1. Thoracic Epidural Analgesia Kristin Washburn May 23, 2014

2. Conflicts of Interest  None

3. Outline  Background/history  Physiologic benefits  Current practice  Current Research  Fluoroscopy and epidurograms  RCT

4. Timeline  1885: Coring documented epidural anesthesia in animals  1901: Sciard and Cattalin first use of epidural anesthesia in form of a caudal  1944: Vasconcellos use of epidural for thoracic surgery  1948: Fujikawa presented 100 cases of TEA for thoracic surgery  1951: Crawford extended to 677 thoracic surgical cases with the patient awake and spontaneously breathing  1953: Crawford described catheter use for prolonging anesthesia  1956: Bonica described paramedian approach O’Connor C J. Thoracic Epidural Analgesia: Physiologic Effects and Clinical Applications. Journal of Cardiothoracic and Vascular Anesthesia 7(5):595-609, 1993 Crawford OB: The technique of continuous peridural anesthesia for thoracic surgery. Anesthesiology 14:317-21, 1953

5. Hanging drop technique Crawford OB, Ottesen P, Buckingham WW, Brasher CA: Peridural anesthesia in thoracic surgery. A review of 677 cases. Anesthesiology 12: 73- 95, 1951

6. Physiologic changes associated with TEA  Hypotension results from sympathetic blockade  Decreased cardiac output due to decreased heart rate and decreased contractility  Decreased systemic vascular resistance Stevens DS, Edwards WT (1991) Management of pain after thoracic surgery. In JA Kaplan (ed.) Thoracic Anesthesia (573) New York, NY: Churchill Livingstone

7. Benefits of TEA High risk surgical patients were found to have a reduction in postoperative complications, incidence of cardiac failure and major infectious complications. Reduction in hospital costs Yeager MP et al. Epidural anesthesia and analgesia in high-risk surgical patients. Anesthesiology 66: 729-736, 1987

8. Benefits of TEA- CARDIAC decreased sympathetic activation from surgical stress decreases myocardial oxygen demand and coronary artery vasoconstriction Moraca RJ, et al. The role of epidural anesthesia and analgesia in surgical practice. Annals of Surgery 23(5) 663-673, 2003 Liu S et al. Epidural Anesthesia and Analgesia Their role in postoperative outcome. Anesthesiology 1995 82: 1474-1506

9. Benefits of TEA- PULMONARY decreased postoperative atelectasis, pneumonia and hypoxemia 59% reduction in respiratory depression in patients treated with TEA as compared with PCA Moraca RJ, et al. The role of epidural anesthesia and analgesia in surgical practice. Annals of Surgery 23(5) 663-673, 2003 Ballantyne et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analysis of randomized, controlled trials. Anesth Analg. 1998;86:598-612

10. Benefits of TEA- HEMATOLOGIC Sympathetic stimulation increases factor VIII, vWf, decreases AT III and initiates platelet activation Bredbacka S, et al. Pre and postoperative changes in coagulation and fibrinolytic variables during abdominal hysterectomy under epidural or general anesthesia. Acta Anaestheiol Scand. 1986; 30:204-210 Modig J et al. Role of extradural and of general anesthesia on fibrinolysis and coagulation after total hip replacement. Br J Anaesthe. 1983;55:625-629 Rem J et al. Postoperative changes in coagulation and fibrinolysis independent of neurogenic stimuli and adrenal hormones. Br J Surg. 1981;68:229-233

11. Benefits of TEA: GI  Unopposed parasympathetic innervation of the gut reduces post operative ileus that is caused by inhibitory sympathetic efferent activation and narcotics  Return of bowel function 2-3 days sooner in patients with a thoracic epidural Moraca RJ, et al. The role of epidural anesthesia and analgesia in surgical practice. Annals of Surgery 23(5) 663-673, 2003 Carpenter RL. Gastrointestinal benefits of regional anesthesia/analgesia. Reg Anesth. 1996; 21:13-17

