placement of lumbar epidural for thoracotomy

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I've got an older partner who placed a lumbar epidural for a thoracotomy, threading it upward (or so he thought). i tried to dose it up towards the end of the case, and got no response. Then I noticed how low he placed it (he forgot to mention that), so then really tried to bolus it up, giving 25cc over 45min w/o any response. i will say that it did feel right upon injection. i finally just waited for the CXR in pacu to check placement since it was radio-opaque, and didn't see it anywhere.
i have never seen this done anywhere but peds' caudals threaded upward, and then we used a stim catheter or shot an intraop XR to confirm placement.
any one have ideas on how to trouble-shoot this approach? i like to bolus my epidurals up before emergence, and don't want to have to keep pounding away with local just waiting for a response, or wait to flip supine and get an XR.
 
I've got an older partner who placed a lumbar epidural for a thoracotomy, threading it upward (or so he thought). i tried to dose it up towards the end of the case, and got no response. Then I noticed how low he placed it (he forgot to mention that), so then really tried to bolus it up, giving 25cc over 45min w/o any response. i will say that it did feel right upon injection. i finally just waited for the CXR in pacu to check placement since it was radio-opaque, and didn't see it anywhere.
i have never seen this done anywhere but peds' caudals threaded upward, and then we used a stim catheter or shot an intraop XR to confirm placement.
any one have ideas on how to trouble-shoot this approach? i like to bolus my epidurals up before emergence, and don't want to have to keep pounding away with local just waiting for a response, or wait to flip supine and get an XR.

That's a weird thing to do if it was intentional. I remember a handful of similar cases from residency when a junior resident with an inattentive attending would bone things up by putting the catheter 5 or 6 spaces low. Volume would sometimes help, but at the obvious expense of giving the thoracotomy patient solid lower extremity blocks too. They were unsatisfying and embarrassing ...

I think the correct thing to do is pull it and put one in the right place. Assuming no anticoagulation issues.
 
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Put the epidural near the dermatome for the incision. When I would do acute pain rounds almost every lumbar epidural placed for a thoracic incision was worth crap and we pulled it. I would always place my epidurals for thoracic cases between T4 and T7 and they worked perfectly.
 
That's a weird thing to do if it was intentional. I remember a handful of similar cases from residency when a junior resident with an inattentive attending would bone things up by putting the catheter 5 or 6 spaces low. Volume would sometimes help, but at the obvious expense of giving the thoracotomy patient solid lower extremity blocks too. They were unsatisfying and embarrassing ...

I think the correct thing to do is pull it and put one in the right place. Assuming no anticoagulation issues.

yeah i replaced it, but wasn't happy about it.
thanks, i was just wanting to make sure there wasn't some old school trick that i was missing.
 
I've got an older partner who placed a lumbar epidural for a thoracotomy, threading it upward (or so he thought). i tried to dose it up towards the end of the case, and got no response. Then I noticed how low he placed it (he forgot to mention that), so then really tried to bolus it up, giving 25cc over 45min w/o any response. i will say that it did feel right upon injection. i finally just waited for the CXR in pacu to check placement since it was radio-opaque, and didn't see it anywhere.
i have never seen this done anywhere but peds' caudals threaded upward, and then we used a stim catheter or shot an intraop XR to confirm placement.
any one have ideas on how to trouble-shoot this approach? i like to bolus my epidurals up before emergence, and don't want to have to keep pounding away with local just waiting for a response, or wait to flip supine and get an XR.

If you are going to place a lumbar epidural for a thoracic case you should use high concentration opiates for the epidural instead of relying on the local anesthetic.
Example would be Fentanyl 10mcg/cc running at 5cc/hr.
It does work surprisingly well and there is some old literature that supports it.
It's probably mostly the systemic effect of the opiate but it seems to work significantly better than just an IV PCA.
I would advise your old partner to place a thoracic epidural next time though.
 
If you are going to place a lumbar epidural for a thoracic case you should use high concentration opiates for the epidural instead of relying on the local anesthetic.
Example would be Fentanyl 10mcg/cc running at 5cc/hr.
It does work surprisingly well and there is some old literature that supports it.
It's probably mostly the systemic effect of the opiate but it seems to work significantly better than just an IV PCA.
I would advise your old partner to place a thoracic epidural next time though.

Interesting, I've never seen that. Do they go bonkers itching?
 
If you are going to place a lumbar epidural for a thoracic case you should use high concentration opiates for the epidural instead of relying on the local anesthetic.
Example would be Fentanyl 10mcg/cc running at 5cc/hr.
It does work surprisingly well and there is some old literature that supports it.
It's probably mostly the systemic effect of the opiate but it seems to work significantly better than just an IV PCA.
I would advise your old partner to place a thoracic epidural next time though.

I once took over a case where they had placed a L4-5 epidural for a upper abdominal incision... they were using it intraoperatively at 18 cc/hr of 0.5% lidocaine. I stopped the infusion, slammed in 3 mg of epidural morphine... pulled the LEP at the end of the case. Pt nice and comfy in pacu.

drccw
 
I stopped the infusion, slammed in 3 mg of epidural morphine

From what I have seen...
Best option pull and replace.
Next best option epidural morphine.
Anything else useless.

By the time you get to a volume that touches the upper thoracic segaments you have paralazyed your patient waste down and knocked out just about every sympathetic segement on the way up. In patients prone to atelectasis and hypovolemia this is not a good idea.
 
Lumbar Epidurals should be placed at L1 if possible for Thoracotomies. Dilate the space and most of the time the catheter does go cephalad. That said, they work best running Duramorph or Diluadid through the catheter. For those who have any doubts try this technique on a patient with reasonable PFTs/FEV. Bolus 5 mg duramprph via the L1 Epidural and run at 0.6 mg/hr. Most patients are quite satisfied with minimal side effects.
 
I put 0.2mg of hydromorphone bolus in my thoracic epidurals, then run 0.125% at 4-6 cc/hr. Like said above, epidural opioid goes a long way, especially hydromorphone and morphine.
 
I put 0.2mg of hydromorphone bolus in my thoracic epidurals, then run 0.125% at 4-6 cc/hr. Like said above, epidural opioid goes a long way, especially hydromorphone and morphine.


Yes. But what if the Thoracic Epidural fails or your partner places a Lumbar Epidural?
 
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. [email protected]

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.
 
Ann Thorac Surg. 1990 Dec;50(6):888-93.
Continuous epidural hydromorphone for postthoracotomy pain relief.

Brodsky JB, Chaplan SR, Brose WG, Mark JB.
Source

Department of Anesthesia, Stanford University School of Medicine, California.

Abstract

Forty-four patients were treated with a continuous infusion of lumbar epidural hydromorphone (0.05%) after thoracic operations. Postoperatively, visual analog pain scores were obtained. On postoperative day 1 and 2, more than 90% of the patients experienced either no pain (visual analog pain scale = 0) or mild pain (visual analog pain score = 1 to 3) at rest. The incidence of side effects (hypoventilation, pruritus, and nausea) was less than reported with other epidurally administered opioids. Continuous infusion of lumbar epidural hydromorphone produced safe, predictable analgesia after thoracotomy.
 
Rev Esp Anestesiol Reanim. 1991 Nov-Dec;38(6):365-9.
[Continuous epidural perfusion of morphine and bupivacaine for post-thoracotomy analgesia. Comparison between thoracic and lumbar epidural analgesia].

[Article in Spanish]
Rodríguez Huertas F, Bustos Rivera A, Muñoz Alcántara M, Fuentes Rodríguez R, Almarcha López JM, Torres Morera LM.
Source

Servicio de Anestesiología y Reanimación, Hospital del SAS, Cádiz.

