Thoracic Epidural for Decortication

[Metalblade]

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Wondering how you guys feel about placing thoracic epidurals in patients who have empyemas and are undergoing decortications? Do you avoid completely? Do you go by white count/symptoms?

 

[Noyac]

Not worth it for a few reasons. One, it just isn't that uncomfortable postop. (Disclaimer, I've never had one).
Two, if it's not that uncomfortable then not worth the infectious risk. Ther are more but that's enough for me to not place them.

 

[Wiscoblue]

Single shot paravertebral works well.

 

[Magnus67]

A reasonable chance of puss coming out of the chest tube at some point...... No needle from me. No worth the risk for me , even for PVB.

 

[Arch Guillotti]

One, it just isn't that uncomfortable postop.

A thoracotomy isn't painful postop?

 

[Noyac]

A thoracotomy isn't painful postop?

We do them with the scope, so nope not painful.

Thoracotomy is a different story.

 

[risnwb]

We do them as VATS, and usually surgeon does percutaneous intercostal blocks while watching the local spread on camera. you can see the local tracking along the nerve, and seems to work pretty well...

 

[Metalblade]

What if the procedure is a thoracotomy? I've seen thoracotomies done for empyemas when the surgeon felt the pleural peel needed to be removed manually. Thanks for the responses so far.

 

[2ndyear]

Personally I have done thoracic epidurals for thoracotomies for empyema. I do recognize it's somewhat controversial, so I would qualify that in general antibiotics should be in place and the patient should not be acutely septic.

 

[Noyac]

I agree. If the pt is on antibiotics prior to placement then I would place it.

 

[sevoflurane]

I recently did a thoracotomy for an empyema. Took out a rib for it. I didn't quite know how to feel as I've seen them done very successfully via VATS. Ouch!
Def. give'em an epidural, PVB or intercostal if on abx. These patients need to be able to take breaths post-op to avoid atelectasis and other respiratory insults.

 

[Metalblade]

Would you guys proceed even if there was a white count?

 

[Wiscoblue]

I'd do a para vertebral with a white count. Patient is getting antibiotics. I might not place a PVB catheter but would certainly repeat in 12-24 hours.


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[Noyac]

Would you guys proceed even if there was a white count?

Possibly. It depends on the situation and how badly the pt might need it. Respiratory cripple, yes. Robust pt, probably not.

 

[deleted162650]

One of our surgeons now does these as local/MAC cases with the scope. Took me a while a while to wrap my head around that one but I gotta say it works amazingly well. I agree with others that if the plan is thoracotomy and pt has been on ABX with no sign of disseminated infxn/sepsis I would place one.

 

[bkell101]

I'd do a para vertebral with a white count. Patient is getting antibiotics. I might not place a PVB catheter but would certainly repeat in 12-24 hours.


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Do you guys know of any good papers you can point me towards for paravertebral catheters/ single shot vs epidural for thoracotomy or vats.....

I ask because , If paravertebral is even close to as good, why even bother with what the wbc count and abx status is?

Thanks

 

[Wiscoblue]

I've been doing para vertebrals since 1990. Didn't have ultrasound then and it was all by feel and landmarks. Now ultrasound makes it so easy. Why would you even do an epidural? No risk of sympathetic-block-induced hypotension. Only unilateral blockade. Excellent pain relief because it gets the ligaments near the head of the rib that are ripped by the retractor and which cannot be blocked with intercostal nerve block.

I learned from an old Royal Navy anesthesiologist who had perfected the art of para vertebral blocks. He might have published a case report or review article. His name was Richard Wyatt.

Eason MJ, Wyatt R. Paravertebral thoracic block - a reappraisal. Anaesthesia 1979; 34: 638–42.


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