Intraoperative epidural management

[tweekin19]

Say you decide to do a CSE for a hip/knee revision. At what point do you turn the epidural on? If the case takes shorter than the spinal duration would you still run a low rate infusion (if so, what rate?) to avoid the epidural from clotting if the procedure takes over two hours? Or do you just wait to turn it on in PACU when patient starts to complain of discomfort?

Same for intraoperative epidurals for large abdominal surgeries (whipples, large ex laps, etc). If the patient is hemodynamically stable, would one start the epidural after incision to avoid having to use a lot of general anesthesia for a long case?

If you know of some protocols floating out there for ERAS ortho or abdominal surgeries pertaining to epidural usage, please link below.

Thanks in advance

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[coffeebythelake]

For CSE, usually after couple of hours at around 5 cc per hour. For GA with epidural usually I wait til end of case (around 30 min from emergence) to dose up.

 

[GaseousClay]

for joints or joint revision would never consider an epidural for postop. maybe a CSE for a long revision for intraop. big abdominal cases usually bolus a small amount before incision and then some at the end and begin the infusion. Theres no official cookbook for this you should be able to use clinical judgement on when and how to bolus/start infusion for surgery.

 

[Ronin786]

Maybe I just suck with my thoracic epidurals, but they always seem to be one of those things that offer more promise than results for open abdominal surgery.

 

[MirrorTodd]

The bigger cases that I have done with epidurals (liver resections, vhl type ****e), we bolused the epidural before heading back and then did a lightish general. Titrate epidural to vital signs during the case.

 

[Hork Bajir]

If your thoracic epidurals aren’t giving you excellent results, you’re doing it wrong. It’s not like a TAP block where you shrug and wonder if maybe it’s helping a little… When they work well, it’s not a question. Of course, they can be very humbling to place, and the number needed to become an “expert” is an order of magnitude greater than for lumbar epidurals IMHO.

As others have said, there is no cookbook. The basic approach I have been taught and using successfully is this:

For big abdominal cases, bolus approximately 1 cc per dermatome you’re trying to cover. Re dose throughout the case based on kinetics of the local you choose (Q45 min for lido, Q1hr for bupi, etc). Choose your local based on what you’re trying to accomplish- usually I stick with 2% lido. Run the patient at 0.7 MAC of vapor, expect train track vital signs, and if you’re not on a little bit Of phenylephrine then question how well your epidural is working. At the end of the case, switch over to some more dilute mix which will be continued on a pump postop.

 

[Hoya11]

Say you decide to do a CSE for a hip/knee revision. At what point do you turn the epidural on? If the case takes shorter than the spinal duration would you still run a low rate infusion (if so, what rate?) to avoid the epidural from clotting if the procedure takes over two hours? Or do you just wait to turn it on in PACU when patient starts to complain of discomfort?

Same for intraoperative epidurals for large abdominal surgeries (whipples, large ex laps, etc). If the patient is hemodynamically stable, would one start the epidural after incision to avoid having to use a lot of general anesthesia for a long case?

If you know of some protocols floating out there for ERAS ortho or abdominal surgeries pertaining to epidural usage, please link below.

Thanks in advance

If I did a CSE I would wait two hours and then start the infusion at 6ml/hr, then 10ml/hr at 3hrs and until wake up. Cant think of a situation where this would be my plan though. You don't need to run the epidural to keep the catheter patent, you can just flush it with saline every hour in a 10cc bolus.

More commonly, with a thoracic epidural for chest or abdominal surgery, I start it at 6 as soon as they go to sleep. I bolus about 10cc of 0.25% first. Maybe a small amount of lido 2% mixed in there too. Then titrate the drip up from 6 as needed per vital signs during the case. Usually land on around 10ml/hr running upon wake up/drop off to PACU. Usually im talking about eigth percent bupivicaine infusion.

Giving boluses and Running the infusion during the case is so satisfying. But be cautious because these are big surgeries and surgeons can suddenly cause bleeding, and now youve got epidural induced hypotension plus blood loss. Thankfully havent had that happen..

I like to run my bupivicaine infusions without opioid. Some pharmacies have policies about not giving any other opioids once neuraxial opioids are being given. I find it better to just do a plain local infusion at a relatively high rate like 8-12, and let the primary team supplement with IV or PO opioid.

Sometimes I see docs try to completely ( no supplemental opioids) control a wide thoracotomy incision with just the epidural and its measly 2mcg/ml fentanyl, and even the best placed epidurals can always leave gaps in coverage depending on surgical incision. Another mistake is running it at too low of a rate like 5 which doesnt create a wide enough coverage area. So my philosophy is high volume, dilute local, no opioids neuraxially (unless I can also give it IV and Po too).

 

[Norepi]

Why arent you people using your epidurals intraop?
Paramedian thoracic, bolus 2% lido with epi 5-7 cc q 45-60 mins depending on surgical conditions. Should not be a question of whether its working, if it's working its obvious. Can then get away with running .6-.7 MAC volatile, swap final bolus of the case out for a bump bolus of 10-15 ccs of bupivacaine .1% with hydromorphone 10mcg/ml.

We dont have great data for thoracic, but for lumbar labor epidurals boluses are superior, thus I extrapolate to the thoracic space and bolus them (to mimic "PIEB") for these patients. Data isnt great for intraop "pre-emptive" analgesia either, but I'd rather cause the sympathectomy and combat intraop pain at the source if I can. But I am biased as I am interested in abating the development of persistent post-surgical pain.

 

[pgg]

I did a Whipple today and (as I nearly always do) used the epidural intraop, starting before incision.

Very rarely I'll have enough issues with hypotension or bleeding to slow or stop an epidural. But even in those cases, I'll tolerate and prefer even a hefty infusion of phenylephrine or norepi to allow me to use it. 99% of the time once they're awake the pressor infusion can stop, assuming I've kept up with transfusion and fluids.

Today in PACU, 10 minutes after extubation, had an awake zero pain patient whose only complaint was about the NG tube in his nose. Minimal opioids for the case, probably could've been zero opioids. If you've put an epidural in someone for an abdominal case, I think it makes most sense to get as much use out of it as you can.

 

[deleted875186]

As said above, I always use the epidural intraoperatively. I bolus 5 mL of 1% lido before heading back, and check a level with ice before induction, so I’m 100% certain it’s working. Usually 5-7 cc per hour as noted above. I use lido 1% intraop and switch to bupi at the end.

All intraop opioids are through the epidural. Typically 50 mcg epidural fentanyl before incision, 50 mcg epidural with the bolus before waking up. I will also usually give anywhere from 0.2 - 0.8 epidural hydromorphone at the start or at the end of the case, at least 30 mins before wake up. People should wake up pain free and feeling great. I have used the 0.8 mg epidural dose in opioid tolerant people and it works wonders.

 

[OneFellSwoop]

Never done a CSE for hips or knees, just haven’t needed it.

I Always use a thoracic epidural for cases intraoperatively. It is absolutely obvious if it is working. I give 1cc IV fentanyl for induction and then no narcotics afterward. 0.25%bup boluses 5-10cc is all that is typically needed and then titrated to vitals throughout. As others have said, To me, it’s one of the most satisfying aspects of anesthesia when the only complaint in PACU is the NG and they just had a big belly whack.

 

[Mman]

If I did a CSE for some reason, just turn on the epidural infusion and use it from the start. If you start an epidural with no bolus, it is going to take 45-60 minutes to start having an effect. I mean sure you don't need it right away because the spinal is working, but it is so long to take effect that you might as well get it going.

Also if I am doing a CSE for something, I would give a lower spinal dose than I otherwise would use. So slightly smaller spinal dose plus turn the epidural on right away.



For big abdominal surgeries with an epidural, I either turn it on from the start or just wait til any expected major blood loss is over with. I would rather not deal with vasodilation on top of hemorrhage.

 

[Mman]

To me, it’s one of the most satisfying aspects of anesthesia when the only complaint in PACU is the NG and they just had a big belly whack.

i've got to pee

i've got to pee

i've got to pee


I imagine the PACU nurses dislike having to tell them to just go.

 

[abolt18]

All these patients complaining of NG tube discomfort... Clearly you're not dosing your epidural heavily enough! Load that baby UP!

 

[nimbus]

All these patients complaining of NG tube discomfort... Clearly you're not dosing your epidural heavily enough! Load that baby UP!

Some smart regional guru should develop “the epidural of the nose”.

 

[deleted875186]

I will say I find the mentality of avoiding using an epidural intraoperatively because yojr afraid of hypotension ridiculous. We use vasopressors all the time, you know there will be vasodilation. I have yet to hear anyone have issues even with some surgical bleeding. Granted if your doing some open AAA or something g crazy fine, but for a whipple, ex lap, thoracotomy, etc, I find it crazy.

 

[DrZzZz]

I will say I find the mentality of avoiding using an epidural intraoperatively because yojr afraid of hypotension ridiculous. We use vasopressors all the time, you know there will be vasodilation. I have yet to hear anyone have issues even with some surgical bleeding. Granted if your doing some open AAA or something g crazy fine, but for a whipple, ex lap, thoracotomy, etc, I find it crazy.

Surgeon dependent. In training, we had a surgeon who'd often lose a blood volume in their Whipples. We didn't use the epidural intraop for them. In my current practice, I've never given more than 2 units in a whipple and rarely need any blood. So we regularly use the epidural.

