An Update on

©2008 Thoracic
Epidural Blocks
The University of Iowa
TIMOTHY J. BRENNAN PhD, MD

Department of Anesthesia
DEPTS OF ANESTHESIA
UNIVERSITY OF IOWA
©2008

The University of Iowa

Department of Anesthesia
 THORACIC EPIDURAL
ANALGESIA
©2008
Placement
The University of Iowa
Drugs for thoracic epidural analgesia

Department of Anesthesia
TEA-Thoracic surgery
©2008

The University of Iowa

Department of Anesthesia
TEA-Upper Abdominal surgery

©2008

The University of Iowa

Department of Anesthesia
Hepatic Surgery, Pancreatectomy
TEA-Lower Abdominal surgery

©2008

The University of Iowa

Department of Anesthesia
©2008

The University of Iowa

Department of Anesthesia
©2008

The University of Iowa

Department of Anesthesia
©2008

The University of Iowa

Department of Anesthesia
©2008

The University of Iowa

Department of Anesthesia
1 cm
©2008

The University of Iowa

Department of Anesthesia
1 cm
©2008

The University of Iowa

Department of Anesthesia
©2008

The University of Iowa

Department of Anesthesia
1 cm
©2008

The University of Iowa

Department of Anesthesia
©2008

The University of Iowa

Department of Anesthesia
1 cm
©2008

The University of Iowa

Department of Anesthesia
1 cm
©2008

The University of Iowa

Department of Anesthesia
1 cm
©2008

The University of Iowa

Department of Anesthesia
©2008

The University of Iowa

Department of Anesthesia
1 cm
©2008

The University of Iowa

Department of Anesthesia
1 cm
©2008

The University of Iowa

Department of Anesthesia
1 cm
©2008

The University of Iowa

Department of Anesthesia
1 cm
©2008

The University of Iowa

Department of Anesthesia
1 cm
©2008

The University of Iowa

Department of Anesthesia
©2008

The University of Iowa

Department of Anesthesia
1 cm
©2008

The University of Iowa

Department of Anesthesia
©2008

The University of Iowa

Department of Anesthesia
©2008

The University of Iowa

Department of Anesthesia
©2008

The University of Iowa

Department of Anesthesia
©2008

The University of Iowa

Department of Anesthesia
©2008

The University of Iowa

Department of Anesthesia
EPIDURAL LOCAL ANESTHETICS
©2008
• Bupivacaine 0.05%-0.10%

The University of Iowa

• Ropivacaine 0.125%-0.2%

Department of Anesthesia
 Differential analgesic effects….
Anesth. Analg. 74:362, 1992

©2008

The University of Iowa

Department of Anesthesia
Choice of epidural opioid

©2008
Parenteral to Epidural Ratio

Fentanyl

The University of Iowa

Fentanyl
+
Epinephrine

Hydromorphone

Department of Anesthesia
Morphine
 LOCAL OPIOIDS ADVANTAGES/
ANESTHETIC DISADVANTAGES

©2008
Bupivacaine None opioid side effects/
0.125% aahemodynamic side
effects

Bupivacaine Hydromorphone

The University of Iowa

0.10%
Bupivacaine
5-10 mcg/ml
Hydromorphone
both
hemodynamic and
0.05% 5-10 mcg/ml opioid side effects
Bupivacaine Hydromorphone
0.05% 20 mcg/ml

Department of Anesthesia
None Hydromorphone hemodynamic side
40 mcg/ml effects
opioid side effects
 ADVANTAGES OF POSTOPERATIVE
EPIDURAL ANALGESIA
©2008
LOCAL ANESTHETIC-OPIOID COMBINATIONS

• Reduced Pain Scores With Movement

The University of Iowa

• Earlier Return Of Bowel Function
• Reduced Pulmonary Complications
• Shorter ICU Stay
Department of Anesthesia
• Shorter Hospital Stay
 LIMITATIONS OF EPIDURAL ANALGESIA
FOR ACUTE PAIN RELIEF
©2008
Requires hemodynamic stability

Side effects will occur

The University
Pain is of Iowa
not necessarily eliminated

Non-surgical pain must be assessed

Department
It is not without risk
of Anesthesia
 THORACIC EPIDURAL
ANALGESIA
©2008
Placement

The
DrugsUniversity
for thoracic epiduralof Iowa
analgesia

Coagulation and thoracic epidural analgesia

Department of Anesthesia
 MOnday
©2008
an update on interscalene and

The University of Iowa

infraclavicular blocks

an update on femoral and

popliteal blocks

an update on thoracic epidural

blocks

Department of Anesthesia
www.anesth.uiowa.edu/cabo