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Thoracic Epidurals (TEA) in Adult Surgical Patients: An Overview, Clinical Pearls & Lessons Learned 1 Year After Introducing Opioid Free TEA

Board Certified-Pain ManagementNurse Practitioner, Acute Pain ServiceSunnybrook Health Sciences CentreAdjunct Lecturer, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto.

Jason Sawyer, RN (EC), MN, BC

Conflict of Interest Disclosure

Authors Conflicts of Interest;

– Jason Sawyer. Has received financial compensation from Purdue

Pharma for preparing & providing pain management lectures. Last

lecture: Winter 2013

•1212 beds - 677 acute care•16 000 operative procedures/year•1.2 million patient visits/year•10 000 + employees•5th largest cancer centre in North America

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Acute Pain Service

• 2 Nurse Practitioners Monday-Friday

• Staff or Fellow Anesthesiologist 7 days – Tues-Tues

• 3300-3500 patients/year

• 400-500 surgical epidurals

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Agenda• Losing the battle with postoperative pain management?

• Overview of the advantages of TEA

• Overview of thoracic epidural analgesia (TEA)

– Anatomy of the epidural space

– Review of commonly used local anesthetics and opioids

• ASPMN Listserve Survey results (2014)

• Describe common TEA related side effects and their treatment

– Hypotension, pruritus, nausea, vomiting, urinary retention

• Describe our experience with epinephrine as a substitution for opioid in thoracic epidurals

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What Do We Know……• Pain is still poorly managed postoperatively ( Sawyer et al. 2008, 2010)

• Higher in-hospital pain scores correlate with higher post-discharge pain scores (Vandenkerkhof, 2006)

• Pain, depression and fatigue account for 1/3 of variation in older adultsfunctional status 1 month after major abdominal surgery (Zalon, 2004)

• Post-discharge health care utilization is greater in those with higher pain scores in-hospital and post-discharge (Vandenkerkhof, 2006)

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What Do We Know……

• Pain severity adversely effects quality of life in the immediate postop period (Wu, 2003)

• Post-op pain contributes to decreased HRQL 1 month post-discharge, & interfered with ADL’s and sleep (Strassels, 2004)

• Patients that experienced severe pain and utilized the most analgesics the first 7 days postop have ↑ risk of developing chronic post surgical pain (CPSP) (Visser 2006)

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If you were given a strong pain killer like morphine after surgery, how worried would you be about becoming addicted?

1. Not worried at all

2. A little bit worried

3. More than a little bit worried

4. Very worried

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Would you try to limit how much strong pain killers like morphine you use because you worried about becoming addicted?

1. Yes

2. No

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“Oh, Just Give Them PCA”…..

• Opioids are not benign

• Opioid Induced Hyperalgesia (OIH)

• Significant increase in addiction to legal opioid prescriptions

• 5 –fold increase in prescription opioid related deaths in the US(CDC 2013)

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Brief Summary

• Effective postoperative pain management remains an elusive goal

• Severe pain in the postoperative period is a key factor in developing CPSP

– But not everyone with severe acute pain develops chronic pain

• Patients and families have strong beliefs regarding opioids

• What to do…..what to do….

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• Postop matched pair cohorts epidural and PCA (88 188 patients) across surgical populations

• Epidural associated with small reduction in 30 day mortality (1.7 vs2.0 RR 0.89 CI 0.81-0.98 p= 0.02 NNT=477)

• Epidural patients generally had a higher co-morbidity burden

• “Furthermore, the increased burden of co-morbid illness in patients who received epidural anaesthesia would suggest that our study, if anything, is biased against epidural anaesthesia” pg 567

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Year : 2009 | Volume : 12 | Issue : 2 | Page : 166-167

High thoracic epidural analgesia for cardiac surgery: Time to move from morbidity to quality of recovery indicators

Colin F RoyseAnaesthesia and Pain Management Unit, Department of Pharmacology, University of Melbourne; and Cardiothoracic Anaesthetist, The Royal Melbourne Hospital, Australia

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• The analgesic benefits of TEA are well described in the literature across many surgical populations

• Efforts to find reductions in morbidity and mortality are difficult because incidence rates of serious outcomes are very low

– Despite epidurals are often placed in less well patients

• More evidence required regarding TEA (and ultimately quality pain management)

– Quality of recovery

– Quality of life

– Chronic post surgical pain

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Thoracic Epidurals- Some Lingo

• Cephalad/Rostral towards the head (up)

• Caudal towards the tail (down)

• Attenuate dampen

• Lipophillic fat friendly

• Hydrophillic water friendly

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Where It All Started

August Bier 1861-1949

surgeon

James Leonard Corning 1855-1923

neurologist

1885 Spinal cocaine1898 Spinal AnestheticAssisted by August

Hildebrandt

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Epidural Anatomy

• Epidural space is a potential space, containing crevices around the epidural contents (fat, veins, lymphatics, nerve roots, dural sac)

• These layers and textures affect the flow of analgesics through the space

• Epidural venous flow is predominantly located anteriorly

• Veins lack valves

McLeod, 2004, Richardson, 2005, Bauer, 2012

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Epidural Anatomy

• Ligamentum flavum is non continuous and not pain sensitive

• Proximity to CSF/Spinal Cord is crucial

• Sympathetic fibres T1-L2

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Some Effect

• Age– 40% less dose for (60-79) vs (20-

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– Diminished fatty tissue

– Decrease in myelinated nerves

– Increased epidural space compliance

• 4-6 cm threaded into epidural space

Minimal/No Effect

• Height, weight BMI

• positioning

• Gravity

• Needle direction

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Some Effect• Site of insertion determines

distribution

• Total mass of LA more important than concentration or volume

Minimal/No Effect

• Fractional vs single bolus injection

• Epidural pressures

• Pressure in adjacent body cavities

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What Analgesics?

• Local Anesthetics

• Opioids

• Epinephrine

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Epidural Local Anesthetics

• Primary route of action is spinal nerve roots

– Weak effect on spinal cord and paravertebral nerves

• Majority absorbed systemically via venous system (peak 10-30 mins)

– Epidural fat

– Diffusion across dura

• Lipid soluable

• Ester local anesthetics metabolized by plasmapseudocholinesterase (rarely used for epidural analgesia)

• Amide local anesthetics metabolized in the liver– Most commonly used are bupivacaine and ropivacaine

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• Smaller nerves more susceptible to effects of LA– Pain, temperature, touch, motor proprioception -

• Myelinated fibres are more susceptible to effects of LA– Myelination speeds conduction in Nodes of Ranvier which contain high

concentrations of Na+ channels

• Positive temperature or pin prick (qualitative) assessments do notnecessarily equal analgesia- only let you know where the LA is spreading

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Epidural Opioid Site of ActionSubstantia Gelatinosa of Spinal Cord

Primarily Spinal Effect Hydrophilic Lipophilic Primarily

Supraspinal

Morphine Hydromorphone (Dilaudid)

Fentanyl

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Why THORACIC Epidural?

• Virtually no Motor Block– Vs Lumbar Epidural

• Incision Congruent Placement

• Minimizes the surgical stress response

• Earlier return of bowel function– Sympathetic blockade– Increases GI blood flow & splanchnic perfusion aiding in return

of motility

Kozian et al 2005

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– Earlier return of bowel function (Taqi 2007, ; Carli 2001)

• Inhibition of splanchnic reflexes (Kehlet, 2001)

• Inhibition of nociceptive afferents

• Inhibition of sympathetic efferents

– Compensatory activation of non anesthetized sympatheticsegments (Waurick 2005)

• Vasodilation of veins and arteries in blocked area

• Blockade of spinal reflex arcs– (Wetterslev 2001)

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Questions Without An Answer

– Ideal mixture of solution (LA and/or opioid) still unknown

• LA only - no opioid side effects but possibly more hypotension• Opioid only no better than systemic opioids and ↑ side effects• LA + opioid best ?• Other adjuncts?

