What is the procedure for a thoracic epidural (thoracic epidural anesthesia)?

From the Guidelines

Thoracic epidural analgesia is not recommended for postoperative analgesia due to its associated complications and the availability of alternative regional analgesic techniques 1.

Procedure Overview

A thoracic epidural is performed by inserting a catheter into the epidural space of the thoracic spine to deliver pain medication.

• The procedure begins with patient positioning, typically in a sitting or lateral decubitus position with the back flexed to open the vertebral spaces.
• After sterile preparation, the anesthesiologist identifies the appropriate thoracic interspace, usually corresponding to the dermatomal level of the surgical incision.
• Local anesthetic (1-2% lidocaine) is injected to numb the skin and deeper tissues.
• Using a loss-of-resistance technique with either air or saline, the anesthesiologist advances a Tuohy needle through the ligamentum flavum until the epidural space is reached.
• Once the epidural space is identified, a catheter is threaded 3-5 cm beyond the needle tip, the needle is removed, and the catheter is secured.
• A test dose (typically 3 mL of lidocaine 1.5% with epinephrine 1:200,000) is administered to rule out intravascular or intrathecal placement.

Alternative Techniques

Regional analgesic techniques such as paravertebral block and erector spinae plane block are recommended as alternatives to thoracic epidural analgesia 1.

• These techniques provide effective pain control and have a more favorable safety profile compared to thoracic epidural analgesia.
• Multimodal analgesia, including the use of paracetamol, non-steroidal anti-inflammatory drugs, and opioids, is also recommended for postoperative pain management 1.

Key Considerations

The choice of analgesic technique should be individualized based on the patient's specific needs and comorbidities, weighing analgesic efficacy against potential risks 1.

• The use of thoracic epidural analgesia may be associated with significant disadvantages, including hypotension and mobility issues, which can be detrimental to rapid recovery 1.
• Optimal postoperative management is key to avoiding these complications and ensuring a smooth recovery.

From the FDA Drug Label

During epidural administration of bupivacaine hydrochloride, 0.5% and 0. 75% solutions should be administered in incremental doses of 3 mL to 5 mL with sufficient time between doses to detect toxic manifestations of unintentional intravascular or intrathecal injection. Injections should be made slowly, with frequent aspirations before and during the injection to avoid intravascular injection

The thoracic epidural is performed by administering bupivacaine hydrochloride in incremental doses of 3 mL to 5 mL with sufficient time between doses.

• Injections should be made slowly, with frequent aspirations before and during the injection to avoid intravascular injection.
• A test dose should be administered initially and the effects monitored before the full dose is given.
• The test dose should contain epinephrine to serve as a warning of unintended intravascular injection 2.

From the Research

Thoracic Epidural Procedure

• The procedure involves the insertion of a catheter into the thoracic epidural space to administer analgesia, as seen in studies 3, 4, 5, 6.
• The target interlaminar space between T9 and T12 is typically identified, and the needle is advanced under real-time ultrasound guidance until it reaches the posterior complex 3.
• The catheter is then inserted, and its position is confirmed using fluoroscopy, with the tip usually located between T9 and T10 3.
• The procedure can be performed using different techniques, including real-time ultrasound-guided placement 3 or landmark-based techniques.

Key Considerations

• The success rate of thoracic epidural catheter placement can be high, with a first-pass success rate of 76.3% reported in one study 3.
• The procedure requires careful consideration of the patient's anatomy and the potential risks and complications, such as hypotension and bradycardia 5.
• The choice of analgesic agent and dosage is also critical, with studies comparing the efficacy of different agents, such as bupivacaine and fentanyl 4, or lidocaine 5, 7.

Comparison with Other Analgesic Techniques

• Thoracic epidural analgesia has been compared with other techniques, such as continuous paravertebral infusion of bupivacaine 6, and intravenous lidocaine infusion 7.
• These studies have shown that thoracic epidural analgesia can provide effective pain relief, but may not always be superior to other techniques, and the choice of technique may depend on individual patient factors and the specific surgical procedure.