American Society of Regional Anesthesia and Pain Medicine August 2017 - 21

potential epidural side effects (including hypotension, hematoma,
abscess, etc) would be outweighed by the improved analgesia.
If the rib fractures had been unilateral, I would have considered
a paravertebral catheter due to the lower risk of hypotension.
However, this patient would have required bilateral paravertebral
catheters, which, in addition to requiring two procedures, would
also have increased the amount of local anesthetic infusion.
Dr. Jacob: Yes. Assuming the patient and family consents to
proceed, the normal INR level is acceptable to initiate neuraxial
analgesia.
Dr. Blake: Potentially, depending on the timing between the
two differing lab value sets and whether any treatments were
given, such as platelets, fresh frozen plasma, or vitamin K. If no
treatments have been given, I would opt to place an epidural
catheter for pain control. The patient meets criteria per ASRA
guidelines and an epidural would greatly benefit him in terms
of pain control. It would hopefully reduce or avoid the need for
opioids, which would be very beneficial for an elderly patient. I
would choose an epidural over paravertebral catheters, because
even though there is only one fractured rib on the right side and it
is high thoracic, there is likely to be some bruising and pain on that
side, and an epidural would provide more efficient and potentially
effective bilateral pain relief. I would also utilize other forms of
multimodal therapy in conjunction with the epidural.
Dr. Rustameyer: This information would encourage me to go ahead
and place a thoracic epidural.
7. Where would you place an epidural or paravertebral
catheter(s)? What would your infusion be and what side
effects might you predict? Are there differences in how
these are dosed/test dosed/placed versus thoracic catheters
for pre-surgical patients?
Dr. Guha: I would place the epidural at T6 to maximize the chance
that local anesthetic would spread cephalad and caudad enough to
cover all the rib fractures. My infusion would consist of bupivacaine
0.125% + hydromorphone 10 mcg/mL. (If the patient appeared
somnolent or there were contraindications to opioids, I would run
only bupivacaine 0.125%). I would run the infusion at 6 mL/hr with
a patient-controlled bolus of 4 mL to be given every 30 minutes
as needed. The placement, dosing, and test dosing would be the
same as for presurgical patients. One difference is that this patient
is already experiencing pain and may require a greater level of
preprocedure sedation and/or pain control so that he is comfortable
enough to sit up for epidural placement.
Dr. Gilloon: I would place the epidural at T6 centered among the
fractures. At my institution, we use ropivacaine exclusively, with or
without fentanyl. I would start with 0.1% ropivacaine with fentanyl

2 mcg/mL at 6 mL per hour with patient-controlled epidural
analgesia of 4 mL every 30 minutes. If the analgesia band proved
too narrow, I would titrate the rate up to 10 mL. If the patient's
blood pressure proved stable and he had persistent pain, I would
consider increasing the concentration of ropivacaine from 0.1%
to either 0.15% or 0.2%. Side effects from the epidural placement
could include hypotension, pruritus, nausea, sedation, and, less
commonly, local anesthetic systemic toxicity. If the patient were
exhibiting nausea, pruritus, or sedation, I would remove the opioid
from the epidural.
Placement of an epidural in the setting of rib fractures compared
to a presurgical patient can be more challenging due to the
patient's diminished ability to cooperate with positioning
secondary to pain.
Dr. Jacob: I would plan to place a thoracic epidural in the T5-6 or
T6-7 space, centrally located to allow for adequate cranial spread
to T3 and caudal spread to T9. After placement, I would test with
a standard 3 mL 1.5% lidocaine + 1:200k epinephrine solution,
followed by a 5 mL loading dose of 0.25% bupivacaine. Once
loaded, I would initiate a continuous infusion 6 mL/hr of 0.075%
bupivacaine mixed with hydromorphone 5 mcg/mL. The main side
effect I anticipate would be hypotension. I would initiate, dose, and
treat this catheter as I would for any patient having an equivalent
level chest surgery.
Dr. Blake: I would place an epidural at level T6/7. This would
place it in the middle of the left-sided rib fractures to hopefully get
spread that will cover all of the fractures for maximal pain relief.
It would be difficult to cover the T3 fracture on the right side; this
is another reason multimodal therapy as an adjunct would be
beneficial. I would start an infusion of 0.1% ropivacaine with a rate
of 5 mL/hr. I would not add opioids to the infusion in this elderly
patient to avoid any mental status changes, confusion, etc.
In presurgical patients, there are typically no limitations in
positioning-most patients are able to maintain a sitting position
for placement. In trauma epidural patients, there are frequently
positioning limitations where patients will be lateral decubitus and
may or may not be able to curl into an optimal position.
Infusions in presurgical patients at my institution are typically
initiated with 0.1% ropivacaine and 10 mcg/mL hydromorphone
at a rate of 6 mL/hr. In trauma epidural patients, we often use
a local anesthetic solution without opioid or put the opioid on a
separate epidural pump. This allows discontinuation of the opioid
if the patient becomes confused or has mental status changes,
often in elderly patients. It also allows discontinuation of the local
anesthetic infusion if the patient becomes hypotensive or has
cardiovascular instability. I generally treat the test dose similarly
between these two groups of patients-typically 3 mL of 1.5%

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