thoracic epidural tips?

[anbuitachi]

Anyone who do a lot of these have tips for VATS/thoracotomies, especially with paramedian techniques? Place i trained didn't have a ton of paramedian numbers for thoracic cases. most of the thoracic epidurals i did was for abdominal cases were lower, which were just mostly midline

I have done some paramedians with variable success long time ago in residency(n probably too low to tell how good i am), but i will be doing more in my new practice.
I did some rereading on paramedians, and it seems some sources say go lateral and aim NW, some say go down and lateral. Any advice from practice?

Also has anyone not hit lamina during the initial perpendicular stick and gone thru the space in between...? Any advice for what to do/when to stop??

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[Justice4all]

There is a SC manion 2011 article that describes the paramedian approach very well with illustrations. It was very helpful when starting out in residency. Hope it helps

 

[PainDrain]

So in my experience the most difficult levels are T8-T12 levels. The higher I go in the thoracic region I have found I have more success. I tend to go midline first and then if I can’t get it I will try paramedian. I palpate and mark the spinous processes for three levels in the target area, then I start approximately 0.5-1cm below my intended space, I hit the spinous process below the space and walk up and off into the space. I find this works most of the time. If I am going paramedian then I measure 1cm lateral to and 1cm below my intended space.

 

[anbuitachi]

So in my experience the most difficult levels are T8-T12 levels. The higher I go in the thoracic region I have found I have more success. I tend to go midline first and then if I can’t get it I will try paramedian. I palpate and mark the spinous processes for three levels in the target area, then I start approximately 0.5-1cm below my intended space, I hit the spinous process below the space and walk up and off into the space. I find this works most of the time. If I am going paramedian then I measure 1cm lateral to and 1cm below my intended space.

I guess more difficulty with midline T8-12 cause of the steeper angulation of spinous?

 

[anbuitachi]

Also do you guys/girls always gown up with full body gown for thoracic epidurals?

 

[Justice4all]

no, sterile gloves and mask. usually done asleep in pediatrics. T8-12 usually midline for me and paramedian for anything above T7.

 

[Mikkel]

Just get good at midline, you don't need paramedian. Look at one of those practice spines, just by looking you can see at every level a straight route from skin to spinal canal.

I don't do upper epidural placement for scoliosis typically. They should be referred to pain for fluoro placement.

 

[deleted875186]

I do all thoracic epidurals paramedian, much higher success rate. Like described above, start 1 cm lateral and 1 cm inferior to the spinous process. Go perpendicular to skin and try as hit lamina with my finder needle. Once you hit bone you are good, can walk medial and superior to get into the space. If I can’t hit bone with the finder, I’ll try the toughy up to 3-4cm, then aim superior and inferior to try and hit bone. If I still don’t hit bone, I’ll angle towards midline and attach the LOR syringe and andvance, you’ll either hit ligament or bone, and again youll be set once you hit either one and you’ll know where you are.

 

[epidural man]

 

[epidural man]

Some key points about the description above (and exactly how I do mine). I don't do it as dripiMAN described - go 1cm lateral to spinous process, but stay at that same level. If you study the picture, the lamina of the level below is at the same level of the spinous process. It is easier to ender the space the closer you are to the TOP of the lamina - so it may be better to just go 1cm lateral to this.

Use your seeker (local) needle and go straight in and hopefully you hit lamina. Then, with the Touhy, do the same thing (straight in) and touch lamina. Notice (mark) the depth. Then walk the needle medially and up the lamina. I like to keep walking medially until I get a feel of when I am waling up the spinous process, and where the middle of lamina is. This medial angulation will get you to midline. Then, walk up cephelad over the top edge of the lamina.

You should NOT be angled much when you enter the epidural space. If you are, you likely missed it and started too low. It's really hard to get into the space with a steep angle (and why doing midline approach sucks - but many people have got good at that.)

 

[epidural man]

The picture shows that after you go straight in - they bring the needle almost to skin and re-advance. I wouldn't do this. I would just withdraw enough to walk on the lamina medially

 

[Noyac]

Also do you guys/girls always gown up with full body gown for thoracic epidurals?

No

 

[woopedazz]

That diagram is fantastic! I've never done paramedian before and this is extremely helpful. Might give it a try with my next thoracic epidural.

