Epidural Indications and Placement

Lumbar technique

Operations below the umbilicus, such as hernia repairs, cesarean section, gynecologic or urologic procedures, and any lower extremity surgeries

Thoracic technique

Operations on the chest and upper abdomen

Analgesia for trauma, such as rib fractures, flail chest, lower extremity trauma

Contraindications

Patient refusal

Uncorrected hypovolemia

Antiplatelet dysfunction or therapy except aspirin

Meningitis

Infection

Intracranial hypertension

Uncooperative patient

Aortic stenosis/tetralogy of Fallot

Severe hypertrophic cardiomyopathy

Previous back surgery/instrumentation/pain

Sepsis

Spinal cord deformity/tumor

Platelet count <100.000 (except pregnant women)

Difficult airway, cv disease

? HIV/MS, but evidence says ok

Placement

Preload the patient with a minimum of 1 L fluid to prevent hypotension

The distal termination of the spinal cord varies from about the level of the 3rd lumbar vertebrae (L3) in infants to the lower border of L1 in adults.

Prepare patient, obtain consent, and do BP supine before sitting pt up to have a baseline

L3-L4/L4-L5/L5-S1

Use T4 - top of iliac crest as guideline for L4 - L4-L5 space. Palpate for spinal processes.

Have pt round back as mad cat. Patient can be sitting/lateral decubitus.

Wash off the area three times with iodine - let dry

Technical Considerations

Insert wheal with Lidocaine using a 25g needle and then go deeper (5 mL of 1% lidocaine = 10 mg/ml) with a longer needle.

18-gauge Tuohy needle with stylet - a large-bore needle with a rounded end. The cutting bevel is curved off to one side, allowing a catheter to be threaded through the needle to exit in an arc rather than straight out of the tip. 1cm markings on Tuohy needle.

Insert the Tuohy needle between the spinal processes, hold on with both hands and advance slowly until it reaches the interspinous ligament

Remove the stylet, fill a 4 mL syringe with air or saline, attach it to the needle, support with the left hand, and advance/pull back on the syringe plunger until there is a loss of resistance. Easy injection indicates epidural space

Note the depth of the Tuohy needle. Thread epidural catheter through needle 4-6cm past the tip of the needle (add depth to length), inject medication and monitor for adverse effects

If unable to advance the catheter, have the patient take a deep breath as the negative intrathoracic pressure will help

Remove the needle slowly while holding on to the catheter, minimizing the risk of removal

Connect the Luer lock, and aspirate on the catheter to ensure no CSF or blood. Tape the catheter in place

Monitor vital signs. Difficulty breathing may be a sign of high block, and nausea may be a sign of hypotension. ALWAYS draw back prior to administering the medication dose.

Monitor for neurological deficits.

Monitor for late respiratory depression if narcotics are in the epidural. Fentanyl is lipophilic and absorbed quicker compared to morphine, which is hydrophilic and has a long absorption time.

Whitacre and Sprotte needles are “pencil-point” needles that have a rounded noncutting bevel, with a solid tip and the opening of the needle to the side about 2 mm proximal to the tip. They have a better “feel” of the resistance of the subcutaneous tissue and a low incidence of post-dural puncture headache - used for combined epidural/spinal and threaded through Tuohy needle until “pop” felt and CSF is seen.