Thoractomy when unable to get thoracic epidural

[Dinkyconductor]

I've seen several instances in my group recently of patients having thoracotomies for lobectomy/pneumonectomy in which the anesthesiologist was unable to place a thoracic epidural. I don't think I ever had this happen as a resident (if I couldn't get it, they could always find an attending who could), but now it seems to happen with some frequency in my group.

I read the thread about continuous paravertebral catheters, which I'd love to try someday, but I'm a little hesitant to do it never having even seen it done. Maybe after a few more regional conferences.

I also remember a resident from another hospital telling me that their standard of practice was a 1.0 mg duramorph spinal instead of a thoracic epidural for thoracotomies. Never heard of that dose being used for anything, and I've never heard of this anywhere else.

Anyone have any advice for what to do when the thoracic epidural just won't go in?

Thanks

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[2ndyear]

Here's a couple of papers, no great studies but some interesting findings nonetheless:
10 mcg/kg intrathecal morphine provided better relief than PCA (probably gets close to 1 mg duramorph in some patients.
http://www.ingentaconnect.com/content/field/jimr/2007/00000035/00000003/art00005

0.5 mg IT morphine better than PCA alone
http://www.anesthesia-analgesia.org/cgi/content/abstract/92/1/31

Interesting study comparing lumbar infusion of epidural morphine alone to thoracic epidural 0.0625% Bupiv with Fentanyl. No difference. Lumbar approach is certainly easier and this one may change my own thinking a bit.
http://stinet.dtic.mil/oai/oai?verb=getRecord&metadataPrefix=html&identifier=ADA426560

Here's a nice summary table
http://www.oqp.med.va.gov/cpg/PAIN/pain_cpg/content/thorax_non_cardiac/thoracotomy.htm

 

[lobelsteve]

Pain guy thoughts:

It is easier to go T12-L1 or caudal and run the catheter up rom there.

For a single T6-7 disc on MRI with concordant mid axial pain or thoracic radic, I'll go lumbar T12-L1 or caudal and run the catheter up to the desired level. The luxury of fluoro..? Can your patient lie on their belly to get on the fluoro table or do you have to go it blind/LOR?

 

[sevo85288]

If I can't get a t. epid. I place and t12/L1. Dose with PF Morphine, depending on pt. anywhere from 2-5 mg. then thread catheter. Morphine is hydrophilic and
will usually rise a couple of levels...and continues up to brainstem, eventually. By the time the case is done, morphine is higher and dose the catheter with 1/8 % Bupiv. infuse bupiv/fent/or morphine...works farily well.

 

[Noyac]

I also remember a resident from another hospital telling me that their standard of practice was a 1.0 mg duramorph spinal instead of a thoracic epidural for thoracotomies. Never heard of that dose being used for anything, and I've never heard of this anywhere else.

Back in residency, radical prostatectomies took 3-5 hrs and the pts remained inhouse for at lest 3 days. I had this attending that sort of did things just a little different from the rest of the crowd. I learned a ton from this guy (mostly about standards of care and myths ) I was in the urology room for the day with him as my attending and he says we are going to do a combined technique today. Great, how are we doing this, I say? Do a spinal and give these guys 1mg duramorph and then put them to sleep.

I was so afraid they were going to stop breathing that night that I probably called the floor every 2-3 hrs through the night. Both pts (big men) had a PCA for their stay. Neither one of them ever used it and were discharged 3 days post-op. They didn't itch, no nausea, nothing. I was impressed but not enough to ever do it again.

As far as the T. Epid. Have you ever tried the paramedian approach? I find it works better for the thoracics.

 

[zippy2u]

OK, Zippy's Bing-Bang-Boom-Done method for these cases. Your goal is to leave a minimal "footprint" on the pt and minimize your headaches. Intrathecal 0.5mgs Duramorph, GETA and intraop have the surgeon, under direct visualization, do about 3-5 intercostal blocks with 0.5% marcaine with epi. Surgeon writes for the PCA and the next day on your post op visit ya take a 20cc syringe of 0.5%marcaine with epi and repeat the intercostal blocks(pt. has chest tube, don't worry about a pneumo). You are done with this pt. now. Noyac was up every 2-3 hrs with the 1.0mg duramorph--don't need that much and you need your sleep. No epidural so no crazy calls in the middle of the night by the nurses. Surgeon can't blame the epidural for hypotension/MI if it occurs and whatever else goes wrong with the pt. Take home message: Minimal footprint, minimal headaches---make it your mantra. Regards, ----Zip

 

[Sevo]

I usually do a single short spinal with 0.5mg duramorph and 50mcg sufenta. Our patients usually go up to the ICU post-op (we're in a community setting) with PCA supplementation.

They tended to do just as well as the thoracic epidurals with PRN narcs and we don't have to field the middle of the night "leaky cathether," shoulder pain, or hypotension calls.

Zippy suggested post-op intercostal blocks. Where I trained, we did a lot of post-op paravertebral blocks which I swore were probably half intercostal, half paravertebral in practice. Worked well, but nowadays I try to avoid going up to the floor at the end of a long work day and face family members, floor nurses, et al.

 

[Tenesma]

i know of a few surgeons who will cancel the case - reschedule with the patient getting a fluoro-guided catheter before hand - these are academic guys of course (ie: luxury of cancelling cases and still getting a salary).

 

[DuckhuntingDoc]

Interesting...

If I can't get one It's PCA time.