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Background and Aims Primary failure of thoracic epidural (TE) analgesia remains an important clinical challenge as its incidence can exceed 20% in teaching centers.1 Reasons for failure include incorrect primary placement or secondary migration of the catheter. Optimal patient positioning, technical approach, and method used to secure the catheter affect success rate.2 Procedural difficulties may drive anesthesiologists away from an effective and unmatched pain management option. We hypothesize that implementing specific metrics to improve and refine the learning process of in-training anesthesiologists will increase success rate of TE analgesia above 80%.

Methods A metric system including 67 items was developed. The protocol withstood an iterative process, including literature review and feedback from experienced anesthesiologists. The metric system was assessed on trainee anesthesiologists with low procedural experience (less than 50 performed TEs). Type of surgery, level of puncture, number of attempts, immediate complications, compliance with the metrics and failure rates (supervisor taking over or inadequate analgesia in the immediate post-operative period) were documented.

Results A total of 13 TEs were performed for thoracic (46%) or abdominal procedures (54%) and the first attempt of catheter placement was performed at T6-T7 or T9-T10 level, respectively. In five cases, an attempt at another level was conducted. No immediate complications were reported. Adherence to the metrics was deemed satisfactory, with 70% of the checklist being effectively completed. The failure rate was 31%.

Conclusions A metric system for TE can provide a standardized, consistent, readily accessible tool to steep procedural learning curve and reduce failure rates.