Kumar K, Horner F, Aly M, Nair GS, Lin C. Why do thoracic epidurals fail? A literature review on thoracic epidural failure and catheter confirmation. World J Crit Care Med 2024; 13(3): 94157 [PMID: 39253309 DOI: 10.5492/wjccm.v13.i3.94157]
Corresponding Author of This Article
Kamal Kumar, MBBS, MD, Associate Professor, Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine, Western University, 800 Commissioners Road East, London N6A 5W9, ON, Canada. kamal.kumar@lhsc.on.ca
Research Domain of This Article
Anesthesiology
Article-Type of This Article
Minireviews
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Crit Care Med. Sep 9, 2024; 13(3): 94157 Published online Sep 9, 2024. doi: 10.5492/wjccm.v13.i3.94157
Why do thoracic epidurals fail? A literature review on thoracic epidural failure and catheter confirmation
Kamal Kumar, Fuhazia Horner, Mohamed Aly, Gopakumar S Nair, Cheng Lin
Kamal Kumar, Fuhazia Horner, Gopakumar S Nair, Cheng Lin, Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine, Western University, London N6A 5W9, ON, Canada
Kamal Kumar, Gopakumar S Nair, Cheng Lin, Department of London Health Sciences, Victoria Hospital, London N6A 5W9, ON, Canada
Mohamed Aly, Schulich School of Medicine and Dentistry, Western University, London N6A5W9, ON, Canada
Author contributions: Kumar K contributed to literature search, data collection drafting of Manuscript; Horner F contributed to literature Search and drafting sections Of Manuscript; Aly M contributed to formatting tables and updating the literature search; Nair GS contributed to references management and correcting the draft; Lin C helped with corrections and drafting the manuscript.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Kamal Kumar, MBBS, MD, Associate Professor, Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine, Western University, 800 Commissioners Road East, London N6A 5W9, ON, Canada. kamal.kumar@lhsc.on.ca
Received: March 12, 2024 Revised: May 30, 2024 Accepted: June 24, 2024 Published online: September 9, 2024 Processing time: 170 Days and 16.4 Hours
Abstract
Thoracic epidural anesthesia (TEA) has been the gold standard of perioperative analgesia in various abdominal and thoracic surgeries. However, misplaced or displaced catheters, along with other factors such as technical challenges, equipment failure, and anatomic variation, lead to a high incidence of unsatisfactory analgesia. This article aims to assess the different sources of TEA failure and strategies to validate the location of thoracic epidural catheters. A literature search of PubMed, Medline, Science Direct, and Google Scholar was done. The search results were limited to randomized controlled trials. Literature suggests techniques such as electrophysiological stimulation, epidural waveform monitoring, and x-ray epidurography for identifying thoracic epidural placement, but there is no one particular superior confirmation method; clinicians are advised to select techniques that are practical and suitable for their patients and practice environment to maximize success.
Core Tip: Thoracic epidural anesthesia is a valuable technique for perioperative analgesia in abdominal and thoracic surgeries, but it is associated with a significant failure rate. Factors such as mis-identifying vertebral level, catheter migrations, anatomic factors and equipment failures can all cause suboptimal outcomes. Techniques such as electrophysiological stimulation and waveform monitoring enable the clinicians to confirm catheter level and location in the epidural space, respectively, but provide no information on the spread pattern. X-ray epidurography, on the other hand, provides information on catheter location and spread pattern but requires special equipment and training to perform.
