Surgeons vetoing thoracic epidurals

[woopedazz]

Not private practice. Not USA.
Major teaching/referral centre. 40+ operating theatres. No paeds, no obs.
A small part of the workload is "big" gen surg - livers/oesophagectomies/etc.

The Upper GI and some hepatobiliary surgeons have decided to veto thoracic epidurals.
Reasons are typically not evidence based, nor congruent across the surgeons within each department. That said... one complaint - the post-op management in our (closed) ICU - is a real issue.

Have any of you experienced similar issues?
Does your centre do thoracic epidurals?
Does your centre utilise alternatives instead (paravertebrals + IT morphine combos/something similar)?
Thoughts on this being a hill to die on?

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[psychbender]

We'll put them in for our Surg Onc surgeons, when requested (big open whacks). It's probably a one a month kind of thing. No issues really post-op. Patients go to the floor, and someone sees them at least once a day, and pulls the catheter when they're ready.

 

[Lecithin5]

We place a lot at our facility (thoracotomies, surg onc belly whacks, lung txp (although recently switching over to intraop intercostal ablations), rib fx, etc). Probably average one every other day. Most of our surgeons love them. And we have a robust acute pain service that follows and manages them postoperatively. But I’m not gonna argue with a surgeon if they decide they don’t want one- not my problem.

 

[anbuitachi]

Not private practice. Not USA.
Major teaching/referral centre. 40+ operating theatres. No paeds, no obs.
A small part of the workload is "big" gen surg - livers/oesophagectomies/etc.

The Upper GI and some hepatobiliary surgeons have decided to veto thoracic epidurals.
Reasons are typically not evidence based, nor congruent across the surgeons within each department. That said... one complaint - the post-op management in our (closed) ICU - is a real issue.

Have any of you experienced similar issues?
Does your centre do thoracic epidurals?
Does your centre utilise alternatives instead (paravertebrals + IT morphine combos/something similar)?
Thoughts on this being a hill to die on?

Aren't epidurals standard of care for some cases? The evidence is high. I forget which cases exactly from evidence but if there is a conflict with surgeon asking you to perform under standard of care, you need to tell the patients /surgeons.

I think it was a hipec case surgeon didn't want and I told her it's evidence based or something and it's standard of care. Then she agreed

 

[Beeftenderloin]

PP, USA. For esophagectomies Rectus sheath or TAP blocks for belly portion, done by anesthesiologist. Intercostals done by surgeon doing thoracic portion. This is mostly driven by the fact that if you place a thoracic epidural, it’s yours to manage until it comes out and that’s not worth the phone calls or the pitiful reimbursement for rounding on it.

 

[ambiturner]

Is the problem how long they take to put in? Need for foley? Something else? If it’s foley then you could do peripheral catheters (PVB, ESP, etc) depending on the case, but these take probably just as long or longer to put in.

If it’s level of evidence, I haven’t seen super convincing evidence for improved non-pain outcomes beyond chest surgery or rib fractures but if others are aware of any I’d love to read it.

 

[GassYous]

Patients are always hypotensive at 3 am
I'm not sure you need a foley if it's high enough
It takes like 10 minutes to put one in, you can do it preop
But it's definitely helpful, people will have a huge incision and smiling pod1 with zero pain

 

[epidural man]

Here are some tips if you are going to run thoracic epidurals.

1. Very low dose local anesthetic (helps with BP issues). If the patients are hypotensive, this will kill the service (as is happening in your neck of the woods). Low dose means bupivicaine <.1%. I think starting with 0.05% works just fine. HOWEVER, these low dose epidurals need hydromorphone in the mix (10mcg/ml).

2. They need to motor spare the LE so the patient can get up and walk. That means the catheter placement needs to be above T10.

 

[anaesthetic]

Aren't epidurals standard of care for some cases? The evidence is high. I forget which cases exactly from evidence but if there is a conflict with surgeon asking you to perform under standard of care, you need to tell the patients /surgeons.

I think it was a hipec case surgeon didn't want and I told her it's evidence based or something and it's standard of care. Then she agreed

I would be careful with specific language, especially when using “standard of care” which has a different weight than practice guidelines, advisories, statements, consensus, etc. I think it’s rare to have any one anesthetic technique or postoperative pain strategy be “standard of care.” Ultrasound-guided central venous access is not standard of care, and neither is twitch monitoring, both of which have been shown to decrease complication rates significantly.

