Epidural for pancreatitis

[PoorInvestment]

---

Members do not see this ad.

So I got consulted to today on a 71 yo F with acute pancreatitis of unknown etiology. Amylase was sky hight, LFTs outta whack, intense pain - standard pancreas stuff. Labs improved since admission 2 days ago except the WBCs which continue to rise Clinically appears to be improving except her pain is still "unbearable". She tolerates absolutely nothing for pain meds - narcs, tramadol, toradol, ASA - you name it she either gets hives or can't breathe or something else dramatic. Hospitalist calls and wants to know if I can drop in a T-epidural. The rising WBCs concerns me and I've never put in an epidural for this purpose. I decline the epidural until we can prove that this lady isn't bacteremic and going to bottom out on me or need more extensive intervention. Anyone have experience putting in an epidural for acute pancreatitis and would you do one in this patient?

 

[Chloroform4Life]

I have no experience with this, and I would be concern about development of an infection as well. The fact is that there isn't enough data to prove the safety of epidural analgesia in this population.

This study of 121 patients found no problem, but that's hardly a big enough N to detect major complications:
http://www.ncbi.nlm.nih.gov/pubmed/11908096

There is a multi center trial going on re: epidural analgesia in acute pancreatitis that should end in 2017. Maybe it will provide more answer:
https://clinicaltrials.gov/ct2/show/record/NCT02126332

But for now, even though I'm sure the risk of an epidural abscess would be low, I wouldn't want to risk it since that is a serious complication that can lead to paralysis and needing surgery. Noone dies from pain. If she's in an ICU setting, you could try ketamine gtt. Could try other multi-modal stuffs that she may not be allergic to like gabapentin.

 

[urge]

I don't have experience either but I don't see a problem with it.

There is no evidence of sepsis or bacteremia. The white count is very unspecific.

 

[sethco]

What's the end game? How long would the catheter stay in? I have seen people have prolonged bouts. Besides the possible bacteria, this would be my other concern

How about a Ketamine infusion?

 

[Ezekiel2517]

If you consider the risks vs benefits, your other options for analgesia, and have an understanding of acute pancreatitis, this is a no brainer

 

[Chloroform4Life]

If you consider the risks vs benefits, your other options for analgesia, and have an understanding of acute pancreatitis, this is a no brainer

No brainer how?

I can't tell from your post if you're pro or anti-epidural. I'm guessing anti.

I think we don't know the right answer on this subject one way or another, which is why there is a large multi-center study going on to answer it.

 

[Hoya11]

So I got consulted to today on a 71 yo F with acute pancreatitis of unknown etiology. Amylase was sky hight, LFTs outta whack, intense pain - standard pancreas stuff. Labs improved since admission 2 days ago except the WBCs which continue to rise Clinically appears to be improving except her pain is still "unbearable". She tolerates absolutely nothing for pain meds - narcs, tramadol, toradol, ASA - you name it she either gets hives or can't breathe or something else dramatic. Hospitalist calls and wants to know if I can drop in a T-epidural. The rising WBCs concerns me and I've never put in an epidural for this purpose. I decline the epidural until we can prove that this lady isn't bacteremic and going to bottom out on me or need more extensive intervention. Anyone have experience putting in an epidural for acute pancreatitis and would you do one in this patient?

offer to do a single shot celiac plexus block instead

 

[Orin]

Would you also tap the brakes on an OB epidural if there was leukocytosis in the setting of chorio?

I agree with the indication for epidural anesthesia if the patient is truly intolerant of the usual options. Agree with ketamine or lidocaine or remi or really a lot of other things, but this scenario isn't that crazy. It's not like they're asking you for a femoral catheter for pancreatitis.

 

[Chloroform4Life]

Would you also tap the brakes on an OB epidural if there was leukocytosis in the setting of chorio?

I agree with the indication for epidural anesthesia if the patient is truly intolerant of the usual options. Agree with ketamine or lidocaine or remi or really a lot of other things, but this scenario isn't that crazy. It's not like they're asking you for a femoral catheter for pancreatitis.

While I agree that an epidural would likely be fine in the OP's scenario, it is a bit different for OB.

OB epidural rarely stays in for >24 hours whereas pancreatitis patients will likely need it for days. The longer the catheter is in, the higher the chance of bacteremia causing epidural infection.

Also to mention, pacreatitis can lead to DIC, coagulation abnormalities, and thrombocytopenia, which may put you in a bind when you try to pull your catheter.

Thats a headache i dont want to deal with so I'd try pharmacologic measures that the patient is not allergic to first.

 

[Orin]

Thats a headache i dont want to deal with

This is probably the biggest factor in most clinician's decision making process with pain procedures

- Risk is minimal at 3 days, but agree it does increase slightly. Could always tunnel, do topical abx, remove/replace, etc to reduce/minimize risk.
- Pregnancy can lead to DIC, coagulation abnormalities, thrombocytopenia, etc.

This seems like a good case to step in and show off the anesthesiologist's role outside the periop realm, but again, agree with pursuing pharmacologic means first.

 

[drmwvr]

Y0u don't mention coags (probably because they're normal) but I like the aforementioned ketamine infusion if the hassle is worth the gratitude of the referring physician.

 

[PainDrain]

offer to do a single shot celiac plexus block instead

I hope this is a joke because this is a REALLY bad idea!!!! The tissue planes around the pancreas are a mess following a bad case of pancreatitis and if the pancreas is diffusely swollen, developed a pseudocyst or hemorrhage you have a good chance of directing a needle into a mess.


I personally would do the epidural but I would explain to the patient and the consulting team and get it in writing that there is a significant risk of infection. I would also stipulate that worsening clinical status or fever spike and the cath gets pulled.

Ketamine is a good thought but in older folks they can get loopy. A short-acting potent opiate such as remi could work with less side effect profile. Could try gabapentin or amitriptyline but these have more of a role in chronic pancreatitis due to neuropathic component of that condition.