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08/06/2015
1
THORACIC EPIDURAL ANALGESIA
IS IT STILL THE GOLD STANDARD IN
THORACIC SURGERY?
Marc Licker, MDDepartment of Anesthesiology,
Pharmacology & Intensive Care Medicine 1
SARA Meeting Fribourg, June 6 2015
What is a STANDARD Technique in thoracic surgery ?
A technique that
Should be done in all cases
Is recommended for all/most cases
2
Scientific evidence
+++
+
08/06/2015
2
Analgesic technique SHOULD:
3
• Be adapted to surgical approach (e.g., Open, VATS)
• Be adapted to individual pain thresholds
• Be highly reliable (>95% success rate)
• Have minimal adverse events
• Protect organs under stressful conditions (e.g., pain, tissue oxygen delivery)
• Improve clinical outcome
• Fast-tracking, accelerate functional recovery
Thoracic epidural analgesia(TEA) in thoracic surgery
1. Historical notes
2. Postthoracotomy pain &
Surgical techniques
3. Physiological aspects of TEA
4. Clinical impact of analgesic techniques
5. How I would perform thoracic anesthesia over the next decade ?
08/06/2015
3
1910 : 1st thoracotomy (Elsberg)
with ET intubation & mechanical ventilation
1933 : 1st pneumonectomy for cancer (Graham)
1949 : Double-Lumen Tube (Carlens)
selective lung ventilation
1970 : Flexible
bronchoscopy
Thoracic Surgery & Anesthesia
Historical notes…
1944-46: Thoracic Epidural Analgesia
1990 : Video-Assisted Thoracoscopy
6
1944: Vasconcellos
Epidural for thoracic surgery 1948: Fujikawa
100 cases of TEA for thoracic surgery 1950: Buckingham 617 thoracic surgical patients
1885: Coring Epidural anesthesia in animals
1901: Sciard and Cattalin Caudal epidural in humans
1951-53: Crawford
Hanging drop technique 677 thoracic surgical pts,
Awake & spontaneously breathing
Catheter to prolong analgesia
1956: Bonica Paramedian approach
08/06/2015
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Marc licker
Respiratory dysfunction (hypoxemia, atelectasis)
Sympathetic-mediated tachycardia, hyperT… risk of myocardial ischemia / infarct
Poor mobilization
7
We need to treatpost-thoracotomy pain because of …
• Use of opiate (> 3 months)
• PTP syndrome (ICD-9-CM Code 338.22 89.22)
pain localized to the operated field, > 12 months postop
5 – 50% after open thoracotomy
Ch
ron
icp
ain
Acu
te p
ain
Hernia
Abd.Hyst.
ThoraxSurg.37.5%
Pain intensity & chronicityImpact of the type of surgery
8
Independent RiskFactor
OR (95%CI)
Surgery Vaginal Hyst.Abdom.Hysterect.
Hernia repairThoracotomy
12.4 (1.6–3.6)1.2 (0.8–1.6)
4.5 (3.1–6.5)
Age > 6418-5051-64
12.3 (1.8–2.9)1.5 (1.2–1.9)
SF-12 Physical (0-33)SF-12 Mental (0-45)
2.6 (1.8–3.6)2 (1.6–2.5)
Preop pain, surgical areaPreop pain, other area
2 (1.6–2.5)1.5 (1.2–1.9)
VaginalHyst.
Montes A et al. 2015 May;122(5):1123-41
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2014;348:g125
N= 39’140 pts > 66 yrs 3.1% use opioids > 3months postop
Ontario Hospitals, 2003 - 2010
Patient related factors
• Younger age
• Lower household income
• Diabetes, Heart Failure, COPD
• BZD, 5-HT inhibitors, ACEI
Surgery related factors
1. Open thoracic S. 8.5%
2. VATS 6.3%
3. CABGS 3.3%
4.Colorectal S (O-MI) 2.8 – 3-2%
5. Radical Prostatectomy 2.8%
6.Hysterectomy (O-MI) 2.5 - 1.5%
10
EMERGING TREND FOR VATS
CLINICAL IMPLICATIONS
• Less pain ?
• Better clinical outcome ?
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VATS vs Open ThoracotomyEUROPEAN SOCIETY OF THORACIC SURGEONS DATABASE COMMITTEE 2014
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
2007 - 2009 2010 - 2012
10.70%
18.80%
N=19’870 N=23’344
?
2015
12 cm
Postop Clinical,Outcome (1)
12 RCTs, N = 670 VATS (vs open T) associated with:
shorter length of stay (- 1.0 to 4.2 days)
less pain and use of analgesics (5/7 RCTs)
Pneumothorax Fewer recurrences (20/100 vs 53/100 pleural drainage, 2 RCTs)
12
BMJ 2004; 329(7473):1008
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Postop Clinical Outcome (2)
13
Cheng D et al. Innovations 2007;2: 261–292
All complications 0.40 (0.32 – 0.70)
Pulmonary complic. 0.39 (0.21 – 0.73)
VATS vs Open thoracotomy
14
Blood Loss (ml): - 79 (-106, - 52)
Cheng D et al. Innovations 2007;2: 261–292
Chest drainage (days): -0.96 (-1.6, - 0.34)
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VATS vs Open thoracotomy postop analgesia
15
VAS (0-10) : – 2.4 (-3.4, - 1.4)
Analgesic dose - 79 ml (-106, - 52)
Marc licker
16
Analgesic techniques in thoracic surgery
Choice is guided by surgical approach!
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Marc licker
17
18
Ann Franc Anesth Rean 2013; 32: 684–690
Réponses : 84 centres / 103 en 2012AG + ALR : 74% thoracotomies
35% VATS
81% des centres 32% des centres
T pose (min) 17 [10–23] 10 [5–13]
Echec (%) 9 ± 9 17 ± 14
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Thoracic epidural analgesia (TEA) in thoracic surgery
1. A brief historical note
2. Clinical impact of surgical techniques
3. Physiological aspects of TEA
4. Clinical impact of analgesic techniques
5. How I would perform thoracic anesthesia over the next decade ?
Marc licker
3. Physiological aspects of TEA
Autonomic nervous system
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PARASYMPATHETIC
Contract
Salivation +
Slow
Constrict
Contract
-
SYMPATHETIC
Dilate
Accelerate
Dilate
Relax
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Marc licker
3. Physiological aspects of TEA
Sympathetic Blockade
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Vagal tone unchanged
• Baroreflex maintained
• Contractility = ()
• Vasorelaxation
• Adrenal medulla
• BLOCK stress-induced release
of catecholamines
• Gut motility
• Bronchial tone unchanged
• Pupil dilatation (Claude-Bernard-Horner s.)
• Bladder retention
Cardiac (gut) protectionBut
Hypotension, urinary cath,
Physiological effects of TEASite of injection
22
Controlled spread of sensory block after thoracic epidural injection at (•) T1/2, (▪) T4/5 and (♦) T8/9.
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Physiological effects of TEA
Age & volume of injection
23
Controlled spread of thoracic sensory block (lidocaine 2%) with regard to age and volume: (•) 9 ml >50 yr; (▪) 9 ml <50 yr; (▴) 5 ml >50 yr; and (♦) 5 ml <50 yr.
9ml >50yr
5 ml <50yr
5ml >50yr 9ml <50yr
Physiological effets of TEA
Somatic nerves
Nociception
(Motor)
Blunting of the SNS
Heart
Vessels
Gut
(Bladder)
24
Stress reduction
Opiate-sparing effect
Mobilization (?)
Preserved baroreflex
No tachycardia, HT
Hypotension
GI perfusion
Enhanced GI motility
(Urin. retention)
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Thoracic epidural analgesia (TEA) in thoracic surgery
1. A brief historical note
2. Clinical impact of surgical techniques
3. Physiological aspects of TEA
4. Clinical impact of analgesic techniques
5. How I would perform thoracic anesthesia over the next decade ?
Marc licker
26
4 RCTs in thoracic surgery (N=613)14 RCTs in abdominal surgery (N=2’556)
Pneumonia 0.54 (0.4-0.7)
Myocardial infarct 0.55 (0.4 - 0.8)
Better PFTs FEV1 + 0.18 (L)
PEFR + 43 (ml)
Better PaO2 (POD1) + 0.9 kPa
Hypotension 2.03 (1.2 to 3.3)
Urinary retention 2.15 (1.1 to 4.3)
Pruritus 2.41 (1.8 to 3.3)
Technical failure rate 7%
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TEA in major surgerySystematic Review RCTs - Pulmonary Complications
27
Ann Surg 2014;259:1056–1067
Level
Surgery
Follow-up
Death
Overall N = 2’201 OR, 0.60; 95% CI, 0.39–0.93 Pulm. Complic. 4.9% 3.1%
Thoracic S. N = 1’065 OR, 0.68; 95%CI, 0.28-1.53) Pulm. Complic. 2.8% 1.8%
Marc licker
28Ann Surg 2014;259:1056–1067
Impact of TEA on postop. complications
Outcome OR (95%CI) NNT
Atrial Fibrillation 0.63 (0.49–0.82) 12
Respir. depression 0.61 (0.39–0.93) 68
Atelectasis 0.67 (0.48–0.93) 22
Pneumonia 0.56 (0.45–0.70) 25
Ileus 0.43 (0.21–0.88) 21
PONV 0.76 (0.58–0.99) 15
Pruritus 1.47 (1.15-1.88) 21
Urinary retention 1.60 (1.02-2.51) 25
Motor block 12.7 (5.26-30.5) 14
Hypotension 4.19 (2.53-6.94) 16
Pruritus 1.47 (1.15-1.88) 21
Fa
vora
ble
Eff
ect
sA
dve
rse
Eff
ect
s
6.1% failure rate
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TEA in open thoracotomyCohort study analysis
Open lungresection 2006-13 US National database
353 Hospitals,
N = 21’756 pts (90% elective)
29
Ozbek U et al2015 (in press) Postop Outcome GA 79% TEA 21%
Mortality 3.1 2.73
Cardiac complic. 23 24.1
Myoc. Infarct 1.1 0.67*
Stroke 0.60 0.79
Pulm. embolism 0.67 0.99
Deep vein thrombosis 0.83 1.17*
Pulmonary compl. 21 19*
Pneumonia 13.9 12.6*
Acute Renal Failure 6.3 5.8
Gastro-intestinal C. 3.0 3.1
Optimal analgesia for VATS ?
TEA and PVB are established analgesic gold standard for open surgery.
There is no gold standard for regional analgesiafor VATS
30
17 articles dealing with analgesia for VATS
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Marc licker
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VAS 24h0.06 (-031 to -0.42)
18 RCTS, N=777
2014 ;9:e96233
32
Thoracic surgery : PVB vs TEA
Failure rate0.21 (0.1 to 0.44)
6.6% PVB vs 13% TEA
Pulmonary complic.0.51 (0.23 to 1.11)
7.7% PVB vs 13.9% TEA
Ding X, et al. PLoS One. 2014 ;9:e96233
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33
Urin. retention0.21 (0.1 to 0.44)
11% PVB vs 31% TEA
PONV0.18 (0.28 to 0.87)
17% PVB vs 27% TEA
Hypotension0.11 (0.05 to 0.25)
1.6% PVB vs 19% TEA
Thoracic surgeryPVB vs TEA
Ding X, et al. PLoS One. 2014 ;9:e96233
34
Nowadays, the impact of analgesictechniques has decreased because :
• Patient’s condition is optimized
preoperatively
• Surgical approach is less invasive
• Shift of periop mortality from Myocardial Infarct
to Respir. Failure
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Marc licker
Analgesic technique SHOULD be:
35
Analgesia
Parameters
ThoracicEpidural Block
ParavertebralBlock
Parenteralmedic (IV, IM, po)
Adapted to surgery Thoracotomy(VATS)
VATS Thoracotomy
VATS (Thoracotomy)
Adapted to patient ++ ++ ++
Successful / reliable + +/- ++
Better outcome ++ ++ (+)
Organ protection + (heart, lung) + (lung) -
Adverse events ++ HypotensionUrinary retention
(failure rate) ++ Sedation, Respir. depression
Fast track process +Thoracotomy- VATS
+ Thoracotomy+ VATS
- Thoracotomy+ VATS
Thoracic epidural analgesia(TEA) in thoracic surgery
1. Historical notes
2. Postthoracotomy pain &
Surgical techniques
3. Physiological aspects of TEA
4. Clinical impact of analgesic techniques
5. How I would perform thoracic anesthesia over the next decade ?
08/06/2015
19
Modern thoracic anesthesiaProtective interventions
1. Optimize preop pt condition (e.g., exercise, nutrition, stop tobacco & alcohol)
2. Secure the airways (DLTs, BBs; FOB)
3. Protective ventilation settings (low VT, PEEP, FIO2, recruitment)
4. Titrate fluid infusion (restrictive, goal-directed)
37
5. Fast-track anesthesia early mobilization, feeding
• Short-acting anesthetics, myorelaxant, analgesics
Avoid/limit use of opioids
• Multimodal analgesia
• Open T (extensive resection) TEA (PVB)
• VATS/robotic PVB or IV-PCA (TEA)
Strategies to reduce mortalityLung Cancer Surgery 1967 - 2015
RestrictiveFLUIDS
ProtectiveVENTILATION
???
Thoracic Epidural
0
2
4
6
8
10
1967-
1976
1977-
86
1986-
94
1995-
99
2000-
04
2005 -
09
2010-
14
Ho
spit
al M
ort
ali
ty (
%)
Surgical Team 1 Surgical team 2 Surgical team 3
Anesthesia team 1 Anesthesia team 2
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Strategies to Attenuate the Risk of Cardio-Pulmonary Complications
0
5
10
15
20
25
1990-94 1995-99 2000-04 2005-09 2010-14
Cardiovascular
PulmonaryRestrictive FLUIDS
ProtectiveVENTILATION
Thank You !
Mont Blanc 4’810 m
Salève 1’330m
08/06/2015
21
Merci !
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