Lumbar Epidural Placement

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS
  • Surgical anesthesia and postoperative analgesia
    • Extensive abdominal procedures
    • Lower extremity orthopedic and vascular procedures
    • Gynecologic procedures
    • Cesarean section
    • Urologic procedures
    • Thoracic procedures (if unable to place thoracic epidural)
    • Hernia repair
  • Labor analgesia
    • Labor
    • Instrument-assisted deliveries
    • Episiotomy repairs
  • Analgesia for chronic lumbar back pain
    • Steroid injections
    • Local anesthetic injections
CONTRAINDICATIONS
  • Absolute contraindications
    • Patient refusal
    • Antiplatelet dysfunction or therapy except aspirin
      • Clodiprogrel
      • HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome
      • Idiopathic thrombocytopenic purpura, Thrombotic thrombocytopenic purpura (ITP, TTP)
    • Anticoagulation
      • IV heparin, 6 hours
      • Prophylactic low-molecular-weight heparin 12 hours
      • Therapeutic low-molecular-weight heparin, 24 hours
      • Coumadin, 5 days or a normal prothrombin time (PT), and international normalized ratio (INR)
      • Stigmata of anticoagulation
        • Petechiae, bleeding from IV site, bruising
      • Any pathologic anticoagulated state
        • Sepsis
        • Uremia
    • Meningitis
    • Localized skin or soft tissue infection
  • Relative contraindications, which may be overlooked in cases where the benefits of analgesia via a lumbar epidural outweigh the risks associated with its placement and use
    • Previous back surgery, back pain, or instrumentation
    • Uncorrected hypovolemia
    • Increased intracranial pressure
    • Anatomic abnormalities involving the spine and spinal cord (e.g., spina bifida, spinal stenosis, severe lumbar scoliosis)
    • Platelet counts <100,000, except in:
      • The parturient
      • Difficult airway
      • Severe cardiovascular disease
  • Presence of neurologic disease, such as multiple sclerosis, or infectious disease, such as HIV infection without central nervous system involvement, is often cited as an absolute contraindication to epidural analgesia. But the prevailing evidence is that lumbar epidural analgesia can be safely delivered in such circumstances.
EQUIPMENT

(Note: Equipment and technique for midline approach using a Tuohy needle are described here. For more information regarding paramedian approach, see Thoracic Epidural Placement: Paramedian Approach. For further information regarding Crawford needles and general information regarding epidural techniques, see Thoracic Epidural: Midline Approach.)

  • Sterile gloves, gown, cap, and eye protection
  • Epidural kit
    • Betadine prep tray
    • Sterile drape
    • 22- and 19-gauge needles for local anesthetic infiltration
    • 1% lidocaine for infiltration
    • 18-gauge Touhy needle with stylet
    • Slip syringe for loss of resistance
    • Sterile saline (for syringe)
    • Epidural catheter with Luer-lock connector
    • 1.5% lidocaine with 1:200,000 epinephrine test dose
    • Bio-occlusive dressing
ANATOMY

The epidural space is a potential space existing between the dura mater and the periosteum that lines the inner aspect of the vertebral canal. The space extends from the foramen magnum to the sacral hiatus. Anterior and posterior nerve roots within a dural cuff traverse the epidural space, uniting inside the intervertebral foramen to form segmental nerves. The anterior border consists of the posterior longitudinal ligament. The space is bordered laterally by the periosteum covering the vertebral pedicles and the intervertebral foramina, and the posterior border consists of the periosteum of the anterior surface of the lamina and articular processes, their connecting ligaments, the interlaminar spaces occupied by the ligamentum flavum, and periosteum covering the spinal roots. The epidural space contains fatty tissue and a large venous plexus.


The epidural space may be segmented and in addition, age-related changes may explain differences in the spread of local anesthetic injected into the epidural space (e.g., higher spread for the same dose of anesthetic as age increases). The presence of a dorsomedian band (the plica mediana dorsalis) in the midline of the epidural space and the possible presence of septa in the epidural space may provide an explanation for nonuniform spread of local anesthetics resulting in a unilateral or “patchy” block.


PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Label the catheter as “epidural.”
  • Before introducing a bolus through the catheter, aspirate using the syringe while watching for blood or CSF in the catheter
  • Monitor routine vital signs in the post anesthesia care unit and watch for signs of possible common side effects of epidural therapeutic agents.
    • Changes in mental , hypotension and urinary retention.
    • Epidural narcotic side effects such as late respiratory depression, nausea, vomiting, and urinary retention. Assess respiratory rate and function every 1 to 2 hours for at least 24 hours after administration.
  • Assess block height periodically whenever an indwelling epidural catheter is in place, and for at least the first day after removal of an epidural catheter. Signs of epidural hematoma or abscess formation include the following:
    • Failure of sensory or motor block to recede within a time frame consistent with the pharmacokinetics of the local anesthetic used
    • Progression of apparent sensory or motor blockade without addition of local anesthetic, with or without the presence of back pain
    • These are indications for IMMEDIATE assessment for possible mass effect in the epidural space with computerized tomographic scanning or magnetic resonance imaging and EMERGENCY surgical decompression if hematoma or abscess is present. 
  • Monitor body temperature as an early warning sign of infection.
  • Inspect the insertion site daily
  • Inspect the catheter tip upon removal to confirm complete retrieval.
  • Before removal of the epidural catheter, ensure that the patient is not coagulopathic, either because of systemic illness or administration of anticoagulant drugs.
COMPLICATIONS
  • Common complications
    • Kinking of the catheter
    • Blockage or obstruction of the catheter
    • Hypotension
    • Urinary retention
  • Infrequent complications, both minor and severe
    • Minor bleeding
    • Intravascular catheter placement
    • Dural puncture with either needle or catheter
    • Post–dural puncture headache
    • Backache
    • Intrathecal catheter placement
    • Inadequate or “patchy” block
    • Paresthesia during catheter advancement
    • Respiratory depression with opioid delivery into the epidural space
    • Pruritus, nausea, or vomiting
    • Delayed local anesthetic toxicity
    • Respiratory functional compromise due to motor block of thoracic segments
    • Bradycardia due to block of cardiac accelerator fibers
    • Retained epidural catheter or catheter fragment
  • Serious and rare complications
    • Unintended high epidural block or total spinal anesthesia
    • Epidural hematoma
    • Epidural abscess or infection
    • Spinal cord injury
    • Anterior spinal artery syndrome
    • Arachnoiditis or transverse myelitis
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