- 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
- 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
- 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.
(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
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.
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Figure 1
:
Equipment pack showing plastic sterile drape, sterile prep solution, and tray containing from left to right: preservative-free saline, loss-of-resistance syringe, sterile 5-mL syringe, lidocaine 1.5% with epinephrine, 1% lidocaine for subcutaneous infiltration, 20-mL syringe, injection needles, Luer-lock adapter for the epidural catheter, 5-mL syringe, and 18-gauge Tuohy epidural needle with stylet in place.
Figure 2
:
Tuohy epidural needle and stylet. From Miller RD: Miller’s Anesthesia, 6th ed, Philadelphia, Elsevier, 2005, p 1666.
Figure 3
:
Epidural catheter.
Figure 4
:
Luer-lock adapter for the epidural catheter.
Figure 5
:
Anatomy of the spinal cord. From Miller RD: Miller’s Anesthesia, 6th ed, Philadelphia, Elsevier, 2005, p 1655.
Figure 6
:
Contents of the epidural space. From Miller RD: Miller’s Anesthesia, 6th ed, Philadelphia, Elsevier, 2005, p 1655.
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