Anesthesiology APPLIED Exam › Regional anesthesia and acute pain

Thoracic epidural analgesia

Regional anesthesia and acute pain·~4 min read· Physician-reviewed✓ Sourced · 3

Stem

A 67-year-old man, 79 kg, with COPD (FEV1 62% predicted) and a 50 pack-year smoking history, is scheduled for a right upper lobectomy through a posterolateral thoracotomy. He takes aspirin 81 mg daily and no other antithrombotic. The surgeon asks for "a good epidural" and a restrictive fluid plan.

Question

How will you provide analgesia for his thoracotomy?

Ideal answer

HeadlineA thoracic epidural, dosed before incision, so he can breathe deeply and cough, because that protects a COPD patient from pulmonary complications.

Offer the epidural, discuss the paravertebral, because both are first-line for open thoracotomy with no clear winner;¹ low-dose aspirin alone does not stop me.
Awake or lightly sedated, paramedian, T5–T7: he can report paresthesia,² the level matches the incision,¹ and the mid-thoracic spinous processes angle steeply.²
Test, then bupivacaine stronger than 0.125%, because weaker solutions are insufficient,¹ with hydromorphone 10 mcg/mL at about 6 mL/h and patient-controlled boluses.
Scheduled acetaminophen and an NSAID, systemic opioids for rescue.¹
Vasopressor, not fluid, for hypotension under one-lung ventilation. Block checked twice daily; if it fails, a paravertebral catheter or erector spinae block; if he is anticoagulated, an erector spinae catheter, as a paravertebral follows neuraxial intervals.³

Breaking down the answer

Paravertebral is an equal alternative — similar analgesia after postoperative day 1, with more stable hemodynamics in the first 24 hours; erector spinae or intercostal blocks are second-line.¹ Less urinary retention. For VATS I usually prefer a paravertebral or erector spinae block.
Placement level — mid-thoracic placement covers the incision with less drug and preserves lower-limb strength and bladder function better than a lumbar catheter.
Awake placement — the cord is directly beneath the needle. Changes if: children, and selected adults who cannot cooperate; I accept placement under general anesthesia.²
Why the pressure falls, and why no fluid — a high thoracic block takes the cardiac sympathetic fibers (T1–T4) and splanchnic tone.² Thoracic surgeons want restriction to avoid post-resection pulmonary edema, classically after pneumonectomy but also after lobectomy.
Opioid in the epidural — hydrophilic hydromorphone spreads over more segments and improves analgesia, but carries delayed respiratory depression, so I avoid parenteral opioids alongside it. PROSPECT advises the lowest effective epidural opioid dose.¹
Benefits — improved FEV1 and cough, earlier mobilization, fewer pulmonary complications; inadequate acute pain control raises the risk of chronic post-thoracotomy pain.¹

Follow-up question

After the right thoracotomy, he is in recovery with pain 9/10 at the anterior end of the incision and a blood pressure of 85/50. What do you do?

Follow-up answer

HeadlineTwo problems, and the dangerous one first: low pressure after thoracotomy is hemorrhage until proven otherwise, and I say so to the surgeon.

I check the chest drain output, hemoglobin and the surgical field with the surgeon, giving a vasopressor while I look. Ice shows T4–T8 on the left only, the wrong side: the catheter has drifted laterally and explains little of his low pressure. I withdraw it 1–2 cm and give a 4–5 mL bolus with the painful right side down. If that fails, I replace it or switch to a paravertebral catheter rather than accept a patient who cannot cough. I tell him the plan and reassess in 30 minutes.

Pitfalls that cost points

Forgetting anticoagulation timing for placement and removal, including the paravertebral, a deep block.³
Treating epidural hypotension with liters of crystalloid in a lung resection patient.

Rapid-fire

Q: Why paramedian at mid-thoracic levels? A: The spinous processes angle most steeply between T4 and T9, so a midline approach is difficult;² paramedian access to the interlaminar space is easier.

Q: Why does a thoracic epidural reduce pulmonary complications? A: Better analgesia improves deep breathing and coughing and reduces splinting, with less opioid-related sedation.

Q: Why is post-pneumonectomy pulmonary edema relevant? A: It is linked to positive fluid balance; the epidural tempts fluid boluses that must be avoided.

Q: What does a high block do to the heart? A: Blocking T1–T4 causes bradycardia and reduced contractility; it also reduces myocardial oxygen demand.

Q: Which systemic adjuncts does PROSPECT advise against after thoracotomy? A: Gabapentinoids, IV ketamine, IV dexmedetomidine, magnesium and IV dexamethasone.¹

Numbers to know

Item	Value
Thoracotomy level	T5–T7, matched to the incision
Infusion	Bupivacaine >0.125%¹ + hydromorphone 10 mcg/mL at 4–8 mL/h
Thoracic dosing	~1 mL per segment
Test dose	Lidocaine 1.5% 3 mL with epinephrine 1:200,000
Cardiac accelerators	T1–T4²

Sources

1.PROSPECT summary recommendations: open thoracotomy (2025 update) · ESRA PROSPECT (Lemoine et al., Anaesthesia), 2026 · esraeurope.orgTEA or PVB first-line with no clear superiority; PVB more hemodynamically stable in the first 24 h; local anesthetic concentration of 0.125% or less appears insufficient.
2.Epidural Anesthesia and Analgesia · NYSORA · nysora.com
3.The risks associated with erector spinae plane block in patients with abnormalities of coagulation · Korean Journal of Anesthesiology (Nair, Seelam), 2019 · europepmc.orgRestates the ASRA 4th-edition rule (Horlocker 2018): perineuraxial, deep plexus or deep peripheral blocks follow the neuraxial anticoagulation guidance. The ASRA 5th edition (Kopp 2025) full text could not be opened.

Facts on this page were checked against these sources on Oct 14, 2026. Guidelines change; confirm doses against current institutional protocols.