 

[caligas]

Study that diagram and practice on a skeleton with your eyes closed, it will click and then seem easy.

Also a tip/cheat for abdominal cases:

if struggling with paramedian at t9, t10 you can easily move down and do a midline approach at around t12, thread the catch a little further up, and run dilaudid for improved spread.

 

[deleted171991]

There is a SC manion 2011 article that describes the paramedian approach very well with illustrations. It was very helpful when starting out in residency. Hope it helps

Thoracic Epidural Analgesia and Acute Pain Management

PAIN continues to be a significant problem for many patients after major surgery. In addition to improving patient satisfaction and decreasing pain scores, enhanced perioperative pain control can improve clinical outcomes. Thoracic epidural analgesia (TEA) remains a critical tool for...

anesthesiology.pubs.asahq.org

 

[Lecithin5]

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I do lots of thoracic epidurals via paramedian (but many of my partners do midline and are good at it)- this diagram is pretty spot on. I always try to hit lamina with my numbing/finder needle, but if patient is obese and you are unable to hit lamina with said needle, you are still likely to hit lamina with Tuohy if you enter skin as the diagram shows (ie a cm lateral to midline, and PERPENDICULAR at 90 deg to start). Once you hit lamina, you are almost golden. I’ve also learned over the years that you don’t need to medially angulate so much, maybe 15-20 degrees. But this obviously depends on how far lateral you start. And then it’s all about walking off the lamina.

 

[pgg]

I guess more difficulty with midline T8-12 cause of the steeper angulation of spinous?

T10-12 midline should be easy since the spinous processes are almost as horizontal as the lumbars. Labor epidural in super morbidly obese women at these levels are a thing precisely because midline approach is pretty easy.

Above T9 is where they start to get steep and where a paramedian approach is almost always going to be easier.

Find a skeleton model and play with it a bit. The paramedian path in is absolutely huge compared to the midline window above T8. This is especially relevant in crusty old spines as the interspinous ligament gets more and more calcified. Once you've done a couple paramedian approaches to mid thoracic epidural you'll never go back to midline approaches.

 

[deleted875186]

I do lots of thoracic epidurals via paramedian (but many of my partners do midline and are good at it)- this diagram is pretty spot on. I always try to hit lamina with my numbing/finder needle, but if patient is obese and you are unable to hit lamina with said needle, you are still likely to hit lamina with Tuohy if you enter skin as the diagram shows (ie a cm lateral to midline, and PERPENDICULAR at 90 deg to start). Once you hit lamina, you are almost golden. I’ve also learned over the years that you don’t need to medially angulate so much, maybe 15-20 degrees. But this obviously depends on how far lateral you start. And then it’s all about walking off the laminate.

True, once you walk off lamina bone superiority, sometimes have to adjust more or less medically directed depending on how lateral you punctured the skin.

 

[10KHertz]

Anyone who do a lot of these have tips for VATS/thoracotomies, especially with paramedian techniques? Place i trained didn't have a ton of paramedian numbers for thoracic cases. most of the thoracic epidurals i did was for abdominal cases were lower, which were just mostly midline

I have done some paramedians with variable success long time ago in residency(n probably too low to tell how good i am), but i will be doing more in my new practice.
I did some rereading on paramedians, and it seems some sources say go lateral and aim NW, some say go down and lateral. Any advice from practice?

Also has anyone not hit lamina during the initial perpendicular stick and gone thru the space in between...? Any advice for what to do/when to stop??

Try to watch a pain interventionalist perform paramedian TESIs under fluoroscopic guidance. Makes it easier to reconstruct the entry Point/target in your mind while performing the procedure with only palpation.

 

[Lecithin5]

Try to watch a pain interventionalist perform paramedian TESIs under fluoroscopic guidance. Makes it easier to reconstruct the entry Point/target in your mind while performing the procedure with only palpation.

Yes. I’ve also looked closely at an exposed thoracic spine during a spine operation- that’s helpful. Or a skeletal model. It’s nice to be able to 3d map in your mind as you perform a paramedian thoracic epidural.

 

[10KHertz]

Yes. I’ve also looked closely at an exposed thoracic spine during a spine operation- that’s helpful. Or a skeletal model. It’s nice to be able to 3d map in your mind as you perform a paramedian thoracic epidural.

Even spinal surgeons have difficulty placing a thoracic paddle lead via a paramedian laminotomy...steep angle

 

[Tramadeezy]

After doing high thoracic ESIs under fluoro in the pain clinic ive come to appreciate two things; 1. The interlaminar space is almost entirely blocked off by the downsloping spinous process and 2. Starting 1cm inferior and lateral to the spinous process puts you much further out on the lamina than people realize. Need to hug the spinous process. Advancing perpendicular just lateral to the upper portion of the SP will place you at the front edge of the lamina and make for an easier path.

 

[10KHertz]

After doing high thoracic ESIs under fluoro in the pain clinic ive come to appreciate two things; 1. The interlaminar space is almost entirely blocked off by the downsloping spinous process and 2. Starting 1cm inferior and lateral to the spinous process puts you much further out on the lamina than people realize. Need to hug the spinous process. Advancing perpendicular just lateral to the upper portion of the SP will place you at the front edge of the lamina and make for an easier path.

Along the lamina is where the majority of “false” loss of resistance occurs and thus false catheter placement. You can have the best technique in the OR but unless you have a CLO or lateral fluoro view , failed manual OR placement will occur. Maybe intraop ultrasound guidance would be a nice study .... get it done residents

 

[deleted875186]

Along the lamina is where the majority of “false” loss of resistance occurs and thus false catheter placement. You can have the best technique in the OR but unless you have a CLO or lateral fluoro view , failed manual OR placement will occur. Maybe intraop ultrasound guidance would be a nice study .... get it done residents

In my opinion, false loss is usually suspected. The LOR doesn’t feel great. I try and avoid “trying to thread the catheter” when I’m in doubt about rhhe LOR, and instead just come back to ligament or towards skin and try again.

 

[Mman]

I prefer paramedian for mid thoracic epidurals because it is simply easier than midline, the target you are aiming for is much bigger than a midline approach.

My technique is to go just barely lateral to the spinous process and go straight in til I contact lamina. Then I aim a little back towards the midline and perhaps a smidge cephalad and see if I can get into ligament. If I contact bone at a more shallow level than the lamina was, that is the spinous process and I just need to get above or below it. If no bone, hopefully on the right path and just advance under either LOR or hanging drop technique.

 

[PieOHmy]

Hanging drop!

Youre welcome!

 

[deleted9493]

Paramedian in pediatrics—particularly in infants. The added distance from skin to epidural space helps reduce site leaking (which in most may be inevitable).

 

[caligas]

Hanging drop!

Youre welcome!

I want to try this. Watched some videos, seems obvious and straight forward. Any pitfalls?

 

[Southpaw]

I want to try this. Watched some videos, seems obvious and straight forward. Any pitfalls?

just one pitfall really - the user you're questioning on this 4 year old thread has had their membership revoked.

 

[T-burglar]

Only way to have a high departmental success rate on these is to use fluoro routinely . I’ve actually been thinking about the logistics of doing this.

 

[deleted875186]

I want to try this. Watched some videos, seems obvious and straight forward. Any pitfalls?

A lot of pitfalls. Drop getting sucked in can be subtle, although usually pretty obvious is sitting upright position. Main limitation is if anything is clogging the needle. Also any heme at all in the needle will prevent the drop from getting sucked in potentially because the blood is viscous. I find no real benefit to this technique, and would never use it again.

 

[JDMcNugent]

There is a SC manion 2011 article that describes the paramedian approach very well with illustrations. It was very helpful when starting out in residency. Hope it helps

Thoracic Epidural Analgesia and Acute Pain Management : Anesthesiology

An abstract is unavailable.

pubs.asahq.org

I had the privilege of training under Dr Mannion. Brilliant guy, excellent paper for thoracic epidurals!

 

[HalO'Thane]

I wonder if it will be just a matter of time before ultrasound becomes utilized for thoracic epidural placement. Not necessarily for the labor epidurals on healthy parturients; but for the older patients with arthritis, bone spurs, and kyphosis coming for thoracic and upper abdominal procedures requiring a thoracic epidural.

 

[epidural man]

I wonder if it will be just a matter of time before ultrasound becomes utilized for thoracic epidural placement. Not necessarily for the labor epidurals on healthy parturients; but for the older patients with arthritis, bone spurs, and kyphosis coming for thoracic and upper abdominal procedures requiring a thoracic epidural.

More likely people with just stop using thoracic epidurals. ESBs have made them very rare in our institution.

 

[FiO2@21]

More likely people with just stop using thoracic epidurals. ESBs have made them very rare in our institution.

Do you feel like they work? I have not reviewed literature but they were frequently unsatisfying.

 

[Urzuz]

More likely people with just stop using thoracic epidurals. ESBs have made them very rare in our institution.

I’ve always thought of ESBs as a poor man’s paravertebral. Epidural > paravertebral >>>>> ESB

 

[Maz777]

I’ve always thought of ESBs as a poor man’s paravertebral. Epidural > paravertebral >>>>> ESB

Exactly. If you do really crappy epidurals and/or PVBs, then yes ESPBs are just as effective. Anyone that thinks they are remotely comparable needs to learn how to do epidurals/PVBs.

 

[abolt18]

Do you feel like they work? I have not reviewed literature but they were frequently unsatisfying.

Do it on a patient with rib fractures or post-op for a thoracotomy or VATS patient in a lot of pain and you'll see that it works very well.

Do it pre-op or pre-emergence, and you'll be wondering if it did anything. I feel the same way about TAP blocks.

 

[epidural man]

Do you feel like they work? I have not reviewed literature but they were frequently unsatisfying.

I don’t know how well they work.

Pros and Cons to everything.

Here is the question - at what percentage (as far as efficacy) do they need to work to replace an epidural?

A well working, excellently placed thoracic epidural is unbeatable. They are magic really.

However, that perfect epidural is a rarity. They generally are a huge pain in the ass, difficult to place, lots of work to manage, can have catastrophic complications, etc.

So if an ESB works only 50% as well, do you go with that? How well does an easily done, no management block need to work to replace the epidural?

 

[gunnershow]

I don’t know how well they work.

Pros and Cons to everything.

Here is the question - at what percentage (as far as efficacy) do they need to work to replace an epidural?

A well working, excellently placed thoracic epidural is unbeatable. They are magic really.

However, that perfect epidural is a rarity. They generally are a huge pain in the ass, difficult to place, lots of work to manage, can have catastrophic complications, etc.

So if an ESB works only 50% as well, do you go with that? How well does an easily done, no management block need to work to replace the epidural?

A single injection ESP lasts 6-12h without dexamethasone. Best case scenario you stretch it to 24h with adjuncts but I haven't observed this duration in practice. If I'm even considering a thoracic epidural, I expect to need multiple days postoperative relief, not just their PACU stay... So I don't really see how people are claiming ESPs as a replacement for thoracic epidurals unless we are conceding that opioid-free pain control really doesn't matter and patients can just limp through with a PCA.

 

[FiO2@21]

A single injection ESP lasts 6-12h without dexamethasone. Best case scenario you stretch it to 24h with adjuncts but I haven't observed this duration in practice. If I'm even considering a thoracic epidural, I expect to need multiple days postoperative relief, not just their PACU stay... So I don't really see how people are claiming ESPs as a replacement for thoracic epidurals unless we are conceding that opioid-free pain control really doesn't matter and patients can just limp through with a PCA.

For a VATS this is probably the case with the available evidence... I think the few open thoracotomies that exist would still benefit.

 

[deleted875186]

I don’t know how well they work.

Pros and Cons to everything.

Here is the question - at what percentage (as far as efficacy) do they need to work to replace an epidural?

A well working, excellently placed thoracic epidural is unbeatable. They are magic really.

However, that perfect epidural is a rarity. They generally are a huge pain in the ass, difficult to place, lots of work to manage, can have catastrophic complications, etc.

So if an ESB works only 50% as well, do you go with that? How well does an easily done, no management block need to work to replace the epidural?

There is a failure rate with everything.

I think thoracic epidurals are much more reliable than you claim. ESP blocks are definitely safer, but even more unpredictable, and definitely nowhere near as good as an epidural. I also think with good technique and experience, complications outside the incidence of PDPH are pretty much non existent with a thoracic epidural. Any open procedure should get a thoracic epidural.

Your point about the effort required to care for these epidurals is valid, ESPs are easier, and for a minimally invasive surgery probably the better block.

 

[pocafx]

Can do esp catheters and not worry about anti coagulation. And don’t have to bolus either so basically no calls from the floor