Analgesia Placement & Perioperative Management
Pisini: May 2014
Thoracic epidural placement
Landmarks are used to approximate the puncture site to
the intended segment
- Prominent C7 spinous process
- Scapular spine (T3)
- Inferior border of the scapula (T7)
- Iliac crest L4
Recommended placement for specific surgical procedure
Because of the extreme caudad angulation of the
thoracic spinous processes, a conventional midline approach to the thoracic
epidural space can be difficult.
A paramedian approach is highly recommended to place
the needle consistently at thoracic epidural segments above T11.
Schematic of thoracic
epidural catheter placement using transverse and posterior views of drawings of
the thoracic spine.
Hustead (or Tuohy) needle with the bevel directed cephalad is introduced
perpendicular to the anesthetized skin approximately 1 cm lateral to the spinous
process of the targeted segment and advanced until the ipsilateral lamina or
medial transverse process is contacted. If lamina is not contacted, avoid
advancing the needle laterally, which will place the needle in the
paravertebral space. Note the needle depth to the lamina (A). Withdraw
the needle back to skin (B). Readvance the needle slightly medially
without a change in cephalocaudad direction (C).With
advancement, lamina again should be contacted (D). Slight medial
revisions of the needle are performed until the needle contacts bone at a
slightly more superficial (_2–5 mm) depth than the original depth (A)
of the lateral lamina. This suggests the epidural needle tip is midline at the
junction of the lamina and spinous process. If the needle contacts bone much
shallower than the original depth of the lateral lamina (1 cm or greater), it
is likely the needle has contacted the posterior part of the spinous process
and the angle is too medial. If this is the case, the needle should be
withdrawn and repositioned slightly more lateral. After the correct medial
angle is determined, the needle is withdrawn and advanced with the same medial
angle but in small increments cephalad to the same depth as in D (E).
If bone is contacted, direct the needle slightly more cephalad and advance. If
bone is no longer contacted and the depth exceeds the depth previously noted,
the epidural needle stilette is removed and loss-of-resistance technique is
Thoracic Epidural Analgesia in Acute Pain
2011; 115:181– 8 184 S. C. Manion and T. J. Brennan
Epidural needle/catheter markings
Epidural placement note
- Length (cm) epidural catheter threaded into space
- Catheter marking (cm) at the skin
Epidural test dose prior to induction
test dose 3cc of 1.5% lido with epi.
documenting a sensory level prior to induction.
StatLock Stabilization Devices
- From a safety point, these improve the visibility of the
verification process for Bag/Dose/Tubing documentation.
- Reduces infection risk by keeping the catheter connector in a
- Minimizes catheter disconnects
- Reduces possible catheter displacement by securing the catheter to
the patient and decreasing chance of entanglement.
management: This is variable and
often case specific, dependent on individual patient hemodynamic status. Options include:
- Intraop epidural bolus: consider 4-6cc of
- Preferable to maintain continuous infusion of
bupivacaine 0.125% or 0.25% intraop at 6-10cc/hr.
- For inadequate analgesia in PACU, recommend 3-4cc
bupivacaine 0.25% to establish a sensory block. Consider epidural bolus of Fentanyl
50-100mcg, depending on patient age/respiratory status.
Trouble shooting possible non-functioning epidural
- Establish sensory block: if no evidence of
sensory block, consider bolusing 3cc 2% lidocaine. Replace if no level or
- Unilateral block: Recommend bolus, if not
resolved then consider withdrawing catheter 1-2 cm and rebolus. Replace if no bilateral level or
- Nonsegmental block: Bolus and increase rate to
maximum 10cc/hr. If motor
weakness, poor pain control or hemodynamic issues, replace catheter.
- Epiduralgram: consider if very difficult
placement or pediatric catheter
- Whenever epidural is bolused (non PACU/SCU
patient), you must remain with patient for 20 minutes with hemodynamic monitoring.
- Following new epidural placement or replacement of
an epidural (non PACU/SCU patient), you are responsible for initiating the
epidural infusion prior to transfer back to the floor (MMC hospital
- The preferred, standard mode for
epidural delivery is PCEA with Hydromorphone 10mcg/ml and bupivacaine
0.125%. Rate ranges from 4-10ml/hr
with demand of 2mls every 20 minutes and 1 hour limit 20mls
- Recommend increasing bupivacaine concentration
if pain control is inadequate despite documented block
- Do not
increase PCEA rate above 10ml/hr
- No other opioids should be ordered while infusing
Chronic opioid tolerant patient
- May consider epidural infusion with standard
solution (Hydromorphone 10mg/ml and Bupivacaine 0.125% or 0.25%) and
addition of low dose IV PCA (discuss with attending first). Patient should have ONE demand
mode (button), PCEA or PCA.
- Thoracic epidurals in very select cases.
- Segmental catheter, ideally tested prior to
- One pump will run 0.0625% bupivacaine 4-6ml/hr
- Second pump will run Hydromorphone 10mcg/ml at
4ml/hr as a PCEA
- Use trifurcated (yellow) extension set (in
- If hypotension is an issue, the bupivacaine will
be held and the patient will receive the Hydromorphone PCEA only
- Discontinue the epidural and start PO analgesics
when the chest tube is removed.
- It is anticipated that the epidural will be out
by POD 3-5
- PO analgesics will be written by APMS
Local anesthetic only epidural with IV PCA
- In rare or special circumstances it might be
preferable to separate the opioid/LA mixture.
- In this situation the epidural will run with
straight bupivacaine (up to 14cc/hr) and IV PCA (see order set for
recommended dosing parameters)
- Discuss with attending prior to instituting this
Adjunct: Epidural clonidine: In opioid tolerant patients and
pediatric population consider augmenting pain relief by adding clonidine.
- Pediatric patients:
0.5-1mcg/kg bolus (see order set for recommended
continuous infusions). Discuss with attending.
- Adult patients:
consider adding clonidine 0.4mcg/ml to epidural solution (need to use
epidural builder/custom order set).
Discuss with attending.
Trouble shooting mechanical/pump problems
- Distal occlusion/air in line – Most of the
time, this is associated with hanging new bag. Air enters the epidural (yellow)
tubing and collects in the epidural filter. The epidural filter is non air eliminating. Instruct nursing to disconnect the
epidural tubing at the filter, apply a sterile red cap to the epidural
catheter and then purge the epidural tubing allowing the epidural filter
to clear the air. You may need
to replace the epidural filter if this fails.
- If pump continues to alarm “distal occlusion”,
try replacing the epidural connector.
Next step would be to visually inspect the epidural catheter
looking for a “kink” in the catheter.
- Catheter disconnect – instruct nursing to
wrap the epidural catheter in sterile gauze (our order set contains this
instruction). You will
need to bring a new clamp style connector and epidural filter with
you. Instruct nursing to
obtain new epidural tubing (possible infection risk). Clean the epidural catheter with betadine, cut with sterile scissors (obtain
disposable sterile suture removal tray) apply new epidural
connector and filter. Resume
infusion. If it is unknown how
long the epidural catheter has been disconnected, most likely remove the
epidural catheter due to potential infection risk (discuss with attending).
May need to replace epidural.
- Leaking – Most pediatric epidurals have
leaking at the insertion site.
See patient to ensure that the epidural is in (check placement note
for marking at skin). Leaking
does not mean inadequate analgesia.
Adult epidural catheters rarely leak. Again see the patient and check the
epidural site to ensure that the epidural is in. May need to replace epidural if
displaced. Discuss with