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10/8/2014
The Science & Art of Providing Thoracic
Epidural Analgesia in the Adult ThoracoAbdominal Surgical Population
Jason Sawyer, RN (EC), MN, BC
Board Certified-Pain Management
Nurse Practitioner, Acute Pain Service
Sunnybrook Health Sciences Centre
Lead, Pain Assessment, Documentation & Management Best Practices
Adjunct Lecturer, Lawrence S. Bloomberg Faculty of Nursing, University of
Toronto.
1
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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10/8/2014
Acute Pain Service
• 2 Nurse Practitioners Monday-Friday
• Staff or Fellow Anesthesiologist 7 days – Tues-Tues
• 3300-3500 patients/year
• 400-500 surgical thoracic/trauma epidurals
– Colorectal, hepatobiliary, gynecological, urological, CV,
trauma rib #’s
4
Agenda
• Unrelieved postoperative pain
• Overview of thoracic epidural analgesia (TEA)
– Anatomy of the epidural space
– Review of commonly used local anesthetics and opioids
• Overview of the advantages of TEA
• 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
• Describe how Organizational Development courses helped guide
improvements in delivering safe and effective TEA
5
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)
• Post-discharge health care utilization is greater in those with higher
pain scores in-hospital and post-discharge (Vandenkerkhof, 2006)
6
6
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10/8/2014
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 postdischarge, & 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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8
9
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10/8/2014
10
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
11
Would you try to limit how much strong pain
killers like morphine you use because you
worried about becoming addicted?
1. Yes
2. No
12
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10/8/2014
13
“Oh, Just Give Them IV-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)
• This does not reflect patient concerns regarding opioids
14
14
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
• Negative impact on quality of recovery, quality of life,
relationships
• Patients and families have strong beliefs/misconceptions
about the side effects of opioids
•15 What to do…..what to do….
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16
17
18
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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 vs 2.0 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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21
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http://www.bpigs.ca/
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Brief Summary
• 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
• Need to focus on TEA (and ultimately quality pain
management) related to
– Quality of recovery
– Quality of life
– Chronic post surgical pain
24
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10/8/2014
• 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 Royse
Anaesthesia and Pain Management Unit, Department of
Pharmacology, University of Melbourne; and Cardiothoracic
Anaesthetist, The Royal Melbourne Hospital, Australia
25
Where It All Started
August Bier 1861-1949
surgeon
1898 Spinal Anesthetic
Assisted by August
Hildebrandt
James Leonard Corning 1855-1923
neurologist
1885 Spinal cocaine
26
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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
28
Epidural Anatomy
•
Ligamentum flavum is non continuous and not pain sensitive
• Proximity to CSF/Spinal Cord is crucial
• Sympathetic fibres T1-L2
29
Some effect
• Age
– 40% less dose for (60-79)
vs (20-39)
– Diminished fatty tissue
– Decrease in myelinated
nerves
– Increased epidural space
compliance
– Dura more permeable
Minimal/no effect
•
•
•
•
Height, weight BMI
positioning
Gravity
Needle direction
30
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10/8/2014
Minimal/no effect
Some effect
• Site of insertion determines
distribution
• Total mass of LA more
important than
concentration or volume
• Distance into epidural space
– 4-6 cm threaded into
epidural space
• Fractional vs single bolus
injection
• Epidural pressures
• Pressure in adjacent body
cavities
31
32
What Analgesics?
• Local Anesthetics
• Opioids
• Epinephrine
33
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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 1030 mins)- highly lipid soluble (lipophillic)
– Epidural fat
– Diffusion across dura
• Ester local anesthetics metabolized by plasma
pseudocholinesterase (rarely used for epidural analgesia)
• Amide local anesthetics metabolized in the liver
– Most commonly used are bupivacaine and ropivacaine
34
• Smaller nerves more susceptible to effects of LA
– Pain, temperature, touch, motor
• 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
not necessarily equal analgesia- only let you know where the
LA is spreading
35
36
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10/8/2014
Epidural Opioid Site of Action
Substantia Gelatinosa of Spinal Cord
philic = friendly
Primarily
Spinal Effect
Hydrophilic
Morphine
Lipophilic
Primarily
Supraspinal
Hydromorphone
(Dilaudid)
Fentanyl
37
Questions Without An Answer
– Ideal mixture of solution (LA and/or opioid) still debatable
• LA only no opioid side effects but possibly more
hypotension
• Opioid only no better than systemic opioids and ↑ side
effects
• LA + opioid best ?
