Post Op Pain Management - Case Question

[doctor712]

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Hello All,

Hoping this finds you having nice holiday seasons, it's your pre-med future anesthesiologist D712.

First off, some good news, as of this morning, I am officially published, a made man, first author on a great paper that I'm very proud of. My co-author may be known by many of you CT Anesthesiologists. I'm hoping this will help with MD school! Exciting. My non-trad path is coming around the corner, home stretch.

So, I continue to observe anesthesia though I haven't been in the hospital for months. I've seen Peds at P&S, Peds at Schneiders, Hearts in SC, Pain at CCFL, General at UM, Ob/Gyn at Boca, the rest is a blur. Totaling over 500 hours, I love every second of it. So, it brings me to this simple case question that I saw yesterday.

58 y/o male, hispanic patient, avid runner, decompression surgery for severe lumbar stenosis, otherwise healthy.

Operation - from induction to cut to extubation, uneventful. Patient is taken to PACU, somewhat "awake", or at least awakening (my POV). I heard the terms, phase one and phase two.
Anyway, patient spots me and tells me that the pain is "excruciating", "they are trying to kill me!" "oh no...why why...help." PCA given to patient as I stood there, he's cursing in Spanish. Buttons pressed, patient very restless.

At the end of the day, I observe my doc who visits patient that is now in significantly less pain, PCA not even being "maxed out". Ok, a good thing. I didn't want to ask the anesthesiologist thinking that perhaps he'd take this the wrong way...

is this typical and good pain control post op (the PACU experience)?

i understand surgery sucks and you have to wake up, but i'm saying to myself the following:
(i had just seen two c-sections that morning) another anesthesiologist told mother, "when the epidural wears off later today, it will be sore, like any other surgery..."

so, i think: why wouldn't an epidural be placed for this spinal surgery patient? place it above the surgical site, let it sit there for 24 hours, get him through the awful pain, then, as the epidural is expected to wear off, have that PCA ready to go? (i hope im not making too many of you laugh right now, but i don't see why this couldn't be done.) in other words, the OB patient seemed to have that epidural buffer, why not spine man?

questions: is an epidural (two-three levels?) north of a lumbar spinal surgical site contraindicated? if, yes, why (bleed risk? clot risk?) if NOT, why not give this patient an epidural for post op pain control? i would think that morphine in the PCA is a respiratory depressant post op, something you'd want to avoid anyway, so, isn't this even more of a reason to give an epidural and keep it in for a day, get him through the really bad waking up PACU experience?

i don't know, it might be a naive question, but i've never seen such a bad PACU event. i understand why you'd extubate and awaken the patient, im not suggesting you keep him asleep, just totally blocked above the site down. he's going to the floor anyway. why not treat him like a recently pregnant woman? 😀

THANKS!
D712

 

[Planktonmd]

Good points,
As for your main question: Can an epidural be done for spine surgery? the answer is definitely yes. It has been done before and it does provide excellent anesthesia and analgesia, actually the whole surgery can be done under epidural anesthesia if you want to.
The reason why it's not done commonly is because many spine surgeons don't like it or don't understand it, also many anesthesiologists don't like to share the liability of any surgical complication with the surgeon.
In theory the presence of an epidural can also mask or delay the diagnosis of a surgical complication.

 

[Jeff05]

#1. unless the epidural is placed under fluoro - you have no idea where you're tip ends up. placing a thoracic epidural like this would require and THEN guiding an epidural catheter in a RETROgrade manner to just above the surgical site is very technically challenging.

#2. complications like abscess and hematoma may be masked by the epidural

#3. you are introducing a solution of questionable sterility to surgical site

#4. opiate/oid was underdosed by anesthesia. if patient was in pain in the pacu, the anesthesiologist dropping him off should have given something.

#5. phase II doesn't make any sense for spine surgery, especially one requiring a pca.

#6. epidurals need to be managed by an acute pain service. pcas do not - they can be managed by primary team and floor nurses.

#7. what can be done is a single shot of IT morphine before starting the surgery. patient would need to be monitored for respiratory depression for 24 hours.

 

[SleepIsGood]

Good points,
As for your main question: Can an epidural be done for spine surgery? the answer is definitely yes. It has been done before and it does provide excellent anesthesia and analgesia, actually the whole surgery can be done under epidural anesthesia if you want to.
The reason why it's not done commonly is because many spine surgeons don't like it or don't understand it, also many anesthesiologists don't like to share the liability of any surgical complication with the surgeon.
In theory the presence of an epidural can also mask or delay the diagnosis of a surgical complication.

I mirror these answers. Also post op, epidurals for spine patients are likely not done for the same reasons, it can 'mask' undesired surgical complications. Also, post op of a laminectomy the epidural space may be obliterated in some areas....typically there is no ligamentum flavum in some areas as it's been scraped off. Therefore, if attempt to cannulate the epidural space, the catheter may not go where you think it's going.

 

[doctor712]

I mirror these answers. Also post op, epidurals for spine patients are likely not done for the same reasons, it can 'mask' undesired surgical complications. Also, post op of a laminectomy the epidural space may be obliterated in some areas....typically there is no ligamentum flavum in some areas as it's been scraped off. Therefore, if attempt to cannulate the epidural space, the catheter may not go where you think it's going.

Thanks very much for the answers!

Happy Holidays gang.

D712