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Pain management and safety profiles after preoperative vs postoperative thoracic epidural insertion for bilateral lung transplantation
Author(s) -
Axtell Andrea L.,
Heng Elbert E.,
Fiedler Amy G.,
Melnitchouk Serguei,
D'Alessandro David A.,
Tolis George,
Astor Todd,
Dalia Adam A.,
Cudemus Gaston,
Villavicencio Mauricio A.
Publication year - 2018
Publication title -
clinical transplantation
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.918
H-Index - 76
eISSN - 1399-0012
pISSN - 0902-0063
DOI - 10.1111/ctr.13445
Subject(s) - medicine , anesthesia , surgery , thoracotomy , epidural hematoma , adverse effect , lung transplantation , pneumonia , mechanical ventilation , transplantation , hematoma
Objective Thoracic epidural analgesia provides effective pain control after lung transplantation; however, the optimal timing of placement is controversial. We sought to compare pain control and pulmonary and epidural morbidity between patients receiving preoperative vs postoperative epidurals. Methods Institutional records were reviewed for patients undergoing a bilateral lung transplant via a bilateral anterior thoracotomy with transverse sternotomy incision between January 2014 and January 2017. Pain control was measured using visual analog scale pain scores (0‐10). Pulmonary complications included a composite of pneumonia, prolonged intubation, and reintubation/tracheostomy. Results Among 103 patients, 72 (70%) had an epidural placed preoperatively and 31 (30%) had an epidural placed within 72 hours posttransplant. There were no differences in the rates of cardiopulmonary bypass (3% vs 0%, P = 0.59); however, patients with a preoperative epidural were less likely to be placed on extracorporeal membrane oxygenation intraoperatively (25% vs 52%, P = 0.01). Pain control was similar at 24 hours (1.2 vs 1.7, P = 0.05); however, patients with a preoperative epidural reported lower pain scores at 48 (1.2 vs 2.1, P = 0.02) and 72 hours posttransplant (0.8 vs 1.7, P = 0.02). There were no differences in primary graft dysfunction (42% vs 56%, P = 0.28), length of mechanical ventilation (19.5 vs 24 hours, P = 0.18), or adverse pulmonary events (33% vs 52%, P = 0.12). No adverse events including epidural hematoma, paralysis, or infection resulted from epidural placement. Conclusion Preoperative thoracic epidural placement provides improved analgesia without increased morbidity following lung transplantation.