nephrectomy level of epidural

[criticalelement]

Just wanted to know what interspace any of you guys use to place epidural for nephrectomy. Lumbar or thoracic? This epidural is presumably being used for post op pain. general for the case

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[Planktonmd]

Just wanted to know what interspace any of you guys use to place epidural for nephrectomy. Lumbar or thoracic? This epidural is presumably being used for post op pain. general for the case

T7-T8

 

[criticalelement]

T7-T8

lumbar not adequate?

 

[vector2]

lumbar not adequate?

I think you'd be able to get a high enough level with a surgical anesthesia bolus dose at a high lumbar level, but for post op it would have to be mid thoracic if you're running like 5cc/hr of 0.2% ropiv

 

[ZzzPlz]

If you want them to be able to mobilize post op you need thoracic

 

[Hoya11]

high lumbar low thoracic where i run an infusion at more like 10-12/hr of 0.125%. patient will still be able to hobble to bathroom and back to bed which is all they really do anyway. 5cc/hr at T7/8 seems too laser beam focused to me, just put it in in an open space in the ballpark and be a little more liberal with more dilute LA, boluses of stronger stuff PRN

 

[Twiggidy]

T7-T8

Yep.

I remember as a resident rotating on Pain getting called all day by the Gen Surg service because one of the more "regional skill lacking" attendings did a "high lumbar" epidural and the patient was miserable. After finally deferring the gen surg resident's calls to him because I got tired of hearing my page,r he thought he'd go bolus the patient to "get the level up". The patient was still miserable and it took an irate Surgery attending to find another anesthesiologist to put it in a thoracic space and the patient was happy.

Thoracic epidurals can be a pain if you dont do them a lot but in cases like these and thoracotomies the patients will love you for it. Also, I like paramedian with thoracic epidurals.

 

[WholeLottaGame7]

Thoracic. T7-T8 seems a little high for insertion site since the catheter will thread up a little, so I'd probably say more like T9 or 10, but not much lower than that. Would not bother with lumbar.

 

[ZzzPlz]

Regardless of level, give them a big dose of duramorph and you're more than likely going to get decent analgesia.

 

[BLADEMDA]

QUEEN’S UNIVERSITY

DEPARTMENT OF ANESTHESIOLOGY

SUBJECT: Epidural Catheter placement for post-operative pain management


NUMBER

PAGE 1 of 6

ORIGINAL ISSUE 2003 10 01

REVIEW

REVISION


Recommendation:



Level

Surgical Procedure/Site of Injury

T 6-7

Thoracic procedures; Rib fractures

T 7-8

Thoracoabdominal procedures ( 2 incisions)

T 7-8; T 8-9

Upper abdominal procedures; Nephrectomy;

T9-10

Mid and lower abdominal procedures

T10-11

AP resection; Pelvic pouch procedure


Landmarking

• Mark the level before prepping and draping - non-transparent drapes may make more difficult when applied – the area of epidural placement should be properly draped with the window of the drape over the interspace for placement;
• Helpful landmarks to find:
  • T1 most prominent spinous process - mark every spinous process below to desired level - most reliable approach;
  • T7 spinous process is located in projection of the line connecting lower scapular angles – note: it is possible to miscalculate one level up or down

 

[BLADEMDA]

Regardless of level, give them a big dose of duramorph and you're more than likely going to get decent analgesia.

I totally agree. I do 80 percent of my epidurals for these cases at L1-L2 or L2-L3 and use duramorph. I bolus with 5-6 mg of duramorph then run an infusion of 0.4-0.6 mg per hour via the pump. My results are excellent with high patient satisfaction.

If I was going to use dilute local then the epidural would be T8-T9.

 

[vector2]

I totally agree. I do 80 percent of my epidurals for these cases at L1-L2 or L2-L3 and use duramorph. I bolus with 5-6 mg of duramorph then run an infusion of 0.4-0.6 mg per hour via the pump. My results are excellent with high patient satisfaction.

If I was going to use dilute local then the epidural would be T8-T9.

