Thoracic epidural and autonomic dysreflexia

[ethilo]

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Hey folks, a question I was pondering:
Let's say you place a T4-5 epidural but get a wet tap then decide to leave a catheter and use it perioperatively. You dose some local and they get a spinal anesthetic, as you expect.

Now question: Are they at risk for autonomic dysreflexia if they get bladder distension, or if they get disimpacted, or experience some sort of low level visceral stimulation of some kind?

 

[Pluto201]

I wouldn’t use a spinal catheter in the thoracic region, you are giving the patient a high spinal.

 

[deleted162650]

Hey folks, a question I was pondering:
Let's say you place a T4-5 epidural but get a wet tap then decide to leave a catheter and use it perioperatively. You dose some local and they get a spinal anesthetic, as you expect.

Now question: Are they at risk for autonomic dysreflexia if they get bladder distension, or if they get disimpacted, or experience some sort of low level visceral stimulation of some kind?

Can you imagine a world with no hypothetical questions?

 

[ethilo]

Fine. T6-7 epidural, I've seen it before with a big abdominal case where neuraxial anesthesia was pretty important to keep even after a wet tap. Creative thinking is required in our profession, people!

 

[ethilo]

I wouldn’t use a spinal catheter in the thoracic region, you are giving the patient a high spinal.

So, how high do you think your c section spinals go?

 

[AdmiralChz]

So, how high do you think your c section spinals go?

About T4-6, sometimes T1 if you have the table tilted wrong. But that’s with a NORMAL neuraxial approach in the lower lumbar region.

I can’t see why I’d EVER place a mid-thoracic spinal catheter. That’s asking for a lot of trouble and poor perioperative analgesia anyway. It sounds reckless and unneeded. The cord is fully intact there and you wish spearing it if you wet tap. I am extremely careful when placing these and I’d rather be totally unsuccessful than wet tap.

 

[deleted875186]

Hey folks, a question I was pondering:
Let's say you place a T4-5 epidural but get a wet tap then decide to leave a catheter and use it perioperatively. You dose some local and they get a spinal anesthetic, as you expect.

Now question: Are they at risk for autonomic dysreflexia if they get bladder distension, or if they get disimpacted, or experience some sort of low level visceral stimulation of some kind?

No, I think your spinal would give a total spinal, not a segmental block like an epidural.

 

[Justice4all]

Rather do a continuous truncal block.

 

[deleted697535]

Hey folks, a question I was pondering:
Let's say you place a T4-5 epidural but get a wet tap then decide to leave a catheter and use it perioperatively. You dose some local and they get a spinal anesthetic, as you expect.

Now question: Are they at risk for autonomic dysreflexia if they get bladder distension, or if they get disimpacted, or experience some sort of low level visceral stimulation of some kind?

Id say no, as the autonomic changes required for ADR require time for the dysregulated feedback.
I would also agree with other posters to not use a Thoracic spinal catheter. Its just asking for trouble, and youre on the hook for it directly you! There are many other options.

 

[Aether2000]

In the pain medicine world, thoracic spinal catheters are the rule rather than the exception and many are dosed with local anesthetics. By using small amounts of local anesthetics it is possible to avoid respiratory compromise, so in this "hypothetical" case, I would use the catheter. It is likely this would be enough to prevent autonomic hyperreflexia. Other alternatives to local anesthetics include dexmedetomidine or a lipophilic opioid such as sufentanil that will not layer very far cephalad when given in the thoracic spine.

 

[Planktonmd]

You know what the problem is going to be? When this patient comes back with post dural puncture headache.
Although the incidence is less in thoracic wet taps, but if it happens, a thoracic blood patch at T4 might require exceptionally big balls!

 

[lobelsteve]

You know what the problem is going to be? When this patient comes back with post dural puncture headache.
Although the incidence is less in thoracic wet taps, but if it happens, a thoracic blood patch at T4 might require exceptionally big balls!

But does the patch have to go in the area of the wet tap, or is it the pressure differential that makes the leak quit? Lumbar blood patches for cervical wet taps are routine.

 

[Planktonmd]

But does the patch have to go in the area of the wet tap, or is it the pressure differential that makes the leak quit? Lumbar blood patches for cervical wet taps are routine.

Good point, but if the blood patch is not actually occluding the hole would the effect last or is there higher incidence of recurrence?

 

[Twiggidy]

For all the residents and students (and hell attendings) following along at home, don't do thoracic spinal catheters. You''d rather have that scenario play out on a SDN forum than in an M&M or deposition.

Risk > Reward

 

[Hoya11]

In the pain medicine world, thoracic spinal catheters are the rule rather than the exception and many are dosed with local anesthetics. By using small amounts of local anesthetics it is possible to avoid respiratory compromise, so in this "hypothetical" case, I would use the catheter. It is likely this would be enough to prevent autonomic hyperreflexia. Other alternatives to local anesthetics include dexmedetomidine or a lipophilic opioid such as sufentanil that will not layer very far cephalad when given in the thoracic spine.

for what purpose are thoracic spinal catheters the norm in the world of pain medicine ? i have never done one in my time as a fellow or brief stint as an attending.

 

[Aether2000]

Intrathecal infusion pumps. The vast majority of catheters placed since the beginning of IT pumps were placed lumbar and advanced into the thoracic region. I have seen some advanced all the way to the C3 level.

 

[woopedazz]

Intrathecal infusion pumps. The vast majority of catheters placed since the beginning of IT pumps were placed lumbar and advanced into the thoracic region. I have seen some advanced all the way to the C3 level.