Abstract

Relief of postoperative pain and the incidence of side effects occurring after continuous epidural infusion of morphine and bupivacaine were evaluated in patients undergoing a thoracotomy. We also studied the relevance of a close proximity of the epidural catheter to the metameric segment were the pain originated. The study involves 17 patients divided into two groups. In one series (lumbar group) (LG) the catheter was located at the lumbar region and in the other series (thoracic group) (TG) the catheter was localized at the thoracic area. The study was carried out during the first 48 hours following surgery. Bupivacaine 2% and 0.2 mg/ml of morphine hydrochloride were administered at an initial rate of 1.5 ml/h. The total dose required for pain relief was greater in LG than in TG (p less than 0.05). There were no significant group differences in the hemodynamic and respiratory parameters measured in this study. Only respiratory rate was occasionally lower in LG. Three patients presented postoperative atelectasis (2 in TG and 1 in LG) and required bronchoscopy. One patient of LG complained pruritus and another one of the same group presented nausea and vomiting. The epidural perfusion was interrupted in only one patient of TG due to the presence of arterial hypotension. The association of narcotics and local anesthetics in continuous epidural perfusion was an excellent method for achieving pain relief with minimum side effects. We conclude that both thoracic and lumbar epidural routes are advisable for post-thoracotomy pain relief.
 
I've got an older partner who placed a lumbar epidural for a thoracotomy, threading it upward (or so he thought). i tried to dose it up towards the end of the case, and got no response. Then I noticed how low he placed it (he forgot to mention that), so then really tried to bolus it up, giving 25cc over 45min w/o any response. i will say that it did feel right upon injection. i finally just waited for the CXR in pacu to check placement since it was radio-opaque, and didn't see it anywhere.
i have never seen this done anywhere but peds' caudals threaded upward, and then we used a stim catheter or shot an intraop XR to confirm placement.
any one have ideas on how to trouble-shoot this approach? i like to bolus my epidurals up before emergence, and don't want to have to keep pounding away with local just waiting for a response, or wait to flip supine and get an XR.


My preference is for a Thoracic Epidural. Even a low thoracic Epidural is better than any Lumbar one. That said, encourage your partner to place it high (at least L1), dilate the space and thread the catheter.

I have no problems using Hydromorphone or Duramorph through a Lumbar catheter.
Is it as good as a Thoracic Epidural? No. Does it work for over 90% of patients in making them comfortable post op? Yes.

Remember, a parvertebral catheter can also be used here. I have supplemented my partners' Lumbar catheters with cont. paravertebral catheters. That works nicely as well. The patient usually has a chest tube so the risk of placing a paravertebral catheter in that situation is minimal
 
In summary, continuous lumbar epidural hydromorphone

(0.3


mg/h) produced predictable, safe analgesia.

More than 90% of our patients experienced no pain or

mild pain at rest. The incidence of drowsiness and sedation,

and other complications (pruritus and nausea), was

relatively

low as compared with those occurring with

other epidural opioids. Administration of lumbar epidural

hydromorphone did not prolong the ICU stay of our

patients. In fact, of the patients admitted to the ICU, most

were transferred to a regular surgical ward on the day

after operation. Epidural opioid analgesia allows earlier

ambulation and cooperation in chest physiotherapy,

which in turn reduces morbidity and shortens hospital

stay. In the absence of surgical complications, the average

length of hospitalization of our patients is

5 to 6 days. We

recommend continuous infusion of lumbar epidural hydromorphone

for postthoracotomy analgesia.
 
How about a bolus of 1mg of Hydromorphone via the Epidural and then run at 0.4 mg/hr post op?
If the patient complains of pain bolus 50 micrograms of Fentanyl and 0.5 mg of Hydromorphone via the Epidural and increase to 0.5 mg/hr.

That should solve any post op pain problems for 95% of your patients.
 
Yes. But what if the Thoracic Epidural fails or your partner places a Lumbar Epidural?

I'd give a much larger dose of hydromorphone, or the morphine like someone mentioned. People place lumbar epidurals for thoracotomies because they can't place thoracic ones. Depending on how strong the indication was (degree of pulmonary cripple) I'd think of placing a thoracic one postop.
 