What's your unbearable pruritus rate like with the duramorph infusion?

 

[sevoflurane]

high lumbar low thoracic where i run an infusion at more like 10-12/hr of 0.125%. patient will still be able to hobble to bathroom and back to bed which is all they really do anyway. 5cc/hr at T7/8 seems too laser beam focused to me, just put it in in an open space in the ballpark and be a little more liberal with more dilute LA, boluses of stronger stuff PRN

That last part sounds complicated. Are your nurses getting a different solution, unhooking the catheter and then bolusing in the middle of the night for breakthrough pain?

 

[Scotty_G]

Woah duramorph infusion, really? How safe is that? I do low thoracic for nephrectomy. I prefer T9-T10 but T7-8 is fine too.

 

[BLADEMDA]

Woah duramorph infusion, really? How safe is that? I do low thoracic for nephrectomy. I prefer T9-T10 but T7-8 is fine too.

Many older anesthesiologists have used epidural morphine or dilaudid with excellent results. My group has been doing this technique for 3 decades and I know many other groups doing the same thing.

Side-effects are mild and itching isn't much of an issue. Sedation can occur with epidural morphine so adjusting the dose for age/procedure is important.

https://books.google.com/books?id=O...&q=duramorph epidural for nephrectomy&f=false

 

[Scotty_G]

I have done epidural dilaudid infusions, but not duramorph.

 

[RxBoy]

I totally agree. I do 80 percent of my epidurals for these cases at L1-L2 or L2-L3 and use duramorph. I bolus with 5-6 mg of duramorph then run an infusion of 0.4-0.6 mg per hour via the pump.

Do you change the formula for the all american team obesity crowd?

 

[BLADEMDA]

June 1984
SCIENTIFIC ARTICLE: PDF Only
Comparison of Intramuscular and Epidural Morphine for Postoperative Analgesia in the Grossly Obese: Influence on Postoperative Ambulation and Pulmonary Function.
Rawal, Narinder MD, PhD; Sjostrand, Ulf MD, PhD; Christoffersson, Esse MD, PhD; Dahlström, Bengt PhD; Arvill, Anders MD, PhD; Rydman, Hans MD

Abstract

In a randomized double-blind study of thirty grossly obese patients undergoing gastroplasty for weight reduction, the effects of intramuscular and epidural morphine were compared as regards analgesia, ambulation, gastrointestinal motility, early and late pulmonary function, duration of hospitalization, and occurrence of deep vein thrombosis in the postoperative period. The patients were operated on under thoracic epidural block combined with light endotracheal anesthesia. A six-grade scale was devised to quantify postoperative mobilization. A radioactive isotope method using 99mTc-plasmin was employed to detect postoperative deep vein thrombosis. For 14 hr after the first analgesic injection, respiratory frequency was noted every 15 min and arterial blood gases were measured hourly. Peak expiratory flow was recorded daily until the patient was discharged from hospital. Spirometry was performed the day before and the day after surgery. Plasma concentrations of morphine were measured after both intramuscular and epidural administration. Both intramuscular and epidural morphine gave effective analgesia, but the average dose of intramuscular morphine was up to seven times greater than that required by the epidural route. A larger number of patients receiving epidural morphine postoperatively were able to sit, stand, or walk unassisted within 6, 12, and 24 hr, respectively. Being alert and more mobile as a result of superior postoperative analgesia from epidural morphine, patients in this group benefited more from vigorous physiotherapy routine, which resulted in fewer pulmonary complications. Furthermore, earlier postoperative recovery of peak expiratory flow and bowel function presumably contributed to a significantly shorter hospitalization in patients receiving epidural morphine. There was no evidence of prolonged respiratory depression in this high-risk category of patients. The 99mTc-plasmin tests revealed no significant difference between the two groups.

