Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content ++Figure 122-1. Choice of Epidural NeedleGraphic Jump LocationView Full Size||Download Slide (.ppt)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.++Table Graphic Jump Location|Download (.pdf)|PrintChoice of LocationLocation of surgeryLevel of epidural placementThoracicT4–8Upper abdomenT6–8Middle abdomenT7–10Lower abdomenT8–11Lower extremityL2–4++Table Graphic Jump Location|Download (.pdf)|PrintLocal AnestheticsAgent1Concentration (%)OnsetSensory blockMotor blockChloroprocaine23Fast2FastAnalgesicDenseMild to moderateDenseLidocaine≤11.52IntermediateIntermediateIntermediateAnalgesicDenseDenseMinimalMild to moderateDenseMepivacaine12–3IntermediateIntermediateAnalgesicDenseMinimalDenseBupivacaine≤0.250.50.75Slow3SlowSlowAnalgesicDenseDenseMinimalMild to moderateModerate to denseRopivacaine0.20.50.75–1SlowSlowSlowAnalgesicDenseDenseMinimalMild to moderateModerate 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.++Table Graphic Jump Location|Download (.pdf)|PrintEpidural AdjuvantsAdjuvant1DoseOnset (min)Peak (min)Duration (h)Comments/side effectsFentanyl50–100 μg5–1010–201–3Itching; nausea; urinary retention; sedation; ileus; respiratory depression (delayed with morphine—↓ dose with elderly or sleep apnea)Morphine2–5 mg15–3060–904–24Hydromorphone0.75–1.5 mg20–3020–301–3Epinephrine1:200,000Prolongs nerve exposure to local anestheticClonidine150–400 μgHypotension; prolonged sensory blockSodium bicarbonate1 mEq/10 mL of local anestheticHastens block onset with lidocaine, mepivacaine, chloroprocaine. Will precipitate with bupivacaine1Opioids 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 salineAdvance needle with stylet through skin into interspinous ligamentResistance should be feltRemove stylet; attach glass syringe with 2–3 mL air or salineAdvance millimeter by millimeter until loss of resistance feltThread catheter 3–5 cm into epidural space Deep catheters prone to kinking/coilingSuperficial catheters may dislodgeIf difficulty finding epidural space, attempt to “walk off” bone or try a different level and/or approachIf 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 directionAvoid injecting local anesthetic onto nerves or cord!One to ... Your Access profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth