Thoracic epidural (TEP) analgesia improves postoperative pain management and reduces pulmonary complications, duration of postoperative ileus, and length of stay after major abdominal surgery compared to opioid therapy alone.1,2
Reported epidural failure rate in teaching institutions can be up to 30%,3 often necessitating either catheter replacement or additional intravenous (IV) analgesia.
At our institution, preoperative TEP placement is a routine part of anesthetic care for complex pain patients undergoing colorectal surgery. We present 2 cases where a second TEP was successfully placed to improve pain management due to insufficient analgesia with the first epidural catheter, despite increasing epidural infusion rate.
Written consent was obtained from both patients.
Case 1 was a 59-year-old man with Lynch syndrome, history of chronic pain, and ongoing polysubstance abuse admitted for a complex abdominal surgery due to colon adenocarcinoma and urothelial cancer. A preoperative TEP was placed and tested by the regional anesthesia team. Loss of resistance to saline was found at 6 cm at the T8/9 level, and the catheter was taped at 11 cm skin level. The epidural infusion was started intraoperatively with bupivacaine 0.1% at 10 mL/h. His 12-hour exploratory laparotomy included a complete proctocolectomy, low anterior colon resection with an end ileostomy, right nephroureterectomy, a partial cystectomy, and left ureteral stent placement.
He recovered in the postanesthesia care unit and started on a hydromorphone patient-controlled analgesia (PCA) due to his substance abuse, in addition to his epidural infusion and an IV ketamine drip. He was discharged to the floor reporting good analgesia. Later, the PCA and ketamine infusion were paused due to increased sedation and confusion. The assessment of the epidural block on postoperative day (POD) 1 found a bilateral block covering the T7-T10 dermatomes, but with absent analgesia to the lower abdomen. Several approaches were trialed to improve pain control. The PCA and ketamine drip were restarted, and the TEP rate was increased to 12 mL/h. Repositioning the patient in a semisitting position did not change the caudal epidural spread as others have shown.4 Not wanting to risk losing analgesia above T10 dermatome level, a second TEP was placed at T11-T12 on POD 1. Loss of resistance was found at 5 cm and taped at 10 cm at the skin (Figure A). The lower dermatomal border after the test dose of 3 mL of lidocaine 1.5% with 1:200,000 epinephrine was found bilaterally at the L1 level.
Both epidurals were started with 0.1% bupivacaine at 6 mL/h. Subsequently, pain control improved. The dermatomal spread of the combined epidurals yielded diminished sensation to pinprick from T5 to L1. Over the next 5 days, the hydromorphone PCA 8-hour shift use regressed from 11.4 to 1.2 mg, suggesting good epidural analgesia. Good mobilization, improved mental status, and absent hypotension were noted during this period. On POD 5, both epidurals were capped and later removed once good analgesia on oral pain medication was confirmed. He was discharged home on POD 5.
Case 2 was a 36-year-old woman with a history of cerebral palsy, Gardner syndrome, and history of a total colectomy with J-pouch creation admitted for an exploratory laparotomy due to small-bowel obstruction. She had a history of chronic lower extremity pain and spasticity due to cerebral palsy. Her reported presurgical visual analog scale ranged from 6 to 10. A preoperative TEP was placed and successfully tested at the T6/T7 dermatomal level. The catheter was infused intraoperatively with a 0.1% bupivacaine and 2 µg/mL fentanyl solution at a rate of 8 mL/h. After an exploratory laparotomy by large periumbilical, midline incision including extensive lysis of adhesions, the patient uneventfully recovered in the postanesthesia care unit. A postoperative block assessment found a bilateral T4-T11 block with poor analgesia in the inferior portion of her incision. Positioning the patient in a semisitting position, increase in infusion rate and concentration to 12 mL/h and later 14 mL/h, respectively, and from 0.1% to 0.15% bupivacaine improved her pain control. On POD 1, she reported continued poor pain control in the lower left abdominal quadrant (LLQ). Epidural analgesia was found to be covering the higher dermatomes only, with absent lower abdominal analgesia. A second epidural was placed at the T10-T11 interspace (Figure B). The test dose injected through the second epidural immediately relieved the LLQ, but not the upper incisional pain. This prompted the decision to restart the upper epidural concomitantly, adjusting the infusion rates of both epidurals to 7 mL/h each of 0.15% bupivacaine and 2 µg/mL fentanyl improving her focal upper abdominal and her LLQ pain. A reported generalized burning sensation over her abdomen was successfully treated with a ketamine infusion at 8 mg/h.