How high can you go? Hypothetical question: If I had a sore brainstem,..

 

[deleted697535]

Intrathecal infusion pumps. The vast majority of catheters placed since the beginning of IT pumps were placed lumbar and advanced into the thoracic region. I have seen some advanced all the way to the C3 level.

That is very different to an inadvertent thoracic spinal catheter after a wet tap. Also a very different type of patient who has had detailed consent signed and discussed

 

[deleted162650]

How high can you go? Hypothetical question: If I had a sore brainstem,..

Pretty common to put a catheter in the lateral ventrical.

Although I typically prefer to ask the question: How low can you go? 😉

 

[Aether2000]

For many years I did home intrathecal trials on infusion pumps with the catheter tip at T7 with an entry point at L3, including the use of local anesthetics in the admixture, without ever having a high spinal. These were left in for several days, so you certainly can dose patients with local anesthetics with a thoracic spine catheter for a surgical procedure, but I suppose much depends on your comfort level and experience using catheters at this level and the degree of understanding of what various administered drug effect is at different levels and whether it is a pH adjusted admixture vs. single medication.

 

[Planktonmd]

For many years I did home intrathecal trials on infusion pumps with the catheter tip at T7 with an entry point at L3, including the use of local anesthetics in the admixture, without ever having a high spinal. These were left in for several days, so you certainly can dose patients with local anesthetics with a thoracic spine catheter for a surgical procedure, but I suppose much depends on your comfort level and experience using catheters at this level and the degree of understanding of what various administered drug effect is at different levels and whether it is a pH adjusted admixture vs. single medication.

So... in other words ... you have zero experience in the specific circumstances presented here... why do you feel that your very short unrelated experience is relevant here???

 

[AdmiralChz]

For many years I did home intrathecal trials on infusion pumps with the catheter tip at T7 with an entry point at L3, including the use of local anesthetics in the admixture, without ever having a high spinal. These were left in for several days, so you certainly can dose patients with local anesthetics with a thoracic spine catheter for a surgical procedure, but I suppose much depends on your comfort level and experience using catheters at this level and the degree of understanding of what various administered drug effect is at different levels and whether it is a pH adjusted admixture vs. single medication.

Sweet. So you placed these for post-op analgesia in abdominal surgical patients? And you ran them on a mixed local anesthetic-narcotic regimen?

Didn’t think so. This is totally and completely different dealing with chronic pain that acute postoperative. I am shocked and honestly dismayed that some people are actually going down this thought process. Lordy!

 

[Aether2000]

Incorrect conclusions. I have had a few intrathecal placement of epidural catheters used for post op surgical pain in the past several years. Left them in for a day, then discontinued. They worked well and the patients had no complications. Back in the 80s and early 90s I also placed many intrathecal microcatheters 27-32 gauge for both surgery and post op pain control. You guys are just too young to have had these experiences with microcatheters. Intraspinal catheters for surgery and post op pain are not novel techniques. There is a significant body of literature using spinal catheters for intraop surgical anesthesia and post op pain control.
Continuous intrathecal fentanyl infusion for postoperative analgesia. - PubMed - NCBI

Comparison of intrathecal fentanyl infusion with intrathecal morphine infusion or bolus for postoperative pain relief after hip arthroplasty. - PubMed - NCBI

Prolonged intrathecal fentanyl analgesia via 32-gauge catheters after thoracotomy. - PubMed - NCBI

An intrathecal fentanyl dose-response study in lower extremity revascularization procedures. - PubMed - NCBI

Intrathecal fentanyl for post-thoracotomy pain. - PubMed - NCBI

Continuous spinal anaesthesia--early experience in University Hospital, Kuala Lumpur. - PubMed - NCBI

Evaluation of the usefulness of intrathecal bupivacaine infusion for analgesia after hip and knee arthroplasty. - PubMed - NCBI

Intrathecal infusion of bupivacaine with or without morphine for postoperative analgesia after hip and knee arthroplasty. - PubMed - NCBI

Applications of intrathecal catheters in children. - PubMed - NCBI

New developments in spinal anesthesia. - PubMed - NCBI

Comparison of three catheter sets for continuous spinal anesthesia in patients undergoing total hip or knee arthroplasty. - PubMed - NCBI

Comparison between repeat bolus intrathecal morphine and an epidurally delivered bupivacaine and fentanyl combination in the management of post-tho... - PubMed - NCBI

Median effective local anesthetic doses of plain bupivacaine and ropivacaine for spinal anesthesia administered via a spinal catheter for brachythe... - PubMed - NCBI

A randomized-controlled study of intrathecal versus epidural thoracic analgesia in patients undergoing abdominal cancer surgery. - PubMed - NCBI

A comparison of three methods of pain control for posterior spinal fusions in adolescent idiopathic scoliosis. - PubMed - NCBI

Comparison of analgesic effect of intrathecal morphine alone or in combination with bupivacaine and fentanyl in patients undergoing total gastrecto... - PubMed - NCBI

An assessment of intrathecal catheters in the perioperative period: an analysis of 84 cases. - PubMed - NCBI

Radical cystectomy in frail octogenarians in thoracic continuous spinal anesthesia and analgesia: a pilot study. - PubMed - NCBI

 

[deleted59964]

Good point, but if the blood patch is not actually occluding the hole would the effect last or is there higher incidence of recurrence?

apparently spontaneous CSF leaks where the location of the leak is not know, still respond to (admittedly large volume) lumber epidural blood patch.