 

[deleted697535]

If your thoracic epidurals aren’t giving you excellent results, you’re doing it wrong. It’s not like a TAP block where you shrug and wonder if maybe it’s helping a little… When they work well, it’s not a question. .

Where are you getting that from?
I work in a centre that is very epidural heavy. Big cancer liver and thoracic centre. Probably 4 thoracic epidurals per day and we have a failure rate of about 10% for one reason or another.

Failure being defined as need to add pca or similar.

Many reasons varying from blocked, disconnected, one sided, patchy or insufficient levels.
Lots of junior residents or fellows unfamiliar with the technical aspects

Ive done epidurals i was certain were good only to find them one sided and others that i thought were useless but worked great post op just the patient had chronic pain as a background...

Admittedly the former is more common than the latter

Tbh im not really a fan of them except for open lung resections in tenuous patients

 

[Katheudontas parateroumen]

Say you decide to do a CSE for a hip/knee revision. At what point do you turn the epidural on? If the case takes shorter than the spinal duration would you still run a low rate infusion (if so, what rate?) to avoid the epidural from clotting if the procedure takes over two hours? Or do you just wait to turn it on in PACU when patient starts to complain of discomfort?

Same for intraoperative epidurals for large abdominal surgeries (whipples, large ex laps, etc). If the patient is hemodynamically stable, would one start the epidural after incision to avoid having to use a lot of general anesthesia for a long case?

If you know of some protocols floating out there for ERAS ortho or abdominal surgeries pertaining to epidural usage, please link below.

Thanks in advance

If I was doing a CSE for hip, it’d be a lumbar CSE. So I would just start the infusion right away at 8-10. No bolus of course after the CSE. Not any different than a labor CSE. I’d just use dilute local solution.

For a whipple mid or low thoracic (which ever level seemed easiest) epidural id bolus with whatever you’d want. Usually I use Bupi 0.2 because that’s what’s available easily for me. Do 6-10cc bolus before going to sleep and check the level. Whatever was needed to get a level is the rate I set at. Usually about 6. Again, I like just dilute local solution.

but yes definitely use the epidural. No reason not to. If hypotensive, use pressors like you would usually anyways. Run the MAC lowish 0.8-0.7.

 

[Hork Bajir]

@Newtwo i don’t think we are disagreeing. I said WHEN they work, not that they always do. 10% failure rate sounds about right. That means 90% of the time they work well. And a failure because it was placed by a junior resident who is unfamiliar with the technical aspects of the procedure- I agree, and I said as much, which is that they are finicky to place and require a lot of experience in order to get good results consistently (unlike lumbar epidurals). I also work at a very high volume epidural center. If I needed an ex-lap, I would 100% want one (and I’d want the most experienced person placing it)

 

[tweekin19]

Thank you everyone for your inputs! I love seeing other anesthesiolgists' way of doing things and am grateful that SDN serves as a platform for that. Some of the things I was learned in residency differ from what my private practice colleagues do.

For instance (going on another tangent), in residency whenever we got a wet tap, we were told to thread a catheter at the site of wet tap to prevent PDPH. The catheter was bolused with 1ml of the epidural mix from cartridge and 0.5 ml increments to set up the block. My shop ran low dose 0.0625% bupiv and fentanyl. The continuous infusion was than ran 2ml/hr ( increased by 0.5 ml/hr if inadequate) with no button given to patient. My current job, we were advised to just remove at wet tap and go a level above or below.

My concern is the dosing of the intrathecal catheter if patient was called for a c-section. I didn't encounter a situation in residency where I had to use an intrathecal epidural catheter for c section. For those who choose to do this, how do you dose it? Or would you not bother and just remove and do a spinal in the OR if there was time?

If this intrathecal catheter was recently bolused and found not to work well (and there was time) would you wait to do a spinal? If no time, go to GA I assume?

 

[Mman]

My concern is the dosing of the intrathecal catheter if patient was called for a c-section. I didn't encounter a situation in residency where I had to use an intrathecal epidural catheter for c section. For those who choose to do this, how do you dose it? Or would you not bother and just remove and do a spinal in the OR if there was time?

if the L&D patient has a spinal catheter that is working well, would be insane to remove and try to stick another spinal. It's literally the best possible anesthesia for a c-section. You get the benefits of the spinal, but can titrate or redose as necessary.

If they have a spinal catheter that isn't working well, then they don't have a spinal catheter.

 

[IMGASMD]

Thank you everyone for your inputs! I love seeing other anesthesiolgists' way of doing things and am grateful that SDN serves as a platform for that. Some of the things I was learned in residency differ from what my private practice colleagues do.

