Thoracic epidural dosings

[apma77]

what is your dosing regimen with thoracic epidurals using:

ropivacaine
bupivacaine

Also....if bolusing with 0.5% ropivacaine how many cc's do you guys give and what kinda infusions are you guys using??

ive been bolusing with 2% lidocaine if the catheter isnt working to check it ..also infusions im using 0.125% bupi with 2mcg fentanyl

any thoughts???

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[dhb]

The protocol of the department is l-bupi 0.5% 5-10 ml bolus then half the initial dose every 2h then 4/1/20 pcea post-op.

What i like to do is bolus 5ml 0.5% then follow with 4ml/h intra-op with 1-2ml bolus if needed and same post-op 4/1/20. This way i don't get the hypotension 15-20min after the bolus.

 

[coprolalia]

Ropivacaine is nice. Less dense block (similar to bupivacaine). We use 0.2% ropivacaine a lot of times for thoracics. Also, 0.1% bupivacaine works well.

You can also do an "opioid only" for a high thoracic epidural (T6 and above). Works great for bilateral mastectomy. Biggest problem, as you probably know, is knocking out the sympathetics and causing hypotension/bradycardia.

-copro

 

[huktonfonix]

we do 0.1 bupivicaine + 3-5 mcg/ml fentanyl or hydromorhone 0.01-0.03 mg/ml running at 3-6/2-4/15. The variation in dosing depends on patient age, size, narcotic tolerance, location of epidural etc.... If the epidural is working, but too much hypotension, consider decreasing local concentration and increasing opioid and vice versa if too much opioid side effects (or can use narcan drip, nalbuphine, etc..). I like 2% lidocaine for testing also. If there is no segmental block with that than I consider it to be a non working epidural.

 

[cchoukal]

Our dept's attendings really vary. We just started having our pain service do most of our epidurals pre-op, and one advantage of this is they can establish a band before we take the patient back and induce. They usually just use the 1.5% lido with epi in the test dose for this.

Many of our attgs will not dose the catheter during the case until the last 20-30 minutes, and, of course, these patients generally wake up screaming. We have one guy that'll dose 2% lido Q hr during the case, 4-8 mL, depending on the level. Most run "the bag," which is usually 0.1% bupiv + hydromorphone 20 mcg/mL at 4-6 mL/hr. Post-op I like the PCEA. I usually start at 4-6 mL/hr + half the hourly rate Q30min on demand.

 

[drccw]

thoracic epidurals...

I love morphine.
3-4 mg upfront... bolus 5 cc of 1/4% as they close and then start bupivacaine plain 1/10% in PACU...

Epidural morphine is a great 18-24 hr drug.. it'll rescuse some crummy epidurals... be careful though in who you use it in..

 

[MTGas2B]

We do thoracic epidurals a little differently in all of our hospitals, but at the UWMC, where we do the most, we generally start with 1/10% bupi + 2 mcg/ml of fent on a PCEA with 2 ml incremental, 10 minute lockout and 6-8 ml/hr continuous. The pain service manages them post-op. While on pain we take call from home.

Generally, for placement, after a test dose, we do an initial bolus with 2% lidocaine. If we do subsequent boluses, which usually only do to test, not to get someone comfortable, we generally use 2% lidocaine. That's what our acute pain service director likes. Our cardiac attendings (who do a lot of thoracic epidurals) tend to do other things for their boluses, 0.5% bupi, epidural morphine, etc. But once their epidurals leave the PACU they are managed by the pain service.

Our pain service director likes 2% lido just for checking how well an epidural is working. We've had bad thoracic epidurals loaded with 0.5% bupi that get comfy in the PACU, then go to floor and by evening, when the pain resident is trying to sleep at home the bolus wears off and they're miserable again. Not fun to fix with a floor nurse over the phone. As long as their BP will take it, we can get more concentrated epidural bupi infusions or push bigger continuous volumes.

 

[jetproppilot]

what is your dosing regimen with thoracic epidurals using:

ropivacaine
bupivacaine

Also....if bolusing with 0.5% ropivacaine how many cc's do you guys give and what kinda infusions are you guys using??

ive been bolusing with 2% lidocaine if the catheter isnt working to check it ..also infusions im using 0.125% bupi with 2mcg fentanyl

any thoughts???

Yes.

My thoughts are....thoracic epidurals are frikkin awesome for intraoperative analgesia.

Don't understand why attendings would wanna place a thoracic epidural and not exploit it's benefits intraoperatively.

Say, for a thoracotomy, you place a preoperative thoracic epidural.

Assuming its in the right place...yeah, laugh, but placing a thoracic takes alotta skill....many, many thoracics are placed...but arent in the RIGHT place.........remember, in contrast to a lumbar, where you're "walking up" the level...... with a thoracic, you're establishing a BAND of anesthesia....a few levels above and a few levels below where you've driven the Tuohy.....

