lung transplant epidural

[cleverusername]

My facility has recently started lung transplantation. Post-op pain management consists of an epidural 24 hours out to lower the incidence of epidural hematoma post on pump heparinization. I have read articles (granted small sample size) regarding pre-bipass epidural placement with no increased incidence of hematoma in CABG patients. Do any of you have experience with pre-op epidural placement in patients going on pump? If so, were there any incidents with hematoma? I realize that epidural hematoma is catastophic and reason enough to not "test the waters", but placing an epidural 24 hours after a clam-shell incision is ridiculously painful. It is also a logistical nightmare. I don't know if time on pump is considered in the decision making process. The point is really moot since a process change in a brand new program is not going to happen, I was just wondering for curiousity sake. I already printed the articles and mischieviously left them outside the rooms for the anesthesia providers to peruse. Thanks in advance.

[Corey Narry, MSN, RN, NP]

I agree, there seems to be a few literature that describes an uneventful course of epidural analgesia placed before patients went on cardiopulmonary bypass in cases that involved CABG and valve replacements. However, I've not seen one in lung transplantation either.

Our facility is a lung transplant center with a high volume (the largest in the area). Our Anesthesiology/Pain service team places epidural catheters the day after lung transplantation just like your new program's protocol. We seem to have no issues logistically with this and the team is well experienced as far as the technical aspects of the procedure and maintaining patient comfort while placing the catheter.

It's worth mentioning that our Pain Service is very conservative and will not place epidural catheters on patients who have a likelihood of being placed on cardiopulmonary bypass or ECLS due to the large Heparin load that you mentioned.

[RN-LOGIC]

Every lung transplant should get an epidural place before extubation. I have noticed that lung transplant patients with epidurals have a reduced length of mechanical ventilation and reduced respiratory complications. Epidural hematoma should not be an issue with the patient. I mean, if your patient has a normal coagulation profile then there is no reason why wait to place an epidural cath. I would be more worry about inactivity of patient r/t pain leading to other complication.

Every lung patient gets an epidural before extubation.

[RNpatterson]

I haven't done any research on the topic but I can say our facility does them fairly quickly; we generally try to get it done before lifting sedation. It's rare, but sometimes they'll do it immediately post-op in the OR and also rare and far more unfavorable, the pt has it done the next day (but still within 24 hours).

[Stormy8]

With my exp post op epidurals are placed as soon as possible. Pt is kept intubated and sedated until the epidural is placed.