Thoracic Epidural Analgesia and Acute Pain Management

Manion, Smith; Brennan, Timothy J.; Riou, Bruno

doi:10.1097/aln.0b013e318220847c

Cited by 180 publications

(88 citation statements)

References 49 publications

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“…29,30 In the thoracic spine (above T11), the caudal angulation of spinous processes explains failure with the traditional midline approach. 1,29 Furthermore, the interlaminar spaces of the midthoracic region are notoriously narrow and partially covered by the slanted spinous processes originating from the upper vertebra. 29,31 Unfortunately, these anatomical challenges are further compounded by the unreliability of the technical end point (LOR).…”

Section: Nonspecific Nature Of Lor Techniquementioning

confidence: 99%

“…[1][2][3] Thoracic epidural analgesia (TEA) attenuates the surgical stress response by preventing afferent stimuli from reaching the central nervous system, and by inhibiting the efferent activation of the sympathetic nervous system. 4 Compared to parenteral opioids, reported benefits of TEA include improved postoperative pain control, 5 decreased incidence of pulmonary complications (atelectasis, infection, hypoxemia), 6 shorter duration of postoperative ileus, 7 decreased protein breakdown, 8 and increased patient satisfaction.…”

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confidence: 99%

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Primary Failure of Thoracic Epidural Analgesia in Training Centers

Tran

Zundert

Aliste

et al. 2016

Regional Anesthesia and Pain Medicine

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In teaching centers, primary failure of thoracic epidural analgesia can be due to multiple etiologies. In addition to the difficult anatomy of the thoracic spine, the conventional end point-loss-of-resistance-lacks specificity. Furthermore, insufficient training compounds the problem: learning curves are nonexistent, pedagogical requirements are often inadequate, supervisors may be inexperienced, and exposure during residency is decreasing. Any viable solution needs to be multifaceted. Learning curves should be explored to determine the minimal number of blocks required for proficiency. The problem of decreasing caseload can be tackled with epidural simulators to supplement in vivo learning. From a technical standpoint, fluoroscopy and ultrasonography could be used to navigate the complex anatomy of the thoracic spine. Finally, correct identification of the thoracic epidural space should be confirmed with objective, real-time modalities such as neurostimulation and waveform analysis.

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Section: Nonspecific Nature Of Lor Techniquementioning

confidence: 99%

mentioning

confidence: 99%

Primary Failure of Thoracic Epidural Analgesia in Training Centers

Tran

Zundert

Aliste

et al. 2016

Regional Anesthesia and Pain Medicine

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“…The benefits of continuous TEA cannot be accurately ascertained if the catheter is not placed at the epicenter of the target dermatomal level, which will be trespassed primarily during the surgical incision and subsequent tissue manipulation 33. Therefore, we set out to determine whether imaging confirmation for successful epidural catheter placement at the correct vertebra level has the potential to provide improved postoperative analgesia and a decreased use of postoperative opioids 34,42.…”

Section: Discussionmentioning

confidence: 99%

“…Traditionally, TEA is performed using percutaneous anatomical landmarks with no recommendations for imaging confirmation after catheter insertion 33. We believe that the majority of the clinical trials conducted to establish the benefits of TEA after major abdominal or thoracic surgery were based on the premise that catheter placement into the thoracic epidural space has a success rate of 100%.…”

Section: Introductionmentioning

confidence: 99%

The impact of fluoroscopic confirmation of thoracic imaging on accuracy of thoracic epidural catheter placement on postoperative pain control

Aijaz

Candido

Anantamongkol

et al. 2018

LRA

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BackgroundThoracic epidural analgesia (TEA) provides superior postoperative pain control compared to parenteral opioids after major thoracic and abdominal surgeries. However, some studies with respect to benefits of continuous TEA have shown mixed results. The purpose of this study was to determine the rate of successful TEA catheter insertion into the epidural space using contrast fluoroscopy and the impact of placement location on postoperative analgesia and opioid use.Patients and methodsAfter Advocate health care institutional review board approval, we conducted a prospective, open-label, single intervention study on patients undergoing thoracic or upper abdominal surgery. A thoracic paramedian epidural approach and a loss of resistance to saline technique were used to place an epidural catheter above the T11 level and fluoroscopic images with injected contrast were taken to locate the catheter tip in the epidural space.ResultsTwenty-five subjects were included in the study, of which 3 catheters (12%) were not identified as being in the epidural space. We found an average difference of 1.5 vertebral levels between clinical and radiological assessments of catheter tips. Thirteen catheters (52%) were more than 1 vertebral level away from the clinically assessed level. No significant difference was found in the pain scores at 1, 24, and 48 hours after surgery between patients with correct versus incorrect catheter placement. Less opioids were used in the correct catheter placement group at 24 hours (256 morphine milligram equivalent [MME] vs 201 MME) and at 48 hours after surgery (250 MME vs 173 MME), but it was not statistically significant (p=0.149 and p=0.068, respectively).ConclusionImprovement in assuring success in the technique for TEA catheter placement following major thoracic or upper abdominal surgery exists, for which contrast-enhanced fluoroscopy might be a promising solution.

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“…Once the needle can be advanced deeper than the previously marked depth, a glass syringe is attached and used to check for loss of resistance in the usual fashion. 3 Prior to the use of ultrasound, there were multiple unsuccessful attempts with the landmark technique because of difficulty locating any bony landmarks including scapula, posterior superior iliac spine, or spinous processes with palpation in our patient population of increasing size. Using ultrasound, we are able to count the transverse processes down to the level of T9 and locate the necessary landmarks so that we may direct the needle to the necessary starting point for placement of thoracic epidurals and ultimately provide analgesia for the patient.…”

mentioning

confidence: 99%