• (Wetterslev 2001, Brown 2004)

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Side Effects, Big & Small

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Presented as Mean %

PruritusN=21 461

NauseaN= 20 606

VomitingN=11 423

Urinary RetentionN=12 513

Mild SedationN= 9451

All 14.7 25.2 20.2 23 23.9

IM 3.4 17 21.9 15.2 53.7

IV-PCA 13.8 32 20.7 13.4 56.5

Epidural 16.1 18.8 16.2 29.1 14.3

Presented as Mean %

Respiratory depression naloxone

useN= 55 404

Hemodynamic depression (all

definitions)N= 24 955

Respiratory depression by decreased ventilatory frequency

N= 29 607

Respiratory depression by decreased O2 sats N= 1516

Respiratory depression by

elevated PaCO2 N= 3170

All 0.3 4.7 1.1 17 3.3

IM 1.4 3.6 0.8 37 1.3

IV-PCA 1.9 0.7 1.2 11.5 1.3

Epidural 0.1 5.5 1.1 15 6

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Do you routinely use etCO2 or continuous pulse oximetry for your patients with thoracic epidurals that contain opioids? N= 73

Yes No

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• Mechanism of Opioid Induced Pruritus (OIP)is poorly understood

• Mu opioid receptors seem to play a key role

– Spinal cord not brain or periphery

• Histamine release has very little role

– So antihistamines will most likely not help!

• The more invasive the opioid administration, the higher the incidence of OIP

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Very few trials

Propofol (IV) 10-20 mg

Nalbuphine (IV) 4mg

Naltrexone (PO) 6 mg

Naloxone infusions (2mcg/kg/hr)

Ondansetron (IV) 8mg

Antihistamines –sedating effect may break the itch/scratch cycle

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What intervention do you use FIRST for pruritus you suspect is from opioid in the thoracic epidural?

Administer Diphenhydramine

Administer Nalbuphine

Administer Naloxone

Administer Naloxone infusion

Administer Ondansetron

Reduce/change the opioid in theepiduralRemove the opioid from the epidural

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PONV 101 (Watcha & White 2002)

12/27/201248

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Urinary Retention

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Side Effects With TEA

• Incidence of nausea, vomiting and naloxone use lower in epidural groups vs IV-PCA

• No single agent will be universally effective for PONV- evidence that algorithms are beneficial in appropriately screened patients (Krancke2007)

• Most side effects are related to the opioids

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Side Effects With TEA

• Incidence of pruritus much higher, but is not histamine mediated. Limited evidence for Ondansetron (Zofran) and opioid reversal agents

• Incidence of urinary retention with TEA is approximately 10% and early removal demonstrates a decrease in UTI

• With the incidence of respiratory depression approximately 0.1%......Why all the Pulse Oximetry/EtCO2 monitoring, and taking up ICU beds for epidural patients?

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Historical TEA delivery at Sunnybrook

• Choice of a single ropivacaine (Naropin) concentration (0.2%) withoptions for hydromorphone (Dilaudid) 5 or 10 mcg/ml

• No PCEA component

• Trouble shooting involved large doses of lidocaine (Xylocaine)

• High infusion rates not uncommon (15-20ml/hr)

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• Perceived excessive failure rate

• Not uncommon to add IV-PCA opioid to epidural

• Suboptimal outcomes for chronic pain/chronic opioid users that receive epidurals

• Despite safely aggressive multimodal analgesia withNSAIDS/Gabapentinoids/Acetaminophen

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Lessons Learned Adding Epinephrine

• Quickly

– Adding epinephrine (Adrenaline) to Ropivacaine (Naropin) /HYDROmorphone (Dilaudid) combination frequently caused pruritus when none existed before (particularly with 10 mcg/ml HYDROmorphone) in the same patient

– Ropivacaine (Naropin) 0.2% with Epinephrine (Adrenaline) 5mcg/ml did not seem to work consistently as well as we would have liked