I'd give a much larger dose of hydromorphone, or the morphine like someone mentioned. People place lumbar epidurals for thoracotomies because they can't place thoracic ones. Depending on how strong the indication was (degree of pulmonary cripple) I'd think of placing a thoracic one postop.

Sure. No issues with that at all. But, why D/C a perfectly good Lumbar Epidural when Hydromorphone or Duramorph works quite well?

If you haven't tried it then how would you know its merits or limitations?

In the past I have bolused 2 mg of Dilaudid via a Lumbar Epidural and started an infusion of 0.4 mg/hr.
The vast majority of patients are very comfy.
 
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Sure. No issues with that at all. But, why D/C a perfectly good Lumbar Epidural when Hydromorphone or Duramorph works quite well?

If you haven't tried it then how would you know its merits or limitations?

I've done it, although with a thoracic epidural. 0.6mg hydromorphone lead to a naloxone gtt for a day. Not quite the scenario we're talking about but I think giving high dose opioid epidural or not, defeats the point of an epidural. Maybe I'd try to keep it in if the indication was weak (like pain) but if the indication was strong (like pulmonary cripple) I'd switch to a thoracic level.
 
i'm sure there will be a next time, so i'll give the opioid approach a shot before pulling the lumbar epi out and replacing it with a thoracic with local/opioid.
i had not seen this before, but from what i've read here, the old guy may have known what he was doing, he just didn't pass that on to me :laugh:
 
I've done it, although with a thoracic epidural. 0.6mg hydromorphone lead to a naloxone gtt for a day. Not quite the scenario we're talking about but I think giving high dose opioid epidural or not, defeats the point of an epidural. Maybe I'd try to keep it in if the indication was weak (like pain) but if the indication was strong (like pulmonary cripple) I'd switch to a thoracic level.

You do realize 0.6 mg/hr is a HUGE infusion of opioid through a THORACIC catheter.
Considering Dilaudid is much more potent than Duramorph I can tell you that giving very high Epidural opioids will leave patients speechless (literally). You can run the infusion at a high enough dose that all you get from the patient is a Resp. Rate of 6-8 (if you are lucky). The study I mentioned on this thread gave most patients a bolus of 1.0-1.5 mg of Dilaudid then started an infusion at 0.3 mg/hr through a LUMBAR EPIDURAL.
 
I've done it, although with a thoracic epidural. 0.6mg hydromorphone lead to a naloxone gtt for a day. Not quite the scenario we're talking about but I think giving high dose opioid epidural or not, defeats the point of an epidural. Maybe I'd try to keep it in if the indication was weak (like pain) but if the indication was strong (like pulmonary cripple) I'd switch to a thoracic level.

Agree. But, a paravertebral block with catheter is just as good as your Thoracic Epidural and easier to place in 85 year olds.


http://clinicaldepartments.musc.edu/anesthesia/intranet/education/resident%20research/files/walker.pdf

http://www.bara2001.be/downloads/oct09_fischer.pdf (PFTs are better with the Paravertebral block Vs Thoracic Epidural)
 
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Reg Anesth Pain Med. 2011 May-Jun;36(3):256-60.
Comparison of continuous thoracic epidural with paravertebral block on perioperative analgesia and hemodynamic stability in patients having open lung surgery.

Pintaric TS, Potocnik I, Hadzic A, Stupnik T, Pintaric M, Jankovic VN.
Source

Department of Anesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia. [email protected]

Abstract

BACKGROUND:

Epidural analgesia can result in perioperative hypotension in patients having thoracotomy. This randomized prospective study assessed the effects of epidural and paravertebral analgesia on hemodynamics during thoracotomy.
METHODS:

Thirty-two patients were randomized to receive either epidural analgesia (n = 16, 0.25% levobupivacaine and 30 &#956;g/kg morphine) or paravertebral block (n = 16; 0.5% levobupivacaine and 30 &#956;g/kg morphine). Oxygen delivery, stroke volume and systemic vascular resistance indices, heart rate, and mean arterial pressure measurements were performed before administration of local anesthetic, after induction of general anesthesia, institution of 1-lung ventilation, first skin incision, retractor placement, lung-inflation maneuver, and at last skin suture. The primary end point was the volume of the colloid infusion necessary to maintain oxygen delivery index of 500 mL/min per squared meter or higher. Postoperative analgesia was provided immediately after surgery by an infusion of 0.125% levobupivacaine and 20 &#956;g/mL morphine in epidural/paravertebral infusion. Pain, rescue-analgesia consumption, arterial pressure, and heart rate were recorded at 6, 24, and 48 hrs after surgery. Administration of anesthesia and data collection were done by research staff blinded to the regional analgesia technique.
RESULTS:

The groups did not differ significantly in heart rate, mean arterial blood pressure, or systemic vascular resistance indices. However, to maintain the targeted oxygen delivery index, a greater volume of colloid infusion and phenylephrine were required, respectively, in the epidural than in the paravertebral group (554 ± 50 vs 196 ± 75 mL, P = 0.04; and 40 ± 10 vs 17 ± 4 &#956;g, P = 0.04). Pain intensity before and after respiratory physiotherapy as well as 24 hr rescue piritramide consumption was similar in the epidural (4.1 ± 3.1 mg) and the paravertebral (2.5 ± 1.5 mg) groups (P = 0.14). Systolic blood pressure after 24 and 48 hrs was lower in the epidural group.
CONCLUSIONS:

Under the conditions of our study, continuous paravertebral block resulted in similar analgesia but greater hemodynamic stability than epidural analgesia in patients having thoracotomy. Paravertebral block also required smaller volume of colloids and vasopressors to maintain the target oxygen delivery index (DO2I).
 
You do realize 0.6 mg/hr is a HUGE infusion of opioid through a THORACIC catheter.
Considering Dilaudid is much more potent than Duramorph I can tell you that giving very high Epidural opioids will leave patients speechless (literally). You can run the infusion at a high enough dose that all you get from the patient is a Resp. Rate of 6-8 (if you are lucky). The study I mentioned on this thread gave most patients a bolus of 1.0-1.5 mg of Dilaudid then started an infusion at 0.3 mg/hr through a LUMBAR EPIDURAL.

It was a bolus. I thought I had included that, but didn't.
 
Sure. No issues with that at all. But, why D/C a perfectly good Lumbar Epidural when Hydromorphone or Duramorph works quite well?

If you haven't tried it then how would you know its merits or limitations?

Bigger question is why anyone would consider placing a lumbar epidural for a thoracic case.

From the OP's post, this case was anything but a perfectly good lumbar catheter.
 
T4-T6 for thoracotomies. You'll have to really run up the lumbar epidurals to get a thoracic effect... causing LE weakness and possibly hypotension and the need of unecessary fluids in a patient who likely needs to be kept more dry than wet. Just replace it and do it right.

Not a big fan of morphine or dilaudid at those thoracic levels, especially bolus doses. I'd rather add a little fent (2mcg/ml)... but that is just me. In a bad COPD'er I'd prolly leave out the narcs all together.

My 2 cents.
 
T4-T6 for thoracotomies. You'll have to really run up the lumbar epidurals to get a thoracic effect... causing LE weakness and possibly hypotension and the need of unecessary fluids in a patient who likely needs to be kept more dry than wet. Just replace it and do it right.

Not a big fan of morphine or dilaudid at those thoracic levels, especially bolus doses. I'd rather add a little fent (2mcg/ml)... but that is just me. In a bad COPD'er I'd prolly leave out the narcs all together.

My 2 cents.

Lumbar epidurals- opioids alone. Works fine for most patients

Thoracic epidural- T5/T6 for me. Works well for pulmonary cripples. Local plus dilute fentanyl or Sufenta

Para vertebrals- works well in all patient groups. Easy to place in the elderly. I place a catheter in the middle of the surgical incision dermatomal level. I run local plus fentanyl or Sufenta.