12. Benefits of TEA: IMMUNE  Stress response, inhaled anesthetics and opioids lead to impairment of the immune system in the post operative period  Suppression of T cell, B cell, monocyte, neutrophil, NK cell function De Leon-Casasola OA. Immunomodulation and epidural anesthesia and analgesia. Reg Anesth. 1996; 21(6s):24-25 Meakins JL. Surgeons, surgery and immunomodulation. Arch Surg. 1991;126:494-498

13. Benefits of TEA: PAIN  Pre-emptive analgesia from TEA reduces acute post-operative pain  TEA provides better postoperative analgesia than opioids  Acute post-operative pain is a predictor for long-term pain after thoracotomy Yegin A et al. Early post operative pain management after thoracic surgery; pre- and postoperative versus postoperative epidural analgesia: a randomized study European Journal of Cardio-thoracic surgery 24; 2003:420-424 Katz J et al. Acute Pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pian 1996;12:50-5

14. Current practice  Blind placement of thoracic epidurals  Failure rate  Epidurograms  Fluoroscopic guidance of epidural steroid injections in pain clinic Riggs JR, et al. Epidural anesthesia and analgesia and outcome of major surgery: a randomized trial. Lancet 2002;359: 1276-1282 Ryu HG et al. The coiling length of thoracic epidural catheters: the influence of epidural approach angle. Br J Anaesth 2007; 98:401-404

15. Research Question  Does the use of fluoroscopic guidance significantly improve epidural function in patients undergoing a thoracotomy?

16. Hypothesis  Primary hypothesis:  Precise epidural placement using fluoroscopic guidance will improve overall catheter function leading to reduced postoperative pain and analgesic requirements  Secondary hypothesis  Precise placement will reduce required volumes of local anesthetic and local anesthetic related side effects including hypotension and bradycardia, improving patient safety

17. Retrospective Review  23 patients underwent thoracotomy between May and June 2011  6 patients with thoracic epidural placed blindly  13 patients with thoracic epidural placed under fluoroscopy  4 patients without an epidural

18. Study Design  Randomized single blinded control trial  Enrollment criteria: patients scheduled for thoracotomy with no contraindication for epidural or fluoroscopy  50 patients in each group:  Treatment group: fluoroscopically placed epidural  Control group: blind placement of epidural

19. Patient enrollment 135 patient enrolled 100 patients participated in the study 47 randomized to fluoro placement 47 patients had epidural placed under fluoro 53 randomized to blind placement 6 of the patients randomized to blind placement had epidural placed under fluoro 47 patients had epidural placed blindly 35 patient withdrew from study Reasons for patient withdrawal Surgery canceled [13] Patient did not require epidural (thoracoscopy) [4] Two procedures [2] Patient decision [10] Allergy to contrast [1] Anticoagulation [1] Withdrawn anesthesia [2] Unable to place epidural [2]

20. Table 1: patient demographics

21. Outcomes measured  Primary outcome: 24 hour morphine equivalent usage  Secondary outcomes: 48 hour morphine equivalent usage, 24 hour local anesthetic usage, functional assessment using incentive spirometer, visual analog scale, dermatomal level identified, hemodynamic consequences of epidural including pressor use

22. Primary outcome: 24 hr ME

23. Secondary outcomes

24. Conclusions  Preliminary retrospective review of fluoroscopic guidance versus blind placement showed a 40% reduction in morphine equivalent usage. The study was adequately powered to show this difference but instead showed equivalent morphine equivalent usage between groups and no difference in secondary outcomes measured.  During this time the acute pain service was started with a select group of physicians dedicated to placement and management of these epidural catheters.  Things that may have made the difference/improvement:  Dedicated service to manage epidurals  Smaller group of individuals with greater expertise placing catheters

25. Research:  Mentor and Co PI: Dr Parra  Acute pain service team: Trish Barr, Kathy Bonham, Kathy Lamb  Acute pain service attendings  Dr Yeager and Dr Loftus  Dr Beach  Kathy Gaudette in Pre admission testing  CT surgeons: Dr Erkmen and Dr Nugent  Residents, CRNAs and attendings who follow the protocol with these patients in the OR

26. Thank you