For instance (going on another tangent), in residency whenever we got a wet tap, we were told to thread a catheter at the site of wet tap to prevent PDPH. The catheter was bolused with 1ml of the epidural mix from cartridge and 0.5 ml increments to set up the block. My shop ran low dose 0.0625% bupiv and fentanyl. The continuous infusion was than ran 2ml/hr ( increased by 0.5 ml/hr if inadequate) with no button given to patient. My current job, we were advised to just remove at wet tap and go a level above or below.

My concern is the dosing of the intrathecal catheter if patient was called for a c-section. I didn't encounter a situation in residency where I had to use an intrathecal epidural catheter for c section. For those who choose to do this, how do you dose it? Or would you not bother and just remove and do a spinal in the OR if there was time?

If this intrathecal catheter was recently bolused and found not to work well (and there was time) would you wait to do a spinal? If no time, go to GA I assume?

We were the opposite in residency. No intrathecal catheters at all, for various reasons.

I now occasionally run spinal catheters, it’s just another catheters as far as I am concerned. Just need to educate the patient, which I don’t mind doing, AND let the nurse know/educate which is the part I hate. L&D nurses are special, as most already aware.

If I had to use it, would just check as we do after a spinal. Establish a level before. If I don’t feel comfortable use the bag for bolus for whatever reason, I would just crack a new vial of whatever I am comfortable use and incrementally dose it up.

Just for my own curiosity, what makes you concerned about dosing the spinal catheter or dosing it?

 

[deleted697535]

An intrathecal catheter on a ward is a lethal weapon. Just disaster waiting to happen. Eventually someone unsuspecting will bolus that up

If its in then ok carry on and use it but why for heavens sake place one in the first place.

Intraop and pulled post op probably ok...
I just cant see why anyone would do that. Do you actually do it intentionally. Like get informed consent to place one?

Tell the lady that there is a far safer alternative that im not going to do just because

 

[IMGASMD]

An intrathecal catheter on a ward is a lethal weapon. Just disaster waiting to happen. Eventually someone unsuspecting will bolus that up

If its in then ok carry on and use it but why for heavens sake place one in the first place.

Intraop and pulled post op probably ok...
I just cant see why anyone would do that. Do you actually do it intentionally. Like get informed consent to place one?

Tell the lady that there is a far safer alternative that im not going to do just because

Nah, I only do it when I wet-tap. Unlike some people, I do occasionally push a little too hard and fast….

I tell the nurse, the patient and write “spinal catheter no bolus” all over. Change the pump to run at 1ml/hr. Like everyone else said, you know it’s working, if it’s working.

 

[deleted697535]

Why do you do it after wet tap? If its to prevent pdph, hasnt that been disproven? Thankfully

 

[Mman]

Why do you do it after wet tap? If its to prevent pdph, hasnt that been disproven? Thankfully

if you wet tap them, why not give them the absolute best analgesia ever? Spinal catheters are great. I mean nobody intentionally places them for labor, but if you wet tap them they are already likely going to get a headache so why not give them a great labor experience? Plus if they need a c-section ultimately (probably 25% chance) you are golden.

Worst thing possible would be to wet tap them, go somewhere else and give them an epidural that ends up not being perfect, and then they still get a headache. You already wet tapped them, at least get the benefits out of it.

I understand people that are afraid nurses will do something stupid to the spinal catheter, but that is an education issue that needs to be fixed, not a reason to not do it.


edit: I guess the worst thing would be to wet tap them at 1 level, start over somewhere else and wet tap them again. Never ending headache....

 

[deleted875186]

if you wet tap them, why not give them the absolute best analgesia ever? Spinal catheters are great. I mean nobody intentionally places them for labor, but if you wet tap them they are already likely going to get a headache so why not give them a great labor experience? Plus if they need a c-section ultimately (probably 25% chance) you are golden.

Worst thing possible would be to wet tap them, go somewhere else and give them an epidural that ends up not being perfect, and then they still get a headache. You already wet tapped them, at least get the benefits out of it.

I understand people that are afraid nurses will do something stupid to the spinal catheter, but that is an education issue that needs to be fixed, not a reason to not do it.

100% agree. Also, why risk another procedure when you can simply thread the catheter and be done with it. It’s almost the more conservative option, just take it and run the low dose spinal catheter, no boluses.

 

[IMGASMD]

edit: I guess the worst thing would be to wet tap them at 1 level, start over somewhere else and wet tap them again. Never ending headache....

Been there, done that. When I first came out. Part of the reason why I changed my practice. If other partners do it, I don’t see why I can’t/shouldn’t.

My first job was a smaller hospital, difficult to recruit new l&d nurses. I was more comfortable than at a “training hospital” that has high turnovers and training new staff all the time.