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

4

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

08/06/2015

5

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 ?

08/06/2015

6

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

08/06/2015

7

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)

08/06/2015

8

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!

08/06/2015

9

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

08/06/2015

10

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

20

PARASYMPATHETIC

Contract

Salivation +

Slow

Constrict

Contract

-

SYMPATHETIC

Dilate

Accelerate

Dilate

Relax

08/06/2015

11

Marc licker

3. Physiological aspects of TEA

Sympathetic Blockade

21

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.

08/06/2015

12

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)

08/06/2015

13

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%

08/06/2015

14

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

08/06/2015

15

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

08/06/2015

16

Marc licker

31

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

08/06/2015

17

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

08/06/2015

18

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

08/06/2015

20

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 !

41