Outline your management of thoracic epidural analgesia in a 56 year old man who has stable angina on a beta blocker who has been involved in a motor vehicle accident causing a left-sided flail chest. What are the most potential complications?
College Answer
Important considerations include:
a) Other injuries need to be ruled accounted for that may have implications – spinal injury, intra-abdo injury (though abdo pain from intra-abdo injury not likely to be totally masked by epidural local anaesthetic)
b) Coagulopathy is a contraindication
c) Epidural Local anaesthetic/opiate combination at thoracic level likely to be associated with hypotension/bradycardia needing volume and likely inotropic support –relatively contraindicated in a middle aged male on beta blockers.
Infusion vs bolus vs PCEA
d) Other epidural analgesics – opiate alone eg fentanyl, pethidine or epidural clonidine –
doses/frequency
Complications:
a) Hypotension, bradycardia
b) Masking of abdominal / evolving neurological signs
c) Inadequate analgesia due to limited / patchy block
d) Increased pain in unblocked areas – relative phenomenon esp with bony injury eg shoulder.
e) Short duration of blockade – catheters usually removed after 3 days.
f) Epidural haematoma / abscess
g) Epidural drug side effects – pruritus, nausea, respiratory depression
h) Hypotension on mobilisation
Discussion
Thoracic epidural anaesthesia is compared to a parenteral opiate PCA in Question 26 from the first paper of 2010.
Management considerations:
- More difficult to assess the patient; abdominal block tends to obscure changes in clinical condition
- Choice of drug needs to be considered
- The injuries will persist longer then the catheter (max. 5 days)
- Contraindicated in coagulopathy
- May be contraindicated in bony vertebral injury
Complications of thoracic epidural
- Hypotension will develop
- Bradycardia will develop
- Changes in sympathetic innervation of the abdominal viscera may increase abdominal visceral perfusion, thus increasing blood loss from damaged solid organs.
- Opiates will cause pruritis
- There may be respiratory depression and respiratory muscle paralysis with a high block
- There is a risk of infection (epidural abscess)
- There is a risk of epidural haematoma
- There is a risk of dural puncture or spinal cord damage
- The epidural may not work, or the block may be patchy
References
Wu, Christopher L., et al. "Thoracic epidural analgesia versus intravenous patient-controlled analgesia for the treatment of rib fracture pain after motor vehicle crash." Journal of Trauma-Injury, Infection, and Critical Care 47.3 (1999): 564-567.
MACKERSIE, ROBERT C., et al. "Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures." Journal of Trauma-Injury, Infection, and Critical Care 31.4 (1991): 443-451.
Kieninger, Alicia N., et al. "Epidural versus intravenous pain control in elderly patients with rib fractures." The American journal of surgery 189.3 (2005): 327-330.
Moon, M. Ryan, et al. "Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma." Annals of surgery 229.5 (1999): 684.
Jarvis, Amy M., et al. "Comparison of epidural versus parenteral analgesia for traumatic rib fractures: a meta-analysis." OPUS 12 (2009): 50-57.
Scherer, R., et al. "Complications related to thoracic epidural analgesia: a prospective study in 1071 surgical patients." Acta anaesthesiologica scandinavica 37.4 (1993): 370-374.
Kapral, Stephan, et al. "The effects of thoracic epidural anesthesia on intraoperative visceral perfusion and metabolism." Anesthesia & Analgesia 88.2 (1999): 402-406.