thoracotomy epidurals

[thegasman]

What level do you guys put your epidurals for thoracotomy? Do you run/bolus during case and what solution/rate do you run? What about breakthrough pain/boluses? Any recs for managing these cases in private practice?

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[dhb]

What level do you guys put your epidurals for thoracotomy? Do you run/bolus during case and what solution/rate do you run? What about breakthrough pain/boluses? Any recs for managing these cases in private practice?

T6-T7, l-bupivaciane 0.5% 5ml bolus then 5-6 ml/h (more hypotension if you are rebolusing every 2h). Same regimen post-op, works well.

 

[proman]

Place ours anywhere from T4 to T8, sometimes use them intraop, sometimes not mostly depending on how healthy the patient is. Some use lidocaine boluses, others will use bupi 0.1% with fentanyl 5mcg/ml at 3-4 cc/hr (and all sorts of other combinations). Postop is more standardized: bupi 0.125% PCEA with fentanyl 5mcg/ml usually start are 4/2/10/6. We also place them on post op day 1 for lung transplants. Then we'll run them 6/4/10/6 for the clamshell incision.

 

[merlebo05]

can someone explain to me when you do a thoracic epidural how does it not block the cardioaccelerator fibers (T1-T4)???

You are going into T4-T8, how do u not get spread into T1-t4 and get total blockage. Especially using 5-6ml of 5% marcaine?????

 

[OB1🤙]

We do T4-T8 for these, probably most often T5-T6. Bupiv 0.1-0.125%, with 3-5 mcg/mL fent (or sometimes 1-2mcg/cc sufent), PCEA usually 5/2/12/4 with further tweakage prn. Usually works well.

Intraop use depends on attending in room. Some run the mix as early as possible with a little bolus up front, rate usually 5-8cc/hr, some bolus in a little 0.25% bupiv up front, some use lidocaine, some give nothing. YMMV.

 

[thegasman]

so the reason i ask is because I just had my first thoracotomy at my pp gig. The group is using ropiv 0.1 with 5mcg/cc fent. I placed it at t5/6. Bolused with 0.25 bupiv during case and started infusion 6cc/hr. In recovery patient seemed to have significant pain from chest tube site - placed lower than I would have expected. His block was pretty good for the thoracotomy incision. I gave him a little extra bolus of lido and I think this may have helped some but he was still kind of sleepy/complaining about his foley too. Gave him some dilaudid and a b&o. What are you guys doing postop for breakthrough when the epidural is helping, but not covering all the pain? In residency we mostly used 0.2 ropiv and put them on pcas if necessary. I don't really think the fent in the epidural is that useful compared to higher conc of local. I have put dilaudid in the infusion in the past but this kind of ties your hands a little if the epidural isn't perfect. I want to help the patient and minimize calls from the nurses cuz I am busy and don't have time to fool with this kind of stuff.

 

[9french]

so the reason i ask is because I just had my first thoracotomy at my pp gig. The group is using ropiv 0.1 with 5mcg/cc fent. I placed it at t5/6. Bolused with 0.25 bupiv during case and started infusion 6cc/hr. In recovery patient seemed to have significant pain from chest tube site - placed lower than I would have expected. His block was pretty good for the thoracotomy incision. I gave him a little extra bolus of lido and I think this may have helped some but he was still kind of sleepy/complaining about his foley too. Gave him some dilaudid and a b&o. What are you guys doing postop for breakthrough when the epidural is helping, but not covering all the pain? In residency we mostly used 0.2 ropiv and put them on pcas if necessary. I don't really think the fent in the epidural is that useful compared to higher conc of local. I have put dilaudid in the infusion in the past but this kind of ties your hands a little if the epidural isn't perfect. I want to help the patient and minimize calls from the nurses cuz I am busy and don't have time to fool with this kind of stuff.

Typically we use 0.1% bupiv with 2 mcg/ml of fentanyl. Although it may be reasonable to start at 6 ml/hr, often times we will need to use a higher rate. Post thoracotomy patients often times try to protect their operative side by keeping pressure off of it, i.e. lying on their non-operative side. This can lead to a great block on the non-operative side secondary to the effects of gravity. Chest tube pain itself is caused by irritation of the diaphragm, which is C3-5, and will not be blocked by the epidural.

 

[dhb]

Typically we use 0.1% bupiv with 2 mcg/ml of fentanyl. Although it may be reasonable to start at 6 ml/hr, often times we will need to use a higher rate.

I don't understand this why use a low concentration? as you say you'll need more volume which will give you more hypotension. Is easier to use a higher concentration and lower volume IMHO.

 

[Bougie]

What are you guys doing postop for breakthrough when the epidural is helping, but not covering all the pain?

Toradol, scheduled for all patients with diaphragm pain from the chest tube unless the beans suck.

 

[thegasman]

any role for gabapentin or pregabalin?