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PharmacologicaloptimizationDose Volume Concentration Choice of

medications

Technical Aspects – Catheter & LineHigher success rate with placement

>5cm into epidural space

tunneling Test dose Line patency

Technical Aspects- PlacementParavertebral, pleural

cavity and intravascular placement

Secondary migration after

insertion

Imprecise catheter

placement

Method of epidural space identification

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History of Epinephrine Use

• Used as an adjunct for saddle block anesthesia in 1950 (Priddle & Andros)

• “ The intrathecal use of vasoconstrictors in conjunction with the various local anesthetic agents as a means of increasing the effectiveness of spinal anesthesia dates back some 45 years” (Priddle &Andros 1950 pp 156)

• Small study (3 groups 6 patients total) obstetrical patients• 3rd group

– 1mg of epinephrine (1cc of 1:1000 epinephrine with 1cc of 5% dextrose into CSF

– “complete relief of pain of uterine contraction”– No systemic effects noted

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How Neuraxial Epinephrine Works

• α2-adreno receptor agonist

• Independently causes segmental hypoalgesia when given epidurally to pinprick (100 mcg) (Curatolo et al 1997) & pinprick/ice (50mcg)(Bromage et al 1983)

• Direct spinal application of epinephrine elevated the nociceptivethreshold in an animal model (Reddy et al 1980)

• Absorbed into the CSF and binds to α2 adrenoreceptors in substantia gelatinosa of the dorsal horn (Curatolo et al 1997)

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• Epidural Epinephrine (100mcg) reduced peak plasma concentrations of 20ml of 0.5% bupivacaine or 2% lidocaine by 25%in 40 patients undergoing minor general/ortho procedures (Burm et al 1986)

• No delayed peak onset time when added to lidocaine and bupivacaine

• Longer duration of block

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• Epidural Epinephrine (100 mcg) decreased peak plasma morphine levels (10mg epidural) by 60% in a study of 3 healthy volunteers (Bromage et al 1983)

• Profound exacerbation of side effects including resp. depression 6-16 hours post morphine

• Rostral spread significantly greater at 2-6 hours

• Similar attenuation of cold pressor test ONLY until 16-22 hrs

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• Niemi et al 2001/2002/2003

• All 3 randomized double blind crossover studies

– Effect of fentanyl added to bupivacaine/adrenaline

– Effect of adrenaline added to ropivacaine/fentanyl

– 3 concentrations of adrenaline added to fentanyl and bupivacaine

• 2mcg/ml more effective than 1 or 1.5mcg/ml (Niemi & Brevik 2003)

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Adding Fentanyl (20 pts) 2001

• Bupiv 0.1% fent & epi 2mcg/ml

• Without fentanyl pain with coughing significantly worse after 3 hours

• Pain decreased within 15 mins and no difference within 1 hr of reintroducing fentanyl

• No change in sensory blockade during non fentanyl times

• No difference in any side effects with or without fentanyl

• No difference in time out of bed

Adding Epinephrine 12 pts 2002

• Ropiv 0.1%/& fent/epi 2mcg/ml

• Without Epi pain with coughing significantly worse within 2 hrs

• Pain decreased within 15 mins and no difference within 1 hr of reintroducing epi

• Significant regression of sensory blockade with removal of epinephrine

• Nausea increases significantly when epinephrine removed

• Significantly more mobilization with epinephrine

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What Does This Mean Clinically?

• Epinephrine given epidurally:

– Has its own antinociceptive properties

– Likely increases the amount of opioid and LA reaching the spinal cord & nerve roots

– More intense and prolonged analgesic effect

– Wider sensory coverage

– Reduced concentrations of each class of analgesia are required– (Niemi et al 2002)

– Reduces systemic absorption of opioids and LA by 25-60%

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ASPMN Listserve Survey Results

• Local anesthetics

– 2/3 bupivacaine (most common 0.1%)

– 1/3 ropivacaine (most common 0.1-0.2%)

• Epinephrine (2) Clonidine (1)

• Opioids– 55% fentanyl (1-5mcg/ml)

– 40% Hydromorphone (4-20mcg/ml)