(C) 1984 International Anesthesia Research Society

 

[BLADEMDA]

http://www.cuhk.edu.hk/med/ans/pain/Epidural morphine protocol.doc


1. Stop conventional epidural local anaesthetic and fentanyl infusion.
2. No parenteral opioid or other CNS depressant to be given except as ordered by APS.
3. Maintain iv access for 24 hr after last dose of epidural morphine.
4. Give morphine bolus 2mg (for age>=80 yrs) or 3mg (for age<80yrs) morphine in 5ml NS via epidural catheter.
5. Consider giving analgesic adjunct via other routes for the interim period before epidural morphine onset (about 30min-1hr).
6. Set up epidural morphine infusion w/ Abott APM-II pumpor Graseby 9300 as indicated in supplement (A)
7. Start epidural morphine (0.009% morphine) infusion at 4-6ml/hr for thoracic or lumbar epidural catheters. Start at slower rate for thoracic epidural catheter.
8. In case of inadequate analgesia after 2 hrs, reassess patient and consider increasing epidural infusion rate 1-2ml/hr. For the interim period, consider giving adjunct analgesia.
9. Metoclopramide 10mg iv Q8h prn and piriton 10mg Q8hr prn as standing order if there is no contraindication.
10. In case of significant side effects (e.g. nausea, vomiting, pruritis, urinary retention), consider decrease rate of epidural morphine infusion by 50% and refer to supplement for details of management.
11. In case of respiratory depression, stop epidural morphine infusion and refer to supplement for emergency management.
12. Routine Acute Pain Service monitoring protocol in surgical ward. Pain observation (including RR and sedation score) q1h for 1st 24 hours. Pain observation should continue for 24hr after last dose of epidural morphine.
13. Case will be reviewed by APS team twice daily.

 

[BLADEMDA]

Do you change the formula for the all american team obesity crowd?

It's fine to just bolus 3 mg of epidural Duramorph then start the infusion at 0.4 mg per hour. Most of these big cases go to the ICU for 1-2 days so I can be a bit more aggressive in my bolus dose.

I do like epidural dilaudid better than epidural morphine but both work well the majority of the time.

 

[BLADEMDA]

Minerva Anestesiol. 2002 Sep;68(9):681-93.
Post-thoracotomy analgesia: epidural vs intravenous morphine continuous infusion.

[Article in English, Italian]
Della Rocca G, Coccia C, Pompei L, Costa MG, Pierconti F, Di Marco P, Tommaselli E, Pietropaoli P.
Source

Department of Anesthesiology and Resuscitation, Umberto I Polyclinic Hospital, University of Rome La Sapienza, Rome, Italy. giorgio.dellarocca@uniroma1.it

Abstract

BACKGROUND:

We compared thoracic morphine epidural analgesia (TEA) and I.V. analgesia (IVA) with morphine, in respect to the time to extubation, the quality of postoperative analgesia, side effects, complications, postoperative hospital length of stay in patients having thoracotomy lung resection.
METHODS:

We prospectively studied 563 consecutive patients, undergoing thoracotomy (lobectomy, bilobectomy or pneumonectomy), randomized in two groups: TEA 286 patients and IVA 277 patients. In the epidural group, before the induction of anesthesia, continuous infusion of 15 mg of morphine in 250 mL of normal saline at 5 mL/h was started. In the IVA group a continuous infusion of 30 mg of morphine associated with 180 mg ketorolac in 250 mL of normal saline at 5 mL/h was started before the induction of anesthesia. The pain degree was evaluated on an analogic scale by Keele modified at 1 (end of anesthesia) 6, 12, 24, and 48 postoperative hours, at rest and after movements. Data obtained were analysed by means of the analysis of variance for repeated measures.
RESULTS:

The time from the end of surgery to tracheal extubation was similar in both groups. Significantly lower numeric verbal pain scores at rest and after movements were found in the epidural group (p<0.001). Postop complications, nausea and vomiting were higher in the IVA group (p<0.05). Postoperative mean hospital length of stay was 9+/-4 days in TEA and 11+/-4 in the IVA group (p<0.05).
CONCLUSIONS:

In our study the epidural root was superior in terms of analgesia, side effects, length of stay and postoperative complications after thoracotomy.

 

[Planktonmd]

Infusing morphine in the epidural space is a strange idea and makes no sense, but people do crazy things all the time!