We used to place tons of thoracic epidurals and ESP catheters for VATS procedures in residency. I haven’t done one since being in PP despite covering a very busy thoracic service. Our surgeons do cryoablation for the lung transplants and intercostal blocks under scope guidance for everything else. That combined with the “multimodal” stuff covers 99% of what we need for postop pain control without the headache of placing, maintaining, and removing epidural catheters. We do TAP blocks for the big belly cases. No complaints or requests for epidurals in a very long time.

 

[Anesthesia_Guy]

Whatever. Let them veto it......wish they would here - less work for me.

 

[ProwlerturnGas]

I’m so glad I don’t have to put these b*tches in where I am. Surgeons don’t ask for them and quite frankly I don’t trust the floor nurses at all.

 

[Katheudontas parateroumen]

I think it’s within the right of the surgeon to request or unrequest such things. At the end of the day, this is a postoperative issue that the surgeons will have to handle. Now if they call you back as a consult for post op acute pain control then it is in our privy to offer it of course. I certainly see it as a “best practices” for peri operative care which is different than “standard of care” which is kinda a fluffy term no one really knows. Although many anesthesiologists in the US probably loath the thought of periopertaive physician, that is exactly what we are. We are consultants for preop, intra op, and post op care for the surgeons. That is literally our job. We have a vested interest and duty to be advocates for “best practices”.

 

[sanityonleave]

Our surgeons mostly (75%) use epidurals for open abdominal cases and probably closer to 90% for thoracotomies, but I agree with other posters that I don't push if they feel strongly against it. There's almost no outcomes-level data that I'm aware of suggesting patients actually do better, and there's definitely pretty good data they have more postop hypotension and require higher volumes of postop fluids (which may be correlated with poorer outcomes though, again, who knows). I agree that I would be very hesitant arguing an epidural is the "standard of care" for any of these cases, except maybe lung transplants (and even those it sounds like many posters are able to get away from it).

I will advocate for them for patients with high baseline opioid use, chronic pain or severe respiratory issues as I think there is a benefit in that population, though I still don't think there's really data. I also will put them in where surgeons are indifferent because I think that they at worst don't cause harm and it's important for resident training to know how to do the procedure.

Interestingly there was a paper a few years ago that showed a mortality benefit in aortic surgery. I'm skeptical about mortality benefit, but all our vascular surgeons requested them anyway for open cases. Epidural-General vs General Anesthesia Alone for Aortic Aneurysm Repair

 

[DrOwnage]

Here are some tips if you are going to run thoracic epidurals.

1. Very low dose local anesthetic (helps with BP issues). If the patients are hypotensive, this will kill the service (as is happening in your neck of the woods). Low dose means bupivicaine <.1%. I think starting with 0.05% works just fine. HOWEVER, these low dose epidurals need hydromorphone in the mix (10mcg/ml).

2. They need to motor spare the LE so the patient can get up and walk. That means the catheter placement needs to be above T10.

Name definitely checks out

 

[coffeebythelake]

just as long as they aren't calling to ask for them postop

 

[medicine2wallstreet]

Our surgeons vetoed them a few years back due to exactly what they vetoed yours for. Poor post operative management...whether perceived or actual. So we do not do them at my residency.

 

[woopedazz]

Thank you all for the feedback, all excellent advice/experience.

One thing to note is the surgeons do not manage analgesia post-op if PCA/regional/other things are utilised. Analgesia is entirely managed by our acute pain service, which is staffed by... me (and the rest of the anaesthesia Dept).

Hence the problem.

 

[DocVapor]

Thank you all for the feedback, all excellent advice/experience.

One thing to note is the surgeons do not manage analgesia post-op if PCA/regional/other things are utilised. Analgesia is entirely managed by our acute pain service, which is staffed by... me (and the rest of the anaesthesia Dept).

Hence the problem.

Yeah I think if I'm in charge of managing post-op pain then they don't get to veto.

 

[woopedazz]

That's my thoughts.

That said, I'll see what I can do to optimise our ICU care and hopefully in doing so will get some surgeon buy-in.

 

[Mehd School]

I'm a big fan of thoracic epidurals in the right patient and right case, but if a surgeon nixes the idea then there's kind of the understanding that they're more of less on their own for post op pain control. If they've taken the best tool out of my tool box then it's on them.

With that said, while I love epidurals, I loathe the post op management and I do feel that it can be unsafe. I do not have a robust acute pain service where I'm at, so I have laminated sheets that I tape to the computer inside the patient's room as well as the nursing station. I also ensure the nurse taking care of the patient understands what to look out for and what not to do.

