Test Out: Epidurals

1. Initial Assessment

• Choose appropriate anesthetic plan: Epidural, spinal, or combined epidural-spinal anesthesia.

• Review H/P

  • Make sure anticoagulation therapy held for appropriate amount of time

  • Check platelet count >85-100k (which can lead to spinal hematoma that then compresses the spinal cord)

  • Other contraindications: infection at site of insertion, DIC, severe aortic stenosis, hemodynamic instability

• Get consent for the procedure and general anesthesia

  • Possible risks: backache, PDPH, spinal hematoma, intrathecal/intravascular injection, conversion to general if patchy/not effective

2. Equipment Check

• Basic machine check with positive pressure check and SCOMMLADIE*******

• Emergency drugs ready: 10 mg ephedrine and 100 mcg phenylephrine

  • ephedrine for hypotension AND bradycardia, or phenylephrine for hypotension AND tachycardia

• 1 L IVF bolus in progress within 15 minutes of procedure start (preloads the patient to prevent spinal induced hypotension)

3. Pt Assessment

• Put on EKG, Blood Pressure, and Pulse Ox to get baseline vital signs.

• Put on fetal monitoring (for obstetric patients)

• Administer O2 and sedation PRN

4. Positioning and Preparation

• Set bed height to a comfortable working level.

• Position the patient with their butt as close to the edge/you as possible, forming a “C” position with neck flexed forward, shoulders relaxed/dropped, