You want info on Thoracic Epidurals

[Noyac]

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For those of you that are pissed at me for my responses to the nurses T. Epi thread, it has been discussed before. You can get it here:

http://forums.studentdoctor.net/showthread.php?t=311651

All the rmh had to do was search.

Now, if after you have read this, you still have questions then by all means fire away.

 

[Noyac]

If that link isn't enough then go to:

http://gasforums.studentdoctor.net/showthread.php?t=315636&highlight=Thoracic+epidural

Look down the page under epidurals.

 

[rmh149]

Thank you Noyac....that was very helpful.

 

[Mofeen]

I want info Noyac, but the links are broken. Haven't done one since residency ended 1 year ago. Have one scheduled tomorrow (thoracotomy) and think a little refresher would help.

 

[bullard]

I want info Noyac, but the links are broken. Haven't done one since residency ended 1 year ago. Have one scheduled tomorrow (thoracotomy) and think a little refresher would help.

Go paramedian Start about 1.5 cm lateral to the T6 spinous process (for thoracotomy), go perpendicular at all angles towards bone until you hit lamina, then walk off medially and cephalad. I usually do LOR to air, but since I think false LORs are more common with thoracics, confirm your LOR with saline as well. If you give all of the test dose, you should be able to get a level to cold.

In residency, the attendings that also did chronic pain always went paramedian for thoracics. I think that's telling.

The "dose it during the case" versus "are you crazy, if you use it during the case you'll just fight a sympathectomy -- how do you know if your hypotension is hypovolemia vs blood loss vs cardiogenic vs epidural overdose" debate is a little silly, I think. i was trained in the latter camp but now I dose it during the case. I figure if it's OK to run a little bit of phenylephrine to counteract the propofol/remi used during a spine case, what's wrong with a little vasoactive agent to go with your thoracic epidural? Unless your surgeon is a complete butcher, in which case all bets are off.

 

[Idiopathic]

Go paramedian Start about 1.5 cm lateral to the T6 spinous process (for thoracotomy), go perpendicular at all angles towards bone until you hit lamina, then walk off medially and cephalad. I usually do LOR to air, but since I think false LORs are more common with thoracics, confirm your LOR with saline as well. If you give all of the test dose, you should be able to get a level to cold.

In residency, the attendings that also did chronic pain always went paramedian for thoracics. I think that's telling.

The "dose it during the case" versus "are you crazy, if you use it during the case you'll just fight a sympathectomy -- how do you know if your hypotension is hypovolemia vs blood loss vs cardiogenic vs epidural overdose" debate is a little silly, I think. i was trained in the latter camp but now I dose it during the case. I figure if it's OK to run a little bit of phenylephrine to counteract the propofol/remi used during a spine case, what's wrong with a little vasoactive agent to go with your thoracic epidural? Unless your surgeon is a complete butcher, in which case all bets are off.

i think you are more likely to get false loss with saline, so i usually reverse that part and confirm with air. it probably doesnt matter.

 

[sevoflurane]

For me, the use of a spring wound catheter is the best test for a false positive. It will NOT thread if you are not in the epidural space. Stiff catheters can go anywhere....

 

[Arch Guillotti]

LOR to air is the only way to do it🙂

 

[pgg]

the links are broken

That's 'cause you necrobumped a 5-year-old thread, a throwback to the days when the anesthesia forums were on their own subdomain. 😉

 

[jetproppilot]

That's 'cause you necrobumped a 5-year-old thread, a throwback to the days when the anesthesia forums were on their own subdomain. 😉

Necrobumped? 😱

Never heard that word....I think you made it up.

I like it.

 

[MTGas2B]

Necrobumped? 😱

Never heard that word....I think you made it up.

I like it.

I hadn't heard it either, but after a quick google search I think its part of the lingo these days:
http://www.urbandictionary.com/define.php?term=necrobump

 

[pgg]

Necrobumped? 😱

Never heard that word....I think you made it up.

I like it.

I can't claim credit 🙂

http://www.urbandictionary.com/define.php?term=necrobump

ETA - beat by 60 seconds by MTGas2B

 

[MTGas2B]

I can't claim credit 🙂

http://www.urbandictionary.com/define.php?term=necrobump

ETA - beat by 60 seconds by MTGas2B

But did you put the most interesting man in the world pic in too?

 

[bullard]

For me, the use of a spring wound catheter is the best test for a false positive. It will NOT thread if you are not in the epidural space. Stiff catheters can go anywhere....

Agreed.

 

[TrustMe]

I'm in the LOR to air for thoracic epidurals camp. Spring wound catheter should slide in like butter. If any resistance, not in the right spot. I like to dose it prior to incision. One of our acute pain guys used to give a huge dose prior to incision (10+mL of 0.5% bupivicaine) and then volume load and run phenylephrine if needed. His opinion was that blocking any sympathetic response to incision resulted in less pain post-operatively. Not sure if this is true, but he swore by it.

 

[Impromptu]

In training residents, I think it is better to use loss of resistance with saline. Far less pneumocephalus that way. Probably smart for attendings to do it that way, too. Do we really have the follow-up or specific questions to know how many painful pneumocephaluses we have caused?