• Vast majority LA/opioid combination

• Very few had multiple options

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TEA Management At SunnybrookOctober 2014-Present

• Transition to opioid free epidural analgesia regimen

• Continuous infusion + PCA component

• Epinephrine (Adrenaline) 5mcg/ml and Ropivacaine (Naropin) 0.3% standard solution

• Additional solutions available for individualizing TEA

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0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

How long, on average, do you keep your thoracic epidurals infusing? N= 74

1 day2 days3 days4 days5 days6 days7 days>7 days

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0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Anesthesiology preference Acute Pain Service preference Customized based on patientfactors

If you have more than 1 epidural solution to choose from, how do you decide which one to use on your patients? (N=64)

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• Ropivacaine plasma concentrations peak in about 67 hrs (of 120 hrs) (2000,Wiedemann)

• Painful Procedure (this is a single procedure!)

– Small bowel resection, closure of loop ileostomy, abdominal wall hernia repair with components separation, placement of biological mesh (10x25cm), intraperitoneal underlay implant, excision of large skin flaps

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# Of Patients Using Each Ropivacaine Concentration

0

50

100

150

200

250

300

350

400

0.125% 0.2% 0.3% 0.4% 0.5%

Pre Opioid FreeEpidurals

Post Opioid FreeEpidurals

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Trouble Shooting (especially at night!)Uncontrolled Pain +/- Sensory Block

• Bolus epidural with morepotent Ropivacaine (Naropin) as opposed to Lidocaine

– 1% Ropivacaine vials

– Cassettes with0.125//0.3//0.5% available on high volume unit

– If satisfactory relief withmore potent bolus- start infusion with same

Appropriate Analgesia & Dense Motor Block

– If shutting off until motor block resolution and restarting at a lower rate does not work

– Lower concentration of Ropivacaine

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42.6%

5.6%1.9%

50.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0% Bolus the epidural with more of the sameepidural solution infusing through the epiduralpump and increase the rate?

Bolus the epidural catheter with a more potent,different, local anesthetic (e.g. lidocaine), thenresume with the same epidural solution

Bolus the epidural catheter to comfort with amore potent dose of ropivacaine, then resumethe infusion at the more potent dose ofropivacaine.Continue the current epidural solution and addIV-PCA/other route of opioid

What do you do FIRST when a patient has an appropriate bilateral sensory block in the surgical area, but still has moderate/severe pain with coughing?

(Epidural solution is Ropivacaine 0.2% + HYDROmorphone 0.010mg/ml; rate 6ml/hr, PCEA 3ml, lockout 15 minutes) incision is midline.Sensory block it T4-

12 bilateral, covering the entire incision. N=57

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Bedside Patient Education

• There is not a needle in your back

• Sedation/nausea/vomiting/pruritus NOT from your pain medication

• Leave TEA > 3 days to minimize exposure to opioids

• Outline daily the process of epidural removal.

– What to expect

– How soon to go home

– Considering handing out little “key messages”

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Clinical Benefits

• No more– Pruritus– Opioid contribution to ileus

• Reduced systemic absorption when using more potent LA concentrations

• No increased motor block observed to date with increased LA concentration

• Reduction in replacement epidurals• Reduction in epidural failure rate• Approximately 15-20% of our major abdominal surgery patients

have no exposure to an opioid during their hospitalization

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Final Summary

• Epidurals continue to be the main stay for analgesia for many post surgical populations

• It seems they are underutilized in many populations

• We still have not identified the ideal medications/combinations

• Room to improve individuality of epidural analgesia

• Need to dedicate key people to deliver this service and provide continuity of care

• Research should focus on quality of life/recovery, and effect on chronic pain/opioid use

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Thank You

“We cannot do everything at once, but we can do something at once”

(Calvin Coolidge)

“Playing small does not serve the world” (Marianne Williamson)

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• jason.sawyer@sunnybrook.ca

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Photo References

• Slide 13 accessed September 2, 2014 at:– http://www.pinterest.com/greatchoicechir/laughter-is-medicine/

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