American Society of Regional Anesthesia and Pain Medicine November 2017 - 51
Examining Advanced Modalities for Thoracic Epidural
Catheter Placement
E
pidural analgesia is a popular method
of postoperative pain control and
is particularly useful when used as
part of a multimodal pain medication
regimen. However, epidural catheter failure
is a frequent problem. Lack of a uniform
outcome measure results in heterogeneous
estimates of thoracic epidural failure rates,
but reported rates range from 34% for
overall failure to 13% for technical failure
alone.1,2
Laura Kirk, MD
Nathalie Lunden, MD
Ryan Ivie, MD
Technical failure is a particular challenge
Resident
Assistant Professor
Assistant Professor
for the teaching physician who must
Department of Anesthesiology
Department of Anesthesiology
facilitate a trainee's practice-based
University of Denver, Colorado
Oregon Health and Science University
learning of a procedure for which tactile
Portland, Oregon
feedback is relied on to confirm correct
epidural placement.3 The role of additional
modalities to confirm or facilitate epidural
Section Editor: Kristopher Schroder, MD
placement may be of notable benefit in
this setting. This requires broadening our
current skill set in an attempt to improve the success of thoracic
the newly placed catheter that may help predict its effectiveness
epidural placement and thereby provide more reliable pain control.
in providing analgesia. These include epidural waveform analysis,
nerve stimulation, ultrasonography, and fluoroscopy.
Traditional methods of ensuring entry into the epidural space
include loss of resistance (LOR) to air/fluid-filled syringe, hanging
Epidural pressure waveform analysis has become a topic of study
drop technique, and fluid column drop (drip method).4 Of these
following the observation that a drop of saline hanging from the hub
traditional bedside techniques, loss of resistance to air and/or
of a needle pulsated synchronously with the heart beat once the
saline was overwhelmingly the most popular method used by those needle was in the epidural space.8 It is theorized that this pulsation
surveyed.5 This is likely secondary to the fact that it is generally
is a dampened waveform originating in the pulsating spinal cord
easily taught, gives decent tactile and visual feedback, and can
and conducted through the cerebrospinal fluid and the dura mater
be done efficiently in a cost-effective manner. Despite these
to the epidural space.9,10 Epidural waveform analysis can provide
advantages, it is still affected by significant false-positive rates
a simple and low cost confirmation of LOR by connecting a sterile
(17%).6,7
pressure transducer to our standard operating room monitors.
Leurcharusmee et al11 conducted a blinded observational study
In an attempt to improve the failure rates for epidural placement,
of patients undergoing thoracic epidural placement and found a
more advanced methods of analyzing epidural catheter placement
91.1% sensitivity and 83.8% specificity with this technique. An
have been described (Table 1). These approaches can demonstrate
earlier study conducted by de Medicis et al12 in patients undergoing
not only entry into the epidural space, but also other properties of
lumbar and thoracic epidurals had a lower sensitivity of 81%;
Table 1: Examples of single studies comparing loss of resistance to alternative localization/confirmation techniques.
Technique
Results versus LOR
Metric
Nerve stimulation23
99% versus 57%
Midline placement into epidural space at goal spinal segment confirmed by
radiograph
Epidural waveform analysis24
98% versus 76%
Block to ice in at least two dermatomes bilaterally
Ultrasonography17
93.9% versus 66.7%
Successful LOR within two or fewer needle punctures
Fluoroscopy18
98% versus 74%
Catheter placement in the epidural space as seen on epidurogram following
live fluoroscopically guided placement.
Abbreviation: LOR, loss of resistance
American Society of Regional Anesthesia and Pain Medicine
2017
51
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