The patient was able to resume physical therapy, which she had previously declined due to pain, on POD 5. Subsequent physical therapy notes reported good progress, despite fluctuations in reported pain score. A capping trial of both epidurals and a transition to an oral pain regimen were successfully performed on POD 6; both epidurals were removed later that day. She was discharged home on POD 6.
We report the successful use of dual epidural catheter (DEC) therapy for postsurgical abdominal pain management in 2 complex pain patients with insufficient incisional coverage with the initial epidural catheter. The DEC technique has first been described by Cleland5 in 1949 and later by Bonica6 in 1967. Both used the DEC technique to alleviate labor pain. Yet, the current literature is sparse on the use of DEC therapy, including reports of successful DEC therapy after Ivor Lewis esophagectomy7,8 and spine surgeries.9,10 For these indications, DEC therapy was shown to improve pain control compared to single epidural therapy or parental opiate therapy. In both reported cases, DEC therapy improved pain control and functionality, after first having increased the epidural infusion rates then trialing gravity to improve epidural caudal spread. Adjunct IV opioid and IV ketamine caused neurological side effects in the first patient, limiting their use. A bilateral block was achieved with the initial TEP, and utilizing a second epidural allowed for increased dermatomal coverage without risking losing the higher incisional coverage that the first epidural achieved. Although IV adjuncts were successfully used in the second patient, the second block would again not have covered the more rostral dermatomes. Blumenthal et al9 hypothesized that inadequate pain control with a single epidural catheter therapy was associated with localization of pain to the upper or lower parts of the surgical field, suggesting inadequate analgesia due to spread of epidural solution. Turner et al11 showed that even in surgically placed epidural catheters with radiographic confirmation, the spread of epidural dye varied from patient to patient, varying from 1 vertebral level to a maximum of 8 vertebral levels. McLeod and Cumming12 reported that low TEP spread depends on several factors including volume of the solution, age of the patient, and anatomical variations and may reach up to 8 dermatomes, evenly distributed above and below epidural catheter insertion site. This is consistent with our cases, where inadequate analgesia using a single epidural catheter was due to inadequate dermatomal coverage with a single catheter and not due to catheter failure.
Adding an α2-adrenoceptor agonist to the epidural mixture could have increased the efficacy and safety of the epidural mixture and improved the coverage of the surgical field in a more controlled and reliable manner than DEP. Unfortunately, α2-adrenoceptor agonists like epinephrine or clonidine are not routinely used at our institution. Triple epidural mixtures including bupivacaine, fentanyl, and epinephrine, infused between 4 and 12 mL/h, depending on the size of the surgical field, have proven its efficacy and safety.13,14 The use of DEC did not show an increase in side effects associated with catheter placement as compared to a single epidural catheter or parenteral opiate therapy.7,9 Typical side effects associated with TEPs include hypotension (2%), nausea and vomiting (3.6%), and pruritus (0.3%).15 Serious complications associated with epidural catheter placement, such as epidural hematoma or epidural abscess, are rare but double with a second epidural placement. No epidural complications, including hypotension, were noted in either of the 2 patients. Using a second epidural catheter complicated patient care from a logistical perspective, staff unfamiliarity with management of a second epidural catheter caused confusion between the 2 epidural pumps. To reduce the risk of error, we elected to use the same epidural solutions at the same rates in both epidural pumps. Additionally, we utilized clear labeling of all epidural pumps and catheters and in-person communication with the nursing staff (Figure C). We anticipate that such issues would improve with increased familiarity with DEC therapy. The use of DEC therapy did not appear to impede mobility or limit physical therapy for our patients. To our knowledge, these are the first reported cases of DEC therapy for abdominal surgeries. Replacing a partially working epidural catheter bears the inherent risk of a second epidural failure; hence, placing a second epidural catheter, even if the target region is a clearly defined anatomical region such as the abdomen, may be a safe and effective alternative.
Further studies are warranted.
Name: Flora M. Li, MD.
Contribution: This author helped collect the data and write the manuscript.
Name: Trefan B. Archibald, MD.
Contribution: This author helped collect the data and write the manuscript.
Name: Laurent A. Bollag, MD.
Contribution: This author helped conceive the report idea, provide administrative support, and write the manuscript.
This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.
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