Procedures Suitable for Epidural Analgesia
Thoracic Epidurals in Trauma Patients
Risks and Benefits of Epidurals
Anticoagulation Guidelines for Epidurals
Procedures Suitable for Epidural Analgesia
Cardiothoracic • Thoracotomy (unless for empyema) • Lobectomy, wedge resection, rib resection, open lung biopsy • Esophagogastrectomy • Median sternotomy (non-cardiac) • AAA repair (check anticoagulation plan, etc.) Orthopedic • Total knee replacement (consider femoral nerve block infusion) • Total hip replacement • Above the knee amputation General Surgery • Laparotomy (check if …
Thoracic Epidurals in Trauma Patients
Indications Rib fractures (3 or more ribs) Patient lightly sedated but arousable. Riker Scale of 3-4. Patient awake if on mechanical ventilation Inadequate pain control despite adequate dose of systemic opioids Adverse effects from systemic opioids given in adequate amounts Consult request from a trauma service physician with adequate knowledge of all pertinent patient details …
Risks and Benefits of Epidurals
Technical Side Effects Failure of proper placement One-sided analgesia Temporary back soreness Headache from accidental dural puncture Side Effects from Local Anesthetics Excessive motor block Excessive sensory block, numbness Hypotension Systemic effects due to intravascular injection Allergic reaction to drug Side Effects from Opioids Itching Sedation Respiratory depression Nausea & vomiting Dizziness Urinary …
Epidural Procedure Overview
1. Know the landmarks Most prominent spinous process in neck = C7 Inferior angle of the scapulae = T7 Level of the iliac crest = body of L4 Line connecting posterior superior iliac spine = S2 posterior foramina. 2. Determine the needle approach The midline approach can be used at any level, but as …
Thoracic Epidural Procedure
Indications: Thoracic surgeries, upper abdominal surgeries Patient Position: Sitting or lateral decubitus position Paramedian Approach: The spinous processes of T4 through T9 are sufficiently angulated to make the midline approach more difficult. A paramedian approach to the epidural space is preferred in this area of the thoracic spine. The needle (skin) insertion …
Lumbar Epidural Procedure
Patient Position: Sitting or lateral decubitus position Midline Approach: 1. Identify the desired lumbar interspace (usually L3-L4 or L4-L5 level). 2. Create a skin wheal with local anesthetic. 3. Introduce the touhy needle and advance slightly cephalad into the midline ligamentous structure (average depth of 4 cm in adult). 4. Connect the syringe to …
Epidural Management
The APS resident is responsible for the quality and safety of epidural analgesia around the clock. See separate section of the website for trouble-shooting the epidural infusion. The APS team will round on the epidural patient daily and will document the assessment and plan of care using the APS Procedure Note. Discontinuing …
Epidural Troubleshooting
Distressful Pain Assess pain intensity at rest and with activity using the 0-10 pain scale. Check tubing connections and epidural site for leakage or catheter migration. Bolus with local anesthetic. Wait 10 min. at bedside, then check BP/relief. • For thoracic usually 3-5 ml (X2). • For lumbar usually 5-10ml (X2). • If concerned epidural …
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