Chapter 111

Epidural or intrathecal injection of local anesthetic with or without opioid can control postoperative pain. Lumbar epidural placement can be used for postoperative pain control following major abdominal, pelvic, or lower extremity surgeries. Epidural medication can also be introduced via a catheter through the sacrococcygeal membrane using a caudal technique for groin, pelvic, or lower extremity surgeries. Thoracic epidurals can be used to control pain after thoracic surgery, upper and lower abdominal surgery, and after multiple rib fractures. Useful landmarks to help approximate the puncture site are the C7 spinous process, the scapular spine (T3), and the inferior border of the scapula (T7).

Epidural analgesia has been shown to decrease the incidence of venous and pulmonary thromboembolism, limit cardiac complications due to increased coronary blood flow, and improve myocardial oxygen balance. Epidural analgesia reduces the incidence of postoperative pneumonia, atelectasis, and respiratory depression. Patients also require less parenteral opioids, which decrease the risk of postoperative ileus and results in earlier return of gastrointestinal function.

Patients are frequently placed on anticoagulation while in the hospital for thromboprophylaxis. It is always important to document when a patient last received anticoagulation as there is a possible risk of neuraxial hematoma. The American Society of Regional Anesthesia and Pain Medicine’s guidelines summarize the anticoagulation status and when to safely perform or discontinue neuraxial blockade.

Vasoconstrictors, such as epinephrine, can be added to the local anesthetic injectate. They help to decrease the uptake of the local anesthetic, thereby increasing the duration and density of the blockade.

Opioids can also be added to local anesthetic or can be the sole agent used for pain control. The most commonly used opioids are morphine and fentanyl. The time of onset and duration of action relates to an opioids’ lipid ...

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