Thoracic epidural

Summary of evidence:

The good	Post-op: · ↓Resp depression, ↓atelectasis, ↓pneumonia · ↓AF, ↓SVT · ↓Ileus, ↓bowel dysfunction, ↓PONV · ↓Sedation · ↓insulin resistance · ↓DVT Thoracic trauma: · ↓Duration of mechanical ventilation · ↓Mortality
The bad	· Failure 13-32% (?) o Half of these are outside the epidural space · Paraplegia 1/6K o Immediate: needle trauma o Hours-days: haematoma o Days-weeks: abscess · Death 1/12K
The unclear	R.E. peri-op mortality and major morbidity: · MASTER trial was powered to find a 10% difference · It found a 3.6% difference · Not massive but comparable to tamoxifen, thrombolysis · A big enough trial will probably never be done
Disaster prevention	· Education · Bundles of care (like for CVCs) · Avoidance: e.g. wound infiltration catheters

DDx

· Inadequate block

· Extra-thoracic pathway

o Phrenic to shoulder

o Vagus to central chest

· Surgical complication

· Medical complication

Assessment

Hx:

· Pain then (was it ever working?)

· Pain now

Ex:

· General appearance (discomfort)

· Vital signs (BP)

· Insertion site and dressing

· Sensory block (note ice unreliable with low concentration local)

· Motor block

Management

· Inadequate block: bolus (2mL upper thoracic, 3mL lower thoracic)

· Extra-thoracic pathway: systemic analgesics

· Complication: treat as appropriate

DDx

· Overdose

· Intrathecal

· Spinal cord ischaemia

Assessment

· Examine neuro

· Examine site

· Aspirate for CSF

Management

· Stop infusion

· Reassess q30 mins

· If no resolution at 2 hours -> MRI