Uniport and Multiport Epidural Catheters in Post-surgical Patients
Condition: Post-operative Pain
MeSH terms: Pain, Postoperative
Study type: Interventional

Summary: 
      The investigators hypothesize that multi-port thoracic epidural catheters will provide
      superior pain relief when compared to uniport catheters for post-surgical patients.
    

Detailed description: 
      Epidural analgesia (pain relief) is an effective treatment for post-surgical acute pain. The
      factors that determine the effectiveness of pain relief with epidural analgesia have been
      studied almost exclusively in the lumbar (low back) spaces for obstetrics (childbirth). These
      factors include the design of the epidural catheter, the type and dose of medications, and
      the volume of solution used. One of the important issues specific to the catheter design is
      whether the tip has a one end-hole, or multiple side holes. The number of holes has been
      suggested to affect the spread of epidural anesthetic over time, especially with low volume
      solutions. This has been demonstrated in older, stiffer epidural catheter designs, but has
      not been shown to be true with the newer, flexible epidural catheters.

      The thoracic (upper back) epidural analgesia is widely employed for a many types of surgical
      pain. While the mechanism of pain relief is similar to that in the lumbar space, there may be
      differences between the two sites. Firstly, thoracic catheters tend to use low volume, high
      concentration medication solutions, which likely do not spread as effectively. Secondly, the
      thoracic catheters often need to be used for prolonged periods of time. Whereas the typical
      obstetric epidural is used for less than 12 hours, the post-surgical catheter is typically
      required for one to three days (or more). Finally, the thoracic space is narrow, with a
      thinner thecal sac, which might promote a difference in the spread of epidural solution.

      Thoracic epidural analgesia is routinely used to control post-operative pain for a wide
      variety of surgical procedures. Based on the improved effectiveness of the one end-hole
      flexible epidural catheter in obstetrics, this design is commonly used in thoracic epidural
      analgesia. It has been observed that thoracic epidurals are somewhat less effective after a
      period of time when compared to the effectiveness of labor epidurals. This may be in part due
      to the inappropriate assumption that the thoracic epidural space of a post-surgical patient
      is the same as the lumbar space of a parturient.

      The investigators seek to determine whether there is a difference in the analgesia provided
      by a thoracic multi-port epidural catheter when compared to a thoracic uniport epidural
      catheter as measured by pain scores, medication given for breakthrough pain, and need to add
      intravenous opioids. As mentioned previously, these catheters have been studied extensively
      in laboring patients but there is a striking paucity of literature regarding how anesthetic
      solutions spread in the thoracic epidural spaces of non-pregnant post-surgical patients and
      how this may be affected by catheter type. If the hypothesis is supported by results, it may
      change the practice within the study institution, and possibly, on a much larger scale. This
      study may also provide a foundation for further research into the physiology of the thoracic
      epidural space, how it differs from the lumbar epidural space, and how a medication solution
      spreads within this unique space.
    

Intervention name(s): Epidural catheter
Intervention type(s): Device
Intervention description(s): The intervention is the use of an end-holed epidural catheter or three-holed side port epidural catheter
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Randomized, double-blinded comparison of two epidural catheter designs
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Treatment