• Is benefit of fentanyl primarily systemic or spinal?
• Other adjuncts?
(Wetterslev 2001, Brown 2004)
38
38
Side Effects, Big & Small
39
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40
41
Presented as
Mean %
Pruritus
N=21 461
Nausea
N= 20 606
Vomiting
N=11 423
Urinary Retention
N=12 513
Mild
Sedation
N= 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 use
N= 55 404
All
0.3
4.7
1.1
17
3.3
IM
1.4
3.6
0.8
37
1.3
IV-PCA
42
1.9
0.7
1.2
11.5
1.3
Epidural
0.1
5.5
1.1
15
6
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
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10/8/2014
What intervention do you use FIRST for pruritus you suspect is from opioid in the
thoracic epidural? N= 70
Administer Benadryl
Administer Nalbuphine
Administer Naloxone
Administer Naloxone infusion
Administer Ondansetron
Reduce/change the opioid in the
epidural
Remove the opioid from the epidural
43
• 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
44







45
44
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
45
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10/8/2014
Postoperative Nausea & Vomiting (PONV)
101
(Watcha & White 2002)
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46
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47
Gan 2007
48
48
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10/8/2014
Hypotension- Local Data
N=64 Epidural 35 IV-PCA 29
Category
Epidural
Age
68.1*
IV-PCA
57.8
Surgical Time
Mean Blood Loss
326* (min)
700* ml
193 (min)
274.4 ml
LOS
7.67
8.1
Post op Comp.
9
10
*= statistical significance
No difference between groups in Sex, preop BP, comorbidities, postop complications,
or pts that were receiving BP meds preop
49
Percentage of Patients
49
Incidence of Patients with a Mean Systolic Blood Pressure Meeting
Hypotensive Criteria (Graph 2)
PCA (H80)
60
PCA (H90)
40
Epidural (H80)
20
Epidural (H90)
0
PACU
Post
Day 1
Day 2
Day 3
Day 4
Time Period
% Patients
Receiving Fluid
Boluses
Incidence of Patients Receiving at Least One Fluid Bolus (Graph 3)
50
80.0%
60.0%
40.0%
Epidural
20.0%
0.0%
PCA
PACU
Post
Day 1
Day 2
Day 3
Day 4
Time Period
50
• Significance of analgesia mode on SBP was dependent on
definition of hypotension
– If definition was 20% drop from baseline SBP then there
was significantly more patients hypotensive in the epidural
group in the initial postop period
– If the definition was a SBP less than 90, there was no
difference between epidural and PCA patients regardless
of timing
– females much more likely to be hypotensive
51
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Urinary Retention
52
Side Effect Summary
• 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 (Krancke 2007)
• Incidence of pruritus with epidurals is much higher, but not
histamine mediated. Evidence supports Ondansetron
(Zofran) and opioid reversal agents
• Incidence of urinary retention with TEA is approximately 10%
and demonstrates a decrease in UTI
53
Survey Results
54
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10/8/2014
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 is T412 bilateral, covering the entire incision. N=57
60.0%
50.0%
50.0%
42.6%
Bolus the epidural with more of the same
epidural solution infusing through the epidural
pump and increase the rate?
Bolus the epidural catheter with a more potent,
different, local anesthetic (e.g. lidocaine), then
resume with the same epidural solution
40.0%
30.0%
Bolus the epidural catheter to comfort with a
more potent dose of ropivacaine, then resume
the infusion at the more potent dose of
ropivacaine.
20.0%
10.0%
Continue the current epidural solution and add
IV-PCA/other route of opioid
5.6%
1.9%
0.0%
55
If you have more than 1 epidural solution to choose from, how do you decide which
one to use on your patients? (N=64)
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Anesthesiology preference
Acute Pain Service preference
Customized based on patient
factors
56
How long, on average, do you keep your thoracic epidurals infusing?
