2020 ESRA-ASRA E-Congress Session

1. A THORACIC EPIDURAL FOR MAJOR OPEN
ABDOMINAL SURGERY? YES!!
KI JINN CHIN, PROFESSOR, DEPT OF ANESTHESIOLOGY & PAIN MEDICINE, UNIVERSITY OF TORONTO
gasgenie@gmail.com
@KiJinnChin

2.  Gold standard for analgesic efficacy: (1) Pain intensity (2) Opioid consumption
 Bilateral coverage, somatic + visceral analgesia, congruent with surgical site
 Opioid-sparing = avoidance of associated adverse effects
 Nausea & vomiting, constipation, cognitive impairment, sedation, etc ……………………………..
 Postoperative ileus 3.6% vs 8.5% (Popping 2014)
 Earlier return of GI function: flatus = 17.5 hours, stool = 22 hours (Guay 2016)
 Improved splanchnic perfusion & GI microcirculation
 TEA is associated with lower mortality in acute pancreatitis: 2% vs 17% (Jabaudon 2018)
 Mortality in major abdominal surgery or but not
 Respiratory complications & Cardiac arrhythmias
BENEFITS OF THORACIC EPIDURAL ANALGESIA ARE UNDISPUTED
gasgenie@gmail.com
@KiJinnChin

3.  Giebler 1997, N = 4185
 Germany, teaching hospital, 500 TEA / year
 Abdominal surgery = 100%
 1983-88: retrospective, 1988-94: prospective
 von Hosslin 2016, N = 7273
 Switzerland, teaching hospital, 800 TEA / year
 Abdominal surgery = 67%
 2003-2012: retrospective review
 Kupersztych-Hagege 2017, N = 2907
 France, teaching hospital, 400 TEA / year
 Thoracic surgery
 2007-2015: retrospective review
 Persistent neurological deficits
 0 / 4185, 1 / 7273, 0 / 2907 = 1 / 14365 = 7 per 100,000
(7 per 10,000)
 Transient neurological deficits
 10 / 4185 = 2.4 per 1000, sensory changes , legs / perineum,
median duration 4d
 Epidural hematoma
 0 / 4185, 0 / 7273, 1 / 2907 = 1 / 14365 = 7 per 100,000
(3.4 per 10,000)
 Epidural abscess
 0 / 4185, 1 / 7273, 2 / 2907 = 3 / 14365 = 2 per 10,000
 All = catheter duration 5 days or longer
THORACIC EPIDURAL ANALGESIA IS SAFER THAN WE THINK
gasgenie@gmail.com
@KiJinnChin

4.  Giebler 1997, N = 4185
 Germany, teaching hospital, 500 TEA / year
 Abdominal surgery = 100%
 1983-88: retrospective, 1988-94: prospective
 von Hosslin 2016, N = 7273
 Switzerland, teaching hospital, 800 TEA / year
 Abdominal surgery = 67%
 2003-2012: retrospective review
 Kupersztych-Hagege 2017, N = 2907
 France, teaching hospital, 400 TEA / year
 Thoracic surgery
 2007-2015: retrospective review
 Dural puncture
 30 / 4185 = 7 per 1000 – none developed PDPH
 Hypotension
 8-9%, even in critically ill ICU patients (Popping 2014, Windisch 2016)
 Readily treatable (250-500ml fluid, vasopressors)
 Lower limb weakness & fall risk
 Rare with thoracic vs lumbar epidural (2% - Loubert 2016) &
appropriate dosing
 No evidence of increased risk of falls (Elsharydah 2016)
 Risk minimized with appropriate dosing regimens
THORACIC EPIDURAL ANALGESIA IS SAFER THAN WE THINK
gasgenie@gmail.com
@KiJinnChin

5. THORACIC EPIDURAL ANALGESIA IS EASIER THAN WE THINK
 Single-puncture, single-catheter technique, bilateral
coverage
 Simple technique
 Slide alongside spinous process
 Contact lamina
 Angle cephalad to slip into the interlaminar space
 Primary failure rate is ≈1% (Giebler 1997) (not 20%)
 Ultrasound imaging will help locate interlaminar space
 https://youtu.be/DrAO5kJyfeE
 Correct catheter placement can be easily confirmed by
epidural stimulation or waveform analysis
Adaptor
for nerve
stimulator
gasgenie@gmail.com
@KiJinnChin

6.  A valuable regional anesthesia technique at risk of being lost
 Concrete, clinically meaningful benefits on patient-centered outcomes
 Risk-benefit ratio is more favorable than commonly-believed
 Fear of the unfamiliar vs realistic risk assessment
 Challenges with implementation and
clinical management are readily addressed
 Aids to technical performance
 Training, education, protocols, attention to detail
THORACIC EPIDURAL ANALGESIA
SHOULD BE USED IN MAJOR OPEN ABDOMINAL SURGERY
gasgenie@gmail.com
@KiJinnChin

7. REFERENCES
 Chin KJ. Ultrasound Imaging of the Spine: Thoracic Epidural Insertion. https://youtu.be/DrAO5kJyfeE
 Giebler RM, Scherer RU, Peters J. Incidence of neurologic complications related to thoracic epidural catheterization. Anesthesiology. 1997;86(1):55-63.
 Guay J, Nishimori M, Kopp S. Epidural local anaesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, vomiting and
pain after abdominal surgery. Cochrane Database Syst Rev. 2016;7(7):CD001893. ublished 2016 Jul 16. doi:10.1002/14651858.CD001893.pub2
 Jabaudon M, Belhadj-Tahar N, Rimmelé T, et al. Thoracic Epidural Analgesia and Mortality in Acute Pancreatitis: A Multicenter Propensity Analysis. Crit Care
Med. 2018;46(3):e198-e205.
 Kupersztych-Hagege E, Dubuisson E, Szekely B, et al. Epidural Hematoma and Abscess Related to Thoracic Epidural Analgesia: A Single-Center Study of
2,907 Patients Who Underwent Lung Surgery. J Cardiothorac Vasc Anesth. 2017;31(2):446-452.
 Leurcharusmee P, Arnuntasupakul V, Chora De La Garza D, et al. Reliability of Waveform Analysis as an Adjunct to Loss of Resistance for Thoracic Epidural
Blocks. Reg Anesth Pain Med. 2015;40(6):694-697.
 Pöpping DM, Elia N, Van Aken HK, et al. Impact of epidural analgesia on mortality and morbidity after surgery: systematic review and meta-analysis of
randomized controlled trials. Ann Surg. 2014;259(6):1056-1067.
 Tanaka K, Watanabe R, Harada T, Dan K. Extensive application of epidural anesthesia and analgesia in a university hospital: incidence of complications
related to technique. Reg Anesth. 1993;18(1):34-38.
 von Hösslin T, Imboden P, Lüthi A, Rozanski MJ, Schnider TW, Filipovic M. Adverse events of postoperative thoracic epidural analgesia: A retrospective
analysis of 7273 cases in a tertiary care teaching hospital. Eur J Anaesthesiol. 2016;33(10):708-714.
 Weiss R, Pöpping DM. Is epidural analgesia still a viable option for enhanced recovery after abdominal surgery. Curr Opin Anaesthesiol. 2018;31(5):622-629.
 Windisch O, Heidegger CP, Giraud R, Morel P, Bühler L. Thoracic epidural analgesia: a new approach for the treatment of acute pancreatitis?. Crit Care.
2016;20(1):116.