I also like a para vertebral block with a lumbar epidural. 2 infusions running at the same time. Local in one and low dose opioid in the other.
 
TPVB's are very nice... especially for the pulm cripples. You avoid s/e such as hypotension with this approach... I'm a big fan of the USG intercostal approach.

[YOUTUBE]http://www.youtube.com/watch?v=w070GgtNUfs[/YOUTUBE]
 
I also like a para vertebral block with a lumbar epidural. 2 infusions running at the same time. Local in one and low dose opioid in the other.

This seems like overkill to me blade. Why not just run them together if you are going to use LA and narcs? My n = 0. Just wondering.... 🙂
 
You and me both.

But that doesn't answer my question of why one would prefer or attempt a lumbar cath. If you cannot place a thoracic, due to either patient anatomy or your own inability, why would you think you would be successful threading the catheter 10 cm cephalad?
 
You and me both.

But that doesn't answer my question of why one would prefer or attempt a lumbar cath. If you cannot place a thoracic, due to either patient anatomy or your own inability, why would you think you would be successful threading the catheter 10 cm cephalad?

As stated above, it does work if you use high concentration opiates.
The reason why someone would do it is most likely related to the skill level and lack of experience with thoracic epidurals.
Many older guys don't like thoracic epidurals because they were not common practice when they trained.
 
This seems like overkill to me blade. Why not just run them together if you are going to use LA and narcs? My n = 0. Just wondering.... 🙂

The catheter technique with a para vertebral is good nut not always perfect. Sometimes you miss a level. I tried adding a lumbar epidural catheter with an infusion of low dose opioids for 2 days. That seemed to smooth things out nicely. Of course, I didn't run a randomized trial comparing 3 groups: para vertebral catheter with local and increased opiods vs para vertebral catheter with local only and epidural opioid infusion vs para vertebral catheter with local and low dose opioids plus PCA.
 
If you are 10 cm in the space.. you're chances of getting a one sided epidural are much much higher than 4cm in the space. If you are using a springwound catheter... it might just curl up somewhere it's not supposed to be.

My catheter of choice for epidurals = springwound
PVB's= stiff catheter du jour.
 
If you are 10 cm in the space.. you're chances of getting a one sided epidural are much much higher than 4cm in the space. If you are using a springwound catheter... it might just curl up somewhere it's not supposed to be.

My catheter of choice for epidurals = springwound
PVB's= stiff catheter du jour.

Great point. A catheter threaded too deep has a much higher chance of getting one sided into a nerve root. And as you mention, it can curl up. When they curl and then you try to pull them out, they become knotted. Not(knot) a good situation. Unless you have a special catheter that has a wire to keep it straight, I would not thread it past ~ 6cm (I usually do 5cm). Those special catheters are usually only used in pain procedures such as for caudal catheters (lysis of adhesions etc) or placement of spinal cord stim leads (and I guess lumbar drains, but that wire is pretty flimsy). I am not aware or one for epidurals and then again, if you are not using fluoro, you have no idea where it is really headed.
 
I never understood people saying that they are going to "thread the catheter up several levels". Once that is in the space you have no idea where it is going. I never appreciated this until the first time I did a vascular case under straight epidural. When they were using fluoro I could see the catheter on the monitor and it was just a wound up mess at the exact level that I placed it. I think the only time you can get it to go up several levels is if you are using a stiff catheter. Otherwise don't expect the catheter to go much beyond the level that you placed it.

In my hands, thoracotomy gets a T4-T6 epidural. Abdominal incision at or above the umbilicus get a T8-T9 epidural. This has yet to fail me except when the epidural completely failed. Easy to get downward spread, more difficult to get upward spread.
 
I never understood people saying that they are going to "thread the catheter up several levels". Once that is in the space you have no idea where it is going. I never appreciated this until the first time I did a vascular case under straight epidural. When they were using fluoro I could see the catheter on the monitor and it was just a wound up mess at the exact level that I placed it. I think the only time you can get it to go up several levels is if you are using a stiff catheter. Otherwise don't expect the catheter to go much beyond the level that you placed it.

