Thursday, April 17, 2014

The myth of High Thoracic Epidurals

 Inserting high thoracic epidurals is another new dimension in my current practice. The last time i used to have a go at this was during my Selayang days when we did a lot of open liver work. A good analgesic cover for post op was important in liver impaired patients as opioids will certainly stay longer in them, and the analgesic requirements can be plentiful with the rooftop incision.
Now i do it for all open thoracic works and a new thing is selected cases of CABGs. Yup believe it or not, open heart surgeries! According to evidence, the morbidity and mortality is the same for epidural or non peidural patients, however for post op analgesia, extubation and cheat expansion, it is very significantly SUPERIOR to other modes of analgesia. Patients do become comfortable and earlier extubation time is achieved. 
Everybody is worried of the minute chance of dural haematoma which can be very damaging. This is true for patients who has the easiest chance to become coagulopathic post op; thus making things tricky in terms of usage and displacement of the catheter. I have decided to embark because evidence show that the possible complications is minute and as a university, why not? Prof did mention that we wanna have a go at awake CABG one day and i definitely have to upskill myself to ensure my high thoracic epidural is top notch.

Previously when i learned to insert T6-T7-T8 epidurals,( Sifu Hashim who is now in Ampang Puteri) it was easier insertion and success with  paramedian approach. But for my CABG with T2-T3-T4, the midline approach seems to bring more success. I have always thought that paramedian would be the first choice but somehow for the past few patients it was otherwise. I have stopped trying initially with paramedian and on to midline instead.
Interestingly when i looked at the japanese and korean literature, they indicated their technique is midline rather than the western text books who mentioned it is better to perform paramedian approach. I guess it has to do something with our Asian physique and spine anatomy.
 Alhamdulillah, it was obvious those with epidural in my patient population to have better analgesia and the lung expansion post op is superb. Smokers do need to keep their lungs open post op as the secretions can be a nightmare to both patients and the nurses. I am glad that i embarked into this technique despite limited practice and observation during my masters training ( in CABG that is).

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