Mid-Thoracic Epidural Placement for Radical Hemicolectomy
For a patient undergoing radical hemicolectomy, the mid-thoracic epidural should be placed between T7-T10 vertebral levels to provide optimal pain coverage for the surgical site. 1
Rationale for Mid-Thoracic Epidural Placement
Optimal Level Selection
- For upper transverse incisions and abdominal surgeries like hemicolectomy, epidural catheters should be inserted between T5 and T10 root levels 1
- Specifically for colorectal procedures, thoracic insertion around level T7-T10 is recommended to provide adequate coverage of the surgical area 1
Benefits of Proper Placement
- Correctly placed mid-thoracic epidurals provide:
- Superior pain relief compared to intravenous opioids
- Reduced respiratory complications
- Earlier return of bowel function
- Decreased stress response
- Improved postoperative mobilization 1
Technical Considerations
Pre-Insertion Assessment
- Sensory block should be tested (cold and pinprick) before induction of general anesthesia
- Daily assessment of sensory block is necessary to ensure proper coverage
- Adjust infusion as needed to provide sufficient analgesia while allowing mobilization 1
Medication Administration
- Local anesthetic combined with low-dose opioid provides optimal analgesia
- For open abdominal surgery, bupivacaine 0.1-0.25% with fentanyl (5 μg/mL) is an effective combination 1, 2
- Ropivacaine is an alternative option at 2 mg/mL (0.2%) with infusion rates of 6-14 mL/hour (12-28 mg/hour) 2
Duration and Management
Recommended Duration
- Epidural analgesia should continue for 48-72 hours post-surgery 1
- After a successful stop-test, transition to oral multimodal analgesia with paracetamol and NSAIDs/COX-2 inhibitors plus oral opioids as required 1
Potential Complications to Monitor
- Hypotension due to sympathetic block (treat with vasopressors if patient is euvolemic)
- Inadequate function (occurs in up to one-third of epidurals in some centers)
- Potential causes of inadequate function include:
- Catheter not located in epidural space
- Insertion level not covering surgical incision
- Insufficient dosage of local anesthetic/opioid
- Pump failure 1
Special Considerations
High-Risk Patients
- Mid-thoracic epidurals are particularly beneficial for pulmonary high-risk patients undergoing colonic resection 3
- They provide pain-free postoperative course with preserved pulmonary function
- Can prevent nocturnal oxygen desaturation and postoperative fatigue 3
Laparoscopic vs. Open Procedures
- While mid-thoracic epidurals are the gold standard for open abdominal surgery, their routine use in laparoscopic colectomy is more debated
- For laparoscopic procedures, alternative analgesic techniques may be considered, but epidurals still show benefits in reducing length of stay 4
By placing the epidural at the T7-T10 level for radical hemicolectomy, you provide optimal pain control while minimizing potential complications, facilitating early mobilization, and promoting faster return of bowel function.