In my hands, thoracotomy gets a T4-T6 epidural. Abdominal incision at or above the umbilicus get a T8-T9 epidural. This has yet to fail me except when the epidural completely failed. Easy to get downward spread, more difficult to get upward spread.


Pretty much correct. It's a crap shoot whether the catheter will actually go cephalad. You might as well toss a coin for the answer.

That's why if you use local in your epidural place it at the appropriate level (I agree with the previous poster); but, if you decide on a high lumbar epidural for a thoracotomy then use Duramorph or Dilaudid and just forget the local.

When your thoracic epidural fails (of course this never happens to you😉) consider an "easy" chip shot lumbar epidural with opioids or a fancy, u/s guided paravertebral block (if patient has a chest tube).
 
Anaesthesia. 2001 Jan;56(1):75-81.
Postoperative pain relief using thoracic epidural analgesia: outstanding success and disappointing failures.

McLeod G, Davies H, Munnoch N, Bannister J, MacRae W.
Source

Ninewells Hospital and Medical School, Dundee DD1 9SY, UK.

Abstract

Six hundred and forty patients received epidural analgesia for postoperative pain relief following major surgery in the 6-year period 1993-1998. Although satisfactory pain relief was achieved in over two-thirds of patients for a median duration of 44 h after surgery, one-fifth of patients (133 individuals) still experienced poor pain relief. Almost one out of three patients (194 individuals) had a problem with their epidural. Eighty-three patients (13%) suffered a technical failure and 84 (13%) patients had their epidurals removed at night time when pain-free because of pressure on beds. Seven patients had their epidural replaced and subsequently experienced excellent pain relief for a median of 77 h. Lack of resources prevented a further 480 patients from receiving the potential benefits of epidural analgesia. These results would suggest that the practical problems of delivering an epidural service far outweigh any differences in drug regimens or modes of delivery of epidural solutions.
 
Kamming and Davies reported that in two large studies [2,3] 'epidurals have failed to achieve adequate analgesia in between 33% and 50% of patients'. On the basis of these figures and on the apparently high percentage of failure they appear to demonstrate for thoracic epidural anaesthesia, the authors questioned whether patients should in fact be submitted to this kind of anaesthesia. Both of the studies cited by them [2,3] included patients who underwent abdominal surgery. Although not specified in either study, it is likely that the thoracic epidural catheters used during surgery were placed in the middle or lower thoracic region and it is known that the approach to the epidural space is more difficult at these levels than at a higher level in the high thoracic area, for example C7-T3. As a result, we would argue that it is not possible to extrapolate the failure rate of middle thoracic epidurals to high thoracic epidurals.
 
That's why if you use local in your epidural place it at the appropriate level (I agree with the previous poster); but, if you decide on a high lumbar epidural for a thoracotomy then use Duramorph or Dilaudid and just forget the local.

When your thoracic epidural fails (of course this never happens to you😉) consider an "easy" chip shot lumbar epidural with opioids or a fancy, u/s guided paravertebral block (if patient has a chest tube).

Another option is single shot intrathecal morphine... I've seen some people drop as much as 1 mg intrathecally.... which is a bit more than I like to use.

drccw
 
Another option is single shot intrathecal morphine... I've seen some people drop as much as 1 mg intrathecally.... which is a bit more than I like to use.

drccw

Done it. Been there. I use 0.5-1.0 mg of spinal duramorph. I don't recommend the 1.0 mg dose in the elderly😱 My dosing experience shows 0.5-0.75 mg is a good range but the drug wears off at 12-16 hours. You dont get reliable analgesia for 24 hours. So, this isn't a good option for a morning case but is acceptable for a late afternoon case going to ICU.

I have found that many older patients may get a bit obtunded with higher doses above 0.75 and I suspect the MU receptors are fully saturated.

Remember the studies on C-Section patients and Duramorph? At a certain point giving more doesn't do much except increase side-effects.
 
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