By Thomas G. Ciccone
Interview with Michael M. Bottros, MD
The importance of incorporating alternative treatment modalities received a great deal of focus during the conference, especially with regard to treating acute pain in the emergency care setting.
Epidural local anesthetics are one such example of an alternative modality clinicians have found useful. Epidurals have the potential for use other than just pain control and may limit patient exposure to opioid-based analgesic regimens; they even may help save lives in an emergency situation, too.
Michael M. Bottros, MD, an assistant professor of anesthesiology and the director of acute pain service at the pain management center of Washington University in Saint Louis, Missouri, presented his own unpublished clinical data that suggested epidurals may offer significant reduction in rates of patient morbidity and mortality, particularly in the trauma setting.1 Dr. Bottros, who administers pain control for many trauma care patients, presented a recent set of data collected from his patients who presented with traumatic injuries to the ribcage.
“These were patients who may have fallen, or were involved in an automobile accident, and experienced rib fractures,” said Dr. Bottros. The data featured a 1:2 ratio of patients receiving epidurals (n=158) and patients who did not (n=301), controlling for age, gender, and the number of ribs broken.
Dr. Bottros found a significantly lower percentage of mortality in the epidural group compared to controls, at 2.5% vs. 9.0%, respectively. Total days spent on the ventilator and total days spent in the ICU also were lower in the epidural group compared to controls.1
“What’s really interesting is when we looked at their injury severity score, patients who had huge, whopping devastating injuries—when they came into our hospital with a severity score greater than 25—when these patients received an epidural, their in-house mortality dropped from 21% down to less than 4%.”
While epidurals traditionally have been thought of as just a tool for pain control, they could be a significant option to improve survival rates in patients treated for traumatic injuries, such as to the ribcage. This has led Dr. Bottros and his colleagues to push for patients to immediately receive epidurals upon admission to the trauma center with this type of injury.
Of course, it is difficult to determine exactly why epidurals appear to associate with a markedly reduced mortality rate. There could be other confounding factors not included in the data. Or, mortality rates may turn out to be comparable for injuries not involving the ribcage.
However, the unpublished data did suggest that shallow breathing seen in patients with traumatic injuries to the rib cage was more severely compromised and at increased risk for respiratory depression common with systemic opioid interventions; this issue of respiratory challenge could be something overlooked in trauma centers, Dr. Bottros told PPM. In any case, epidural analgesia has not become a considered part of the standard of care but may be due for revaluation.
Common Misconceptions About Epidural Analgesia
According to Dr. Bottros, epidurals have been known to provide a number of benefits to postsurgical patients, including helping reduce nausea and the incidence of vomiting. There is also evidence that suggests epidurals may help patients recover more quickly from their procedures.
One randomized controlled trial compared epidural analgesia (EA) to continuous wound infiltration (CWI) of local anesthetics, which has been suggested as an alternative to epidurals.2However, researchers found epidurals were associated with a better rate of functional recovery and less amount of time spent at the hospital, Dr. Bottros noted.
There may still be some long-held misconceptions about EA, however. Some of these misconceptions can stem from the literature. Only a few years ago doctors were studying the efficacy of EA while performing the modality incorrectly, according to Dr. Bottros. For instance, “some practitioners may worry about urinary retention rate with EA, but the issue is avoidable,” noted Dr. Bottros. “I know surgeons are concerned about that with epidurals. There is no difference in urinary rate if the epidural is placed at T10 or higher.”
Dr. Bottros provided a general overview of where epidurals are placed based on the type of the surgery (Table 1).
“These are things to think about in lieu of just opioids. That’s the whole idea of placing the epidural based on where the incision is going to be,” said Dr. Bottros. Only a few years ago, epidurals were somewhat dismissed in the literature because doctors were not placing them in a more strategic fashion.
“We have to be very careful when we are reading the literature, especially these meta-analyses,” because they can be misleading for this very reason, Dr. Bottros explained. “We know that if patients get an epidural, there is a much greater reduction in the risk of (postsurgical) pain syndromes,” with published evidence showing this to be true for a number of conditions, such as thoracotomy for breast cancer patients. “And now, we actually send patients home with regional blockade,” said Dr. Bottros. Patients can remove the epidural after 5 days or so, which is easy to self-perform since it sits right underneath the skin, Dr. Bottros advised.
- Bottros M. A Gathering Storm: Evaluating Perioperative Opioids. Presented at: PAINWeek; September 6-9; Las Vegas, Nevada.
- Jouve P, Bazin JE, Petit A, Minville V, Gerard A, Buc E et al. Epidural versus continuous preperitoneal analgesia during fast-track open colorectal surgery: a randomized controlled trial.Anesthesiology. 2013;118(3):622-630.