Thoracic epidural (TEP) analgesia improves postoperative pain management, reduces pulmonary complications, reduce postoperative ileus duration and decrease length of stay after laparotomies(1,2). Reported epidural failure rate in teaching institutions is about 30% (3) necessitating a catheter replacement and/or adding additional IV analgesia.
We report a case second TEP placement to improve pain management after a larger than expected laparotomy.
CASE REPORT
A 59-year-old man with Lynch’s syndrome, chronic pain and ongoing polysubstance abuse admitted for a complex abdominal surgery due to synchronous colon adenocarcinoma and urothelia cancer.
A pre-operative T8/9 TEP was placed and successfully tested (LOR was at 6cm and taped at the skin at 11cm). TEP was used intraoperativly using bupivacaine 0.1% at 10mL/hr along with ketamine drip (8mg/hr), which were continued post-operatively.
After the 12-hour exploratory laparotomy including complete procto-colectomy, low anterior colon resection with an end-ileostomy, right nephro-ureterectomy, a partial cystectomy, and left ureteral stent via a midline incision, the patient was extubated and recovered in the PACU and started on a hydromorphone PCA.
He initially had good pain, however during the course of the first night, signs of sedation and confusion were noted and the PCA and ketamine infusion were paused.
A subsequent pain crisis lead to an assessment of the TEP block, performed by the APS early on POD1 which found no catheter migration, good bilateral discrimination to pinprick covering the T10-5 dermatomes only, with absent analgesia to the lower abdomen.
The PCA and low dose ketamine were restarted and the TEP rate increased to 12ml/hr. Unfortunately, rectal and lower abdominal pain did not.
Not wanting to risk losing analgesia above dermatome level T10, a second TEP was placed at T11-12 on POD #1 (LOR at 5cm, taped at 10cm skin) (fig 1-3).
The lower dermatomal border after the test dose (45mg lidocaine) was found bilaterally at L1 level. Due to the first TEP, the rostral border could not be identified. Both epidurals were started with 0.1% bupivacaine at 6mL/hr.
Pain control improved (reported VAS 3). The dermatomal spread of the combined TEPs yielded diminished sensation to pinprick from T5 to L1. Over the subsequent five days hydromorphone PCA 8hr-shift use regressed from 11.4mg to 1.2mg. Good mobilization and improved mental status and no hypotension were noted during this period.
On POD #5 both epidurals were capped and later removed once good analgesia on orals was confirmed. He was discharged to home on POD #15.
DISCUSSION
Dual epidural analgesia has been successfully used for esophagectomies (4,5) and spinal fusions (6) without increased adverse events. To our knowledge, this is the first case report of dual epidural analgesia for a large abdominal surgery. No adverse events were noted.
Replacing a partially working epidural catheters bares the inherent risk of a second epidural failure, hence placing a second epidural catheter, even if the target region is a clearly defined anatomical region such as the abdomen, may be a safe and effective alternative. Further studies are warranted.
