Epidurals Flashcards
1
Q
Epidurals
A
Epidurals
- More versatile than spinals
Contraindications:
- Similar to spinal
- Absolute: patient refusal, uncorrected hypovolemia, increased ICP, infection at site
- Relative: coagulopathy, fixed cardiac defect, anatomic abnormalities, unstable neurologic disease
- Controversial: inability to communicate, tattoos, complicated surgery with major blood loss
- Usually at L2-L4
- Can use adult levels after age 8
- Physiological effects similar to spinal
- Below T4
- Vasomotor tone controlled by T5-L1
- Decreased venous return, and subsequent decreased CO
- Vasomotor tone controlled by T5-L1
- Above T4
- T1-T4 cardiac sympathetic fibers
- Profound hypotension and bradycardia
- T1-T4 cardiac sympathetic fibers
- Below T4
- Resp
- Minimal effects in midthoracic region
- Caution with resp compromise
- Resp arrest likely due to sympathectomy and brain and brainstem ischemia
2
Q
Factors Affecting Coverage
A
Factors Affecting Coverage
- Site – segmental block of specific levels
- Concentration
- Lower – sensory
- Higher – may get motor
- Volume: KEY FACTOR
- Adults: 1-2 mL for each level to be blocked
- Lumbar gets more spread cephalad than caudal
- Thoracic even spread up and down
- Adults: 1-2 mL for each level to be blocked
- Position - Not considered a factor
- Age
- Increased age = decreased dose
- Smaller intervertebral foramen?
- Increased age = decreased dose
- Height
- <5’2” use 1mL per level
- >5’2” increase by 0.1mL for each 2 inches
- Other
- Pregnancy and Obesity
- Decreased dose
- Epidural vein engorgement and increased adipose tissue
- Decreased dose
- Pregnancy and Obesity
3
Q
Epidural Numbers
A
Epidural Numbers
4
Q
Redosing
A
Redosing
5
Q
Epidural Tray
A
Epidural Tray
6
Q
Technique
A
Technique
- Same approaches as spinal
- Median
- Paramedian start 1.5-2cm laterally
- Taylor§
- Not the same
- Caudal
7
Q
Epidural Space
A
Epidural Space
- ID epidural space
- Loss of Resistance (LOR)
- Place needle and stylet through supraspinous ligament and into intraspinous ligament
- Remove stylet and attach syringe with air or fluid
- Always secure needle against patient
- 2 ways to proceed
- 1: Alternate very slow advancement and tapping pressure to plunger of syringe until LOR
- 2: Advance needle with continuous pressure on plunger until LOR
- Loss of Resistance (LOR)
- Hanging Drop
- Needle placed as before
- Small amount of fluid placed in needle hub
- Needle advanced until Epidural space encountered
- Drop will suck into needle
- Wha la
- Used mostly for Thoracic
- Ultrasound
- Caudal
- Sacral Hiatus ID’d by Sacral Cornu
- Needle inserted at 45 degree angle
- Distinct POP or snap when through sacrococcygeal membrane
- Lower angle to 160 degrees
- Advance
- Adults no more than 1.5 cm
- Children no more than 0.5 cm
- Aspirate for blood or CSF
- Insert catheter or inject
8
Q
Catheter Placement
A
Catheter Placement
- After epidural space ID
- Note depth on needle
- Place catheter through needle
- Mark for end of needle and resistance
- Advance catheter 5-7 cm more
- Remove needle over catherter
- Withdrawal catheter until 3-5 cm remain in epidural space
- Attach end to catheter
- Aspirate for blood or CSF
- Dressing – clear occlusive
- Test Dose
- 3 mL of 1.5% Lido with 15mcg epi
NEVER WITHDRAW CATHETER THROUGH NEEDLE
9
Q
Dosing
A
Dosing
- ALWAYS ASPIRATE PRIOR TO INJECTION
- Lumbar
- 1-2 mL per segment
- Give in 5 mL increments q 3-5 min
- Thoracic
- 0.7 mL per segment
- 3-6 mL q 30 min
- Caudal
- 3 mL per segment
- Continuous infusion
- 4-15 mL/hr
- Individualize
- Assess continuously
10
Q
Complications
A
Complications
- Hypotension
- Fluid bolus and pressors
- Unilateral block
- Pull catheter back
- Unaffected side down
- Redose
- Replace
- Inadequate block
- Raise head and redose with higher concentration
- Add fentanyl or give 50 mcg
- Questionable quality and need to go to OR
- In OR remove catheter
- Do CSE with new catheter placement
- Dissipating block
- Requires more or doesn’t last
- Check for intravascular placement
- Rebolus with higher concentration and increase rate
- Add opiod
- Minor Back pain
- 20-30% incidence
- Usually self limiting
- NSAIDS, Tylenol, Heat
- PDPH
- Most common in younger female
- Usually expected after wet tap
- Same treatment as before
- Subdural Injection
- Delayed response 10-15 minutes
- Get ready for High spinal
- Subarachnoid injection
- Fast High spinal
- Meningitis
- Non-positional headache, fever, letargy, confusion and classic nuchal rigidity
- Emergent antibiotic therapy
- Head CT, lumbar puncture, neuro consult
- Arachnoiditis
- Also thought to be from adherence of tissue pulling
- Spinal Cord and Nerve Injury
11
Q
Anticoagulation Recommendations
A
Anticoagulation Recommendations
