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

 

Trouble-shooting pain:

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

 

Troubleshooting lower limb weakness

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

 

 

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