N= 74
60.0%
50.0%
1 day
2 days
40.0%
30.0%
20.0%
3 days
4 days
5 days
6 days
7 days
10.0%
>7 days
0.0%
57
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10/8/2014
Do you routinely use etCO2 or continuous pulse oximetry for your patients with
thoracic epidurals that contain opioids? N= 73
Yes
No
• some sites still require ICU monitoring for epidurals (opioid)
Published incidence of respiratory depression requiring Naloxone
(Narcan) approximately 0.1%......
58
Online Survey
• Local anesthetics
– 2/3 bupivacaine (most common 0.1%)
– 1/3 ropivacaine (most common 0.1-0.2%)
• Opioids
– 55% fentanyl (1-5mcg/ml)
– 40% Hydromorphone (4-20mcg/ml)
•
•
•
•
Epinephrine (2) Clonidine (1)
Vast majority LA/opioid combination
Very few had multiple options
% of patients receiving IV-PCA & Epidural
– Highly variable
59
Historical TEA delivery at Sunnybrook
• Choice of a single ropivacaine (Naropin) concentration (0.2%)
with options for hydromorphone (Dilaudid) 5 or 10 mcg/ml
• No PCEA component
• Trouble shooting involved large doses of lidocaine
(Xylocaine)-continue with original epidural solution
• High infusion rates (15-20ml/hr)
60
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10/8/2014
• Perceived excessive failure rate
• Not uncommon to add IV-PCA opioid to epidural
• Suboptimal outcomes for chronic pain/chronic opioid users
that receive epidurals
• Aggressive multimodal analgesia with NSAIDS,
Gabapentinoids, Acetaminophen (Tylenol) > 10 years
• TEA care provided on surgical units for > 15 years
61
Lessons Learned…
• Quickly
– Adding epinephrine (Adrenaline) to Ropivacaine (Naropin)
/HYDROmorphone (Dilaudid) combination frequently
caused pruritus when none existed before (particularly with
10 mcg/ml)-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
62
• Can we have an opioid free epidural program?
• Can we do a better job individualizing TEA?
• Can we trouble shoot more effectively- especially at night?
63
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Can We Have An Opioid Free Epidural
Program?
• History of Epinephrine Use
• Saddle Block for labor
• 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
•
(Priddle & Andros 1950)
64
How Neuraxial Epinephrine Works
• Independently causes segmental hypoalgesia when given
epidurally to pinprick (100 mcg) (Curatolo et al 1997) & pinprick/ice
(50mcg) (Bromage et al 1983)
• Absorbed into the CSF and binds to α2 adrenoreceptors in
substantia gelatinosa of the dorsal horn (Curatolo et al 1997)
65
• 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)
• Epidural Epinephrine (100 mcg) reduced peak plasma
morphine levels (10mg epidural) by 60% in a study of 3
healthy volunteers (Bromage et al 1983)
66
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10/8/2014
Adding Fentanyl (20 pts)
2001
Adding Epinephrine 12 pts
2002
•
•
•
•
•
•
•
•
Bupiv 1mg/ml 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
•
•
•
•
67
Ropiv 1mg/ml fent/epi 2mcg/ml
Without Epi pain at rest & with
coughing significantly worse within
2 hrs
Pain decreased within 15 mins
and no difference within 1 hr of
reintroducing epi compared to
baseline
Significant regression of sensory
blockade with removal of
epinephrine
Nausea increases significantly
when epinephrine removed
Significantly more mobilization
with epinephrine
Overview of Epinephrine for TEA
• 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 2560%
68
69
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10/8/2014
Can We Do A Better Job Individualizing
TEA?
