Thoracic Epidural Analgesia Improves Outcomes after Lung Transplant

Abstract

<h3>Purpose</h3> Pain management after lung transplant is of critical importance. Inadequate pain control can result in low tidal volumes and poor pulmonary toilet which can lead to atelectasis and even pneumonia; however, excessive opioid use can lead to hypercarbia and respiratory failure. Thoracic epidural analgesia has been shown to improve outcomes after lung transplants performed via clamshell incision or thoracotomy. We sought to determine the effectiveness of epidural analgesia at our institution where the majority of lung transplants are performed via sternotomy. <h3>Methods</h3> In December 2019, we implemented a protocol whereby all lung transplant patients receive an anesthesia consult for consideration of TEA. Baseline characteristics and outcome measures were collected for all patients that underwent lung transplant since that time. Outcomes were compared between patients that did and did not receive epidurals using t-tests, chi-squared tests and regression. <h3>Results</h3> Of the 39 patients that underwent lung transplant during the protocol period 19 patients received epidurals. The TEA group was slightly healthier (LAS 37.12 compared to 45.29), and used significantly more opioids pre-operatively. Patients with epidurals spent a shorter time in the ICU (5.5 compared to 11 days), and were intubated for a shorter period of time (2 versus 3.8 days) (see table 1). After adjusting for age, sex, BMI, incision type (sternotomy or thoracotomy), and pre-operative opioid use, patients with epidurals used less opioids on post-operative days 1 and 3, but slightly more opioids on day 2. <h3>Conclusion</h3> TEA is associated with improved outcomes in lung transplants via sternotomy, including reduced ICU stay and reduced length of mechanical ventilation. Secondarily, it appears that there is a trend towards lower opioid use in the epidural group, though this was not significant. We plan to further analyze these relationships by conducting a randomized trial where patients are assigned to either epidural or current standard of care preoperatively.