Epidural, Esophagectomy, and a Stiff Chest on Day Three
A 63-year-old man (82 kg, 178 cm) is on day three after an Ivor–Lewis esophagectomy and was reintubated yesterday for aspiration. Current settings: volume control, tidal volume 420 mL, PEEP 10 cmH₂O, FiO₂ 0.60, respiratory rate 24. Arterial blood gas: pH 7.28, PaCO₂ 52 mmHg, PaO₂ 76 mmHg, lactate 2.6 mmol/L. Airway pressure plateau is 30 cmH₂O. He is on norepinephrine 0.08 mcg/kg/min, urine output 0.4 mL/kg/h, and has a thoracic epidural infusing bupivacaine 0.125% with fentanyl at 6 mL/h. Chest radiograph shows right lower lobe consolidation and patchy left-sided infiltrates. Temperature 38.4°C. The surgeon wants to know when the tracheal tube can come out and whether the epidural should be stopped because 'it is dropping his pressure.'
1. Is this ventilator strategy adequate? State what you would change, if anything, with the numbers you need to justify the decision.
Read the worked answer
First, normalize the numbers. Predicted body weight for 178 cm is about 73 kg, so 420 mL is roughly 5.7 mL/kg - within the accepted 6 mL/kg range. Driving pressure is plateau minus PEEP = 30 − 10 = 20 cmH₂O, which is higher than the 15 cmH₂O threshold associated with better outcomes in ARDS. The PaO₂/FiO₂ ratio is roughly 127, consistent with moderate ARDS.
What to do
- The problem is not the tidal volume; it is the driving pressure and the PEEP level. Measure a PEEP titration: if raising PEEP to 12–14 lowers driving pressure and improves compliance and oxygenation without raising plateau above 30, that is beneficial recruitment.
- If raising PEEP raises plateau and lowers compliance, you are overdistending; stay at 10 and accept the gas.
- Permissive hypercapnia is acceptable here (pH 7.28 is tolerable in a patient without raised intracranial pressure), so do not chase the CO₂ with a higher respiratory rate - at 24 breaths/min with a stiff chest, auto-PEEP is already likely and will worsen the hypotension you are attributing to the epidural.
- Check the actual measured total PEEP with an expiratory hold before making any changes.
The fixed right lower lobe consolidation suggests aspiration rather than diffusely recruitable lung; bronchoscopy and suctioning may buy more oxygenation than any ventilator manipulation.
2. The surgeon blames the epidural for the hypotension. How do you evaluate that claim, and what do you do with the epidural?
Read the worked answer
Do not accept or reject the claim on assertion - test it.
An epidural infusing bupivacaine 0.125% with fentanyl at 6 mL/h covering T5–T9 will lower SVR and can contribute to hypotension. But this patient also has fever, lactate 2.6, oliguria, and a new infiltrate, which raises sepsis or anastomotic leak as the more dangerous explanation.
Assessment sequence
- Check the sensory level and lower-limb motor power; a level above T4 or new leg weakness means the infusion is too high or the catheter has migrated.
- Review the coagulation profile and platelet count and examine the back, because a neuraxial hematoma is rare but catastrophic.
- Examine drain fluid - a pleural drain with high amylase or creatinine suggests an anastomotic leak and should trigger CT imaging and surgical discussion, not a change in analgesia.
- A fluid challenge plus a vasopressor trial distinguishes hypovolemia and vasoplegia from a purely neuraxial effect.
Decision: do not abandon the epidural reflexively. Thoracotomy analgesia improves cough, secretion clearance, and respiratory mechanics, which is exactly what this patient needs in order to be extubated. Reduce the bupivacaine concentration (for example to 0.0625–0.1%) or drop the local anesthetic and run fentanyl alone; if hypotension resolves with that change, the epidural was indeed contributory, and you have preserved analgesia. Stop it only if there is a neuraxial complication, coagulopathy, or refractory hypotension with a clear temporal link.
3. What is your answer to 'when can the tube come out,' and what would you do if he is still intubated on day seven?
Read the worked answer
Not today. A daily sedation interruption and spontaneous breathing trial are appropriate, but extubation requires more than a passing gas exchange criterion: he needs an effective cough, manageable secretions, a secure airway given yesterday's aspiration, and hemodynamic stability off escalating vasopressors. Fever, lactate, and driving pressure of 20 all argue for continuing to treat the underlying process first.
Daily readiness bundle
- Sedation holiday, sitting up, and spontaneous breathing trials with rapid shallow breathing index and cuff-leak assessment.
- Nutrition and fluid balance review; cumulative positive balance worsens oxygenation.
- Speech and swallow evaluation before any oral intake, because aspiration was the reason for reintubation.
If still ventilated on day seven, discuss tracheostomy rather than letting the decision drift. The evidence does not support routine very early tracheostomy, but prolonged translaryngeal intubation in a patient with a fresh esophagogastric anastomosis and weak cough carries its own risks. A predicted prolonged course, sedation requirements, and secretion burden are reasonable triggers for a shared decision with the family and the surgical team, framed around mobilization, sedation reduction, and earlier participation in recovery rather than around a single landmark trial.