•
•
•
•
Lean Healthcare
Identifies the least wasteful way to provide better, safer care
Doing more with resources available
5 principles
– Specify Value
– Identify the value stream/patient journey
– Make the process and value flow
– Deliver care on demand, with the resources required
– Pursue perfection
• 7 types of waste
– Correction, waiting, transportation, over processing,
inventory, motion, over production
70
Technical Aspects- Placement
Paravertebral, pleural
cavity and intravascular
placement
Higher success rate
with placement
>5cm into epidural
space
Secondary
migration after
insertion
Imprecise
catheter
placement
Method of
epidural space
identification
Technical Aspects – Catheter & Line
tunneling
Test dose
Line patency
Pharmacological
Dose
Volume optimization
Concentration
Choice of
medications
71
Correction
Waiting
Transportation
Initial epidural plan as per OR
anesthesia
APS not involved until POD #1
Limited TEA solutions available
Patients waiting until “Pain Service
arrives”
“Hoping” initial interventions work
LA not available on high volume epidural
units
Vasopressors also not available
72
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10/8/2014
Overprocessing/Inventory
Motion
Overproduction
Several cassettes of plain
ropivacaine 0.2% on a
single, high volume unit, but
no other options
Drugs to trouble shoot had to be
brought to unit (analgesics and
vasopressors- variability
Difficult to find space for rescue
epidurals
Wastage of premade ropivacaine cassettes
($16 000/year)
73
TEA Management At Sunnybrook
Implementation Fall 2014
• Transition to opioid free epidural analgesia regimen
• Consultation with Pharmacy (clinicians and manufacturing)
• Continuous infusion + PCA component
• Epinephrine (Adrenaline) 5mcg/ml and Ropivacaine (Naropin)
0.3% standard solution
• Additional solutions available for individualizing TEA
74
Primary Approach
•
•
•
•
•
•
Collaborate with Anesthesia Intraop
Normotensive preop
No chronic pain/opioid use
Epidural placed T6-10
Plan
Ropivacaine (Naropin) 0.3% and Epinephrine (Adrenaline)
0.005mg/ml
• Rate: 6ml/hr (range 3-8ml/hr) PCEA 3ml Lockout 15 minutes
75
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10/8/2014
Customization Option 1
• Collaborate with Anesthesia
• No chronic pain/opioid use + any of the following
– “hypotensive” preoperatively
– Elderly/frail
– Epidural placed T10-12 (increased risk for motor block)
• Plan
• Ropivacaine (Naropin) 0.125% and Epinephrine
(Adrenaline) 0.005mg/ml
• Rate: 6ml/hr (range 3-8ml/hr) PCEA 3ml Lockout 15
minutes
76
Customizing Option 2
•
•
•
•
•
•
Normotensive preop
Chronic pain/opioid use and/or
Painful procedure
Epidural placed T6-10
Plan
Ropivacaine (Naropin) 0.5% and Epinephrine (Adrenaline)
0.005mg/ml
• Rate: 6ml/hr (range 3-8ml/hr) PCEA 3ml Lockout 15 minutes
• Preoperative opoids by same route
• Plasma concentrations peak in about 67 hrs (of 120 hrs)
(2000,Wiedemann)
77
• 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
• In all instances
– Adjuncts as able
– Midodrine 10 mg po q 8h prn x3 for SBP <90 mmHg
– PONV algorithm
78
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10/8/2014
Can We Do A Better Job of
Troubleshooting?
• Uncontrolled Pain –bilateral/unilateral, +/- sensory block
• Bolus epidural with more potent Ropivacaine (Naropin) as
opposed to Lidocaine
– 1% Ropivacaine vials and
– cassettes with 0.125/0.2/0.3/0.4/05% available on high
volume unit
– If satisfactory relief with more potent bolus- start infusion
with same
– Rescue epidurals significantly reduced
– When required- perform on the patient unit
– Minimal hypotension requiring intervention (vs. using
Lidocaine)
79
Trouble Shooting
• Appropriate analgesia and dense motor block
– If shutting off until motor block resolution and restarting at
a lower rate not satisfactory
– Lower concentration of Ropivacaine available
80
81
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10/8/2014
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
• Epidurals are a way to avoid opioids
• Outline daily process of epidural removal.
– What to expect
– How soon to go home
– Considering handing out little “key messages”
82
Benefits Of Our New Approach
• Perhaps the combination of Epi +LA is “Just Right”
• No more
– Pruritus
– Opioid contribution to ileus
• Reduced systemic absorption when using more potent LA
concentrations
• No increased incidence of motor block observed to date with
increased LA concentration
83
• Reduction in replacement epidurals
• Reduction in epidural failure rate
• Many patients not exposed to opioid during hospital
admission
84
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10/8/2014
Conclusions
• Epidurals continue to be the main stay for analgesia for many
post surgical populations
• Evidence for improved analgesia compared to all traditional
modes of analgesia is indisputable
• We still have not identified the ideal medications/combinations
85
• 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
86
Thank You
• jason.sawyer@sunnybrook.ca
87
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10/8/2014
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• 1.
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