And with all these precautions, I had a traveling nurse come on for his night shift last month give a good dose of lovenox 40 minutes after I pulled the catheter and went home.

 

[deleted875186]

low dose thoracic epidural with opioid and bupi 0.1% or less is great for postop pain. I beleive there’s evidence it reduces time to return of bowel function and postop pulmonary complications in open abdominal cases. Definitely labor intensive and causes issues postop however. If yojr rounding on these patients and handling the post op pain it seems ridiculous for the surgeon to veto the thoracic epidural.

 

[anbuitachi]

I would be careful with specific language, especially when using “standard of care” which has a different weight than practice guidelines, advisories, statements, consensus, etc. I think it’s rare to have any one anesthetic technique or postoperative pain strategy be “standard of care.” Ultrasound-guided central venous access is not standard of care, and neither is twitch monitoring, both of which have been shown to decrease complication rates significantly.

We used to place tons of thoracic epidurals and ESP catheters for VATS procedures in residency. I haven’t done one since being in PP despite covering a very busy thoracic service. Our surgeons do cryoablation for the lung transplants and intercostal blocks under scope guidance for everything else. That combined with the “multimodal” stuff covers 99% of what we need for postop pain control without the headache of placing, maintaining, and removing epidural catheters. We do TAP blocks for the big belly cases. No complaints or requests for epidurals in a very long time.

interesting i didtn realize ultrasound central lines are not standard of care today in the US.

 

[Mehd School]

interesting i didtn realize ultrasound central lines are not standard of care today in the US.

I've seen this thrown around here a few times but I think the fact remains that if you have a line complication and elected to not use ultrasound when it's readily available you'd have a hard time defending it.

 

[vector2]

interesting i didtn realize ultrasound central lines are not standard of care today in the US.

Depends on how you define standard of care. Mediocolegally, it means

2. In legal terms, the level at which an ordinary, prudent professional with the same training and experience in good standing in a same or similar community would practice under the same or similar circumstances. An "average" standard would not apply because in that case at least half of any group of practitioners would not qualify. The medical malpractice plaintiff must establish the appropriate standard of care and demonstrate that the standard of care has been breached, with expert testimony​

I think we've essentially reached the point, both in the literature and in common practice, where it could reasonably be called a standard. And even if you want to argue the point, the plaintiff will have no problem finding a dozen expert witnesses who will detail the literature showing the reduced complication rate with US, and who will speak to the ubiquity of ultrasound even in the poorest, most bfe rural hospitals.

 

[kb1900]

I’m so glad I don’t have to put these b*tches in where I am. Surgeons don’t ask for them and quite frankly I don’t trust the floor nurses at all.

have had a nurse hang potassium into the the thoracic epidural here. only caught because she was about to pull it because the pump kept alarming and pin service was rounding at the time

patient also had no iv access which was another mess up. Because she removed the OR 14 and 16g because those are “too big for the floor”

boy was that a debrief to attend

 

[Lecithin5]

have had a nurse hang potassium into the the thoracic epidural here. only caught because she was about to pull it because the pump kept alarming and pin service was rounding at the time

patient also had no iv access which was another mess up. Because she removed the OR 14 and 16g because those are “too big for the floor”

boy was that a debrief to attend

Scary. You are at the mercy of floor nurses and others (ie if you put a prn fentanyl bolus, that they are *sterile* and push the correct med; they don’t give certain anticoagulants, etc). If you are ocd or very hands-on, epidurals aren’t worth the stress. Lots could go wrong. I still love them- nothing like rounding on someone who has 0/10 pain.

 

[DocVapor]

Scary. You are at the mercy of floor nurses and others (ie if you put a prn fentanyl bolus, that they are *sterile* and push the correct med; they don’t give certain anticoagulants, etc). If you are ocd or very hands-on, epidurals aren’t worth the stress. Lots could go wrong. I still love them- nothing like rounding on someone who has 0/10 pain.

... am I reading this right? You write orders allowing nurses to give fentanyl boluses via the epidural?

That's not anything I ever have actually even thought of enough to even consider. It's just straight up crazy talk.

 

[Lecithin5]

... am I reading this right? You write orders allowing nurses to give fentanyl boluses via the epidural?

That's not anything I ever have actually even thought of enough to even consider. It's just straight up crazy talk.

Yes. It is on a floor that deals with a high volume of epidurals.