 

[fakin' the funk]

Would go somewhere like T9-10, T8-9, T7-8.

Run dilute LA and narcotic like 0.0625% bupivacaine with 2 mcg/ml fentanyl. 6-8ml/hr, 4 q 30 PCEA

Low risk of hypotension, low incidence of pruritus, good chance patient will be able to get out of bed (you really have to whack L2 in part for it to be an issue)

Agree that thoracic epidurals are difficult. Definitely prefer paramedian; it's just easier to "sneak into" the interlaminar space in the thoracic area than midline, where you have essentially no margin for erroneous needle track. But, it introduces "degrees of freedom" and takes a good understanding of the anatomy. I like to go 1cm lateral and 1cm inferior to the spinous process of the upper level, local in a axial and parasagittal plane, then do the same with Tuohy until landing on lamina. Then "walk" superior and medial (the book says 10-15 degrees deviation) until you come just over the inferior lamina and engage LF.

 

[deleted162650]

Agree with Funk's approach. I would try to place the epidural as close to the dermatomal level of the incision as possible. Err on a level or 2 higher than lower. I like paramedian approach as well. After hitting lamina I like to first walk medially until find the "crotch" of the lamina and the spinous process. Then I walk cephalad and off lamina into LF. I think this eliminates some "degrees of freedom" you have when you just start walking at diagonal cephalo-medial direction.

 

[Hoya11]

That last part sounds complicated. Are your nurses getting a different solution, unhooking the catheter and then bolusing in the middle of the night for breakthrough pain?

Yes its usually 0.125% for the contiuous infusion on the pump, and when I go see them if called, bolus of 5-8mls 0.25% from the bottle.

 

[Hoya11]

Agree with Funk's approach. I would try to place the epidural as close to the dermatomal level of the incision as possible. Err on a level or 2 higher than lower. I like paramedian approach as well. After hitting lamina I like to first walk medially until find the "crotch" of the lamina and the spinous process. Then I walk cephalad and off lamina into LF. I think this eliminates some "degrees of freedom" you have when you just start walking at diagonal cephalo-medial direction.

When you look at a lot of epidurals done for pain under fluoro with contrast, youll realize that 9 times out of ten, when you give a bolus of fluid, it goes UP, not down.

 

[Hoya11]

Yep.

I remember as a resident rotating on Pain getting called all day by the Gen Surg service because one of the more "regional skill lacking" attendings did a "high lumbar" epidural and the patient was miserable. After finally deferring the gen surg resident's calls to him because I got tired of hearing my page,r he thought he'd go bolus the patient to "get the level up". The patient was still miserable and it took an irate Surgery attending to find another anesthesiologist to put it in a thoracic space and the patient was happy.

Thoracic epidurals can be a pain if you dont do them a lot but in cases like these and thoracotomies the patients will love you for it. Also, I like paramedian with thoracic epidurals.

The "rule of 10s" 10cc of 2% lidocaine will get you a T10 level in 10 minutes, or the catheter is not working. You get a level up to the nipples with a 15-20cc bolus. Maybe the lumbar catheter just wasnt in. The bolus should have worked, though it may have compromised the legs.

 

[deleted162650]

When you look at a lot of epidurals done for pain under fluoro with contrast, youll realize that 9 times out of ten, when you give a bolus of fluid, it goes UP, not down.

I agree that you never really know which way fluid in the epidural space is going to spread. There's a paper which showed (using contrast/fluoro) that injections in the low thoracic levels tend to spread upward, while injections in the upper thoracic levels tend to spread downward. I think is probably particularly true if the pt is supine and the fluid settles into the thoracic kyphosis. In the pt that is reclined or sitting upright (most pts in the post-op period) the fluid will gradually flow downward with gravity (just like that laboring that spent the last 2 hrs on her side and now has a dependent leg that is number than the other side) which is why I would err on the side of higher rather than lower. This helps minimize total volume/dose which helps minimize side effects: leg weakness, hypotension, itching, etc.