Thoracic Epidural Placement: Paramedian Approach

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS
  • Intraoperative and/or postoperative management of anesthesia and analgesia for operations involving the thorax and upper abdomen
  • Pain control in some types of thoracic trauma, such as rib fractures and flail chest
  • Labor analgesia
CONTRAINDICATIONS
  • Relative contraindications may be overlooked in cases in which the benefits of analgesia via a thoracic epidural (TEP) outweigh the risks associated with its placement and use.
  • Presence of neurologic disease, such as multiple sclerosis, or infectious disease, such as HIV, without central nervous system involvement is often cited as an absolute contraindication to epidural analgesia, but the prevailing evidence is that thoracic epidural analgesia can be safely delivered in such circumstances.
  • Absolute contraindications
    • Patient refusal
    • Coagulopathy
    • Therapeutic anticoagulation
    • Uncorrected hypovolemia
    • Skin infection at insertion site
    • Increased intracranial pressure
    • Thrombocytopenia (platelet count below 50,000/cm3)
  • Relative contraindications
    • Sepsis
    • Anatomic abnormalities of the vertebral column (e.g., spinal stenosis)
    • Neurologic disease (e.g., multiple sclerosis)
    • Uncooperative patient
    • Prophylactic antiplatelet medication or low-dose heparin
    • Thrombocytopenia (platelet count below 100,000/cm3)
    • Anesthesiologist inexperience
EQUIPMENT
  • Standard monitors: ECG, blood pressure cuff, pulse oximeter
  • Resuscitation drugs and equipment: oxygen, bag and mask, suction
  • Patient must have IV access for intravenous fluid and medication delivery.
  • Sterile gloves and mask (some institutions may require a sterile gown)
  • Sterile prep and drape
  • Local anesthetic for epidural injection and for local infiltration of skin and subcutaneous tissues
  • Adjunct epidural injection agents, such as epinephrine, narcotic
  • 3- or 5-mL sterile syringe for local infiltration and anesthetic agent
  • 18-gauge epidural needle (Tuohy or Crawford)
  • Loss-of-resistance syringe, usually 5 mL, plastic or glass
  • 19-gauge epidural catheter
  • Luer-Lok adapter for catheter
  • Preservative-free saline
  • Adhesive label for epidural catheter
  • Sterile dressing
ANATOMY
  • The epidural space is the part of the vertebral canal that is not occupied by the dura mater and its contents. It is a potential space existing between the dura mater and the periosteum that lines the inner aspect of the vertebral canal.
  • The epidural 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, which covers the vertebral bodies, and the intervertebral discs.
  • The epidural space is bordered laterally by the periosteum covering the vertebral pedicles and the intervertebral foramina.
  • The posterior structures defining its borders are the periosteum of the anterior surface of the laminate and articular processes along with their connecting ligaments, the interlaminar spaces occupied by the ligamentum flavum, and the periosteum covering the spinal roots.
  • The epidural space can be rich in venous plexuses and fatty tissue content, which is also continuous with fat present in the paravertebral space.

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
  • Post-procedure care should include clearly labeling the catheter as “epidural.”
  • Monitor the patient in the postanesthesia care unit after surgery for local anesthetic side effects, epidural narcotic side effects, and block height.
  • Monitor temperature periodically in patients with indwelling epidural catheters.
  • Inspect the epidural insertion site daily for signs of infection, bleeding, or dislodgement of the catheter.
  • When the catheter is removed, inspect the tip to confirm that the entire catheter has been removed.
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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