wiped with an alcohol pad (assuming the room is cold).

 

[foxtrot]

Anyone every run lidocaine infusions in the epidural space (low concentration, low dose) in post surgical chronic pain patient's on high dose narcs? I have seen IV lidocaine infusions for chronic pain pt's (especially fibromyalgia). Just curious, I probably would never do it though.

 

[huktonfonix]

Anyone every run lidocaine infusions in the epidural space (low concentration, low dose) in post surgical chronic pain patient's on high dose narcs? I have seen IV lidocaine infusions for chronic pain pt's (especially fibromyalgia). Just curious, I probably would never do it though.

??. Isnt this just a normal epidural? Or if it isnt, why wouldnt you just run a normal epidural dosage for this patient since the catheter is in? Unless you're talking about a patient thats out of the acute pain management stage.

 

[Idiopathic]

i think the longer you run that the worse your rebound will be, but my experience is limited.

i mean it has to come off sometime

 

[foxtrot]

??. Isnt this just a normal epidural? Or if it isnt, why wouldnt you just run a normal epidural dosage for this patient since the catheter is in? Unless you're talking about a patient thats out of the acute pain management stage.

I realize that it is a regular epidural I guess I have just never used a "lidocaine only" infusion in the epidural space (due to motor block, TNS, and sympathectomy issues, etc). I know that you can get into problems with 4% Lido but I guess you could run a lower concentration of Lido and not have to worry about TNS...I don't know, I have never done it. Just wondering if anyone has done Lido only infusions in the epidural space.

 

[seamonkey]

my attending told me i was in the correct space (probably my 4th epidural ever). The patient did not at all show any temperature differential after a bolus with 1% lidocaine. Attending thought it would be OK, so we induced GA....i expressed doubts throghout the case, but a second attending took over for a little and felt it was working....original attending back for emergence, again i express concern and am told respiration rate of 14 as we emerge indicates all is well.....tube pulled....first breath...followed immediately by "verbal indications of significant nociceptive stimulation".....

as a CA-1 i tend to defer to my attendings, but in this case i had to explain to this person what suboxone was the night before the case, and my concerns.

Any advice on how to tell someone with 30yrs of experience on you that thay might be wrong?

 

[Apollyon]

Any advice on how to tell someone with 30yrs of experience on you that thay might be wrong?

You don't. It's a bummer, it irritates you, and you wonder, but the BEST situation would be to, somehow, delicately, tell a colleague of that person, who might raise it, but even that BEST situation is fraught with peril and likely failure.