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Chapter 122. Surgical Epidural

Toni Torrillo, MD

Figure 122-1. Choice of Epidural Needle
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A blunt, curved tip helps push the dura away and avoid inadvertent puncture. Straight needle facilitates catheter insertion but may increase the incidence of dural puncture. Reproduced from Morgan GE, Mikhail MS, Murray MJ. Clinical Anesthesiology. 4th ed. Figure 16-18. Available at: www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.

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Choice of Location
Location of surgeryLevel of epidural placement
ThoracicT4–8
Upper abdomenT6–8
Middle abdomenT7–10
Lower abdomenT8–11
Lower extremityL2–4
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Local Anesthetics
Agent1Concentration (%)OnsetSensory blockMotor block
Chloroprocaine
  • 2
  • 3
  • Fast2
  • Fast
  • Analgesic
  • Dense
  • Mild to moderate
  • Dense
Lidocaine
  • ≤1
  • 1.5
  • 2
  • Intermediate
  • Intermediate
  • Intermediate
  • Analgesic
  • Dense
  • Dense
  • Minimal
  • Mild to moderate
  • Dense
Mepivacaine
  • 1
  • 2–3
  • Intermediate
  • Intermediate
  • Analgesic
  • Dense
  • Minimal
  • Dense
Bupivacaine
  • ≤0.25
  • 0.5
  • 0.75
  • Slow3
  • Slow
  • Slow
  • Analgesic
  • Dense
  • Dense
  • Minimal
  • Mild to moderate
  • Moderate to dense
Ropivacaine
  • 0.2
  • 0.5
  • 0.75–1
  • Slow
  • Slow
  • Slow
  • Analgesic
  • Dense
  • Dense
  • Minimal
  • Mild to moderate
  • Moderate to dense

Fast and intermediate agents reach maximum block height in 15–20 minutes. Slow agents can take up to 30 minutes for maximum block height to be achieved.

1Always use preservative-free local anesthetic.

2Fast is approximately 5–10 minutes.

3Slow is approximately 15–20 minutes.

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Epidural Adjuvants
Adjuvant1DoseOnset (min)Peak (min)Duration (h)Comments/side effects
Fentanyl50–100 μg5–1010–201–3Itching; nausea; urinary retention; sedation; ileus; respiratory depression (delayed with morphine—↓ dose with elderly or sleep apnea)
Morphine2–5 mg15–3060–904–24
Hydromorphone0.75–1.5 mg20–3020–301–3
Epinephrine1:200,000Prolongs nerve exposure to local anesthetic
Clonidine150–400 μgHypotension; prolonged sensory block
Sodium bicarbonate1 mEq/10 mL of local anestheticHastens block onset with lidocaine, mepivacaine, chloroprocaine. Will precipitate with bupivacaine

1Opioids affect quality more than duration: they prolong the surgical block without significantly delaying recovery. Epinephrine prolongs chloroprocaine, lidocaine, and mepivacaine better than it does bupivacaine and ropivacaine. Peak blood levels of local anesthetic are lower with epinephrine.

Performance:

  • LORA/LORS—loss of resistance to air or saline
  • Advance needle with stylet through skin into interspinous ligament
  • Resistance should be felt
  • Remove stylet; attach glass syringe with 2–3 mL air or saline
  • Advance millimeter by millimeter until loss of resistance felt
  • Thread catheter 3–5 cm into epidural space
    • Deep catheters prone to kinking/coiling
    • Superficial catheters may dislodge
  • If difficulty finding epidural space, attempt to “walk off” bone or try a different level and/or approach
  • If persistent pain or paresthesia on threading catheter or injecting local anesthetic, remove catheter and try a different level. Ask patient which side the pain/paresthesia is and redirect needle in the opposite direction
  • Avoid injecting local anesthetic onto nerves or cord!
  • One to ...

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