SOOOO.....

You drive the Tuohy.

Say its T-10.

And you'd bet your last-months 40K paycheck that its in the right place.

Time to dose.....before the operation starts, of course.

Take 2% lido, .5%bupiv, or .5% ropiv.

Squirt in 5 mL. Thirty minutes before the operation.

That initial volume, assuming the catheter is in the right place, should give enough analgesia for a thoracotomy such that when the surgeon opens on, say, a lobectomy, your volatile agent end-tidal should be surprisingly low.....say a sevo ET of .8.....or a des ET of 1.8.....skin incision and subsequent rib manipulation shouldnt bring a labile hemodynamic rise...

in other words....your paralyzed patient thats just received an astoundingly painful stimulus is requiring just enough gas to tolerate the endotracheal tube.....and your thoracic epidural is providing the analgesia for the operative site.

Keep dosing it.

About 5mL an hour.....

I use BP as an indicator.

Art line trending up?

More thoracic local.

Art line holding steady?

Wait a while.

Remember, Dude/Dudettes, this anesthesia sh it is a science....yeah....but its also an art. Patients havent read the book on how to respond...you write the book with your responses. I use blood pressure trends to dictate how to dose an intraoperative epidural.

Blood pressure going up=dose more local.

Blood pressure holding= wait a while, maybe dose 2-4mL judiciously, if the one-hour-time-has-arrived.

If you are placing a thoracic epidural and not using it intraoperatively you are.....NO......the PATIENT is missing out on the benefits of your preoperative work.

Keep dosing intraoperatively.

Usually about 5mL/hr for a thoracic catheter.

 

[epidural man]

what is your dosing regimen with thoracic epidurals using:

ropivacaine
bupivacaine

Also....if bolusing with 0.5% ropivacaine how many cc's do you guys give and what kinda infusions are you guys using??

ive been bolusing with 2% lidocaine if the catheter isnt working to check it ..also infusions im using 0.125% bupi with 2mcg fentanyl

any thoughts???

Bupivicaine 0.05% (1/20th) with HM10mcg/cc. If they are uncomfortable, we increase it to 0.1%. I am amazed at how well the 0.05% works most of the time.

 

[jetproppilot]

Bupivicaine 0.05% (1/20th) with HM10mcg/cc. If they are uncomfortable, we increase it to 0.1%. I am amazed at how well the 0.05% works most of the time.

Seriously? POINT-OH-FIVE-PERCENT?

Thats hard for me to believe on a thoracotomy patient.

Seems damn-near placebo verses telling the dude to bite on a pieca-lead after a shot of Jack Daniels.

but hey, I'm all ears.

WAIT....LETS GO FOR POINT-OH-OH-OH-OH-FIVE PERCENT!!!!

.00000000000000000005%!!!

Sorry for the laughs in advance.

Hard to believe, though.

 

[epidural man]

Seriously? POINT-OH-FIVE-PERCENT?

Thats hard for me to believe on a thoracotomy patient.

Seems damn-near placebo verses telling the mutha fukka to bite on a pieca-lead after a shot of Jack Daniels.

but hey, I'm all ears.

WAIT....LETS GO FOR POINT-OH-OH-OH-OH-FIVE PERCENT!!!!

.00000000000000000005%!!!

Sorry for the laughs in advance.

Hard to believe, though.

I agree. I had the same response when I got here, but I got to tell you, it works much better than i would have ever predicted. I became a believer. We have to increase it to .1% a lot, maybe 30% of the time.

 

[CerebralEdema]

When I started as an attending I too couldn't believe that 0.05% bupi would work ... but ... low and behold one of my collegues asked me on my third day why the hell I was using 0.2% ropi when I could use 0.05% bupiv.

I didn't beleive him but he said he used it all the time with 5 or 2 mcg/ml fentanyl running at 8ml/hr after testing the catheter. He starts it immediately after his test dose of 2%lido with epi (prior to induction) and runs it through the whole case. His patients were very comfortable and rarely do we have to turn it up to 0.1%. I'm a beleiver now! Try it out for yourself...

 

[dhb]

If you are placing a thoracic epidural and not using it intraoperatively you are.....NO......the PATIENT is missing out on the benefits of your preoperative work.

Keep dosing intraoperatively.

Usually about 5mL/hr for a thoracic catheter.

 

[Arch Guillotti]

thoracic epidurals...

I love morphine.
3-4 mg upfront... bolus 5 cc of 1/4% as they close and then start bupivacaine plain 1/10% in PACU...

Epidural morphine is a great 18-24 hr drug.. it'll rescuse some crummy epidurals... be careful though in who you use it in..

Interesting, we almost universally dose em up w/local only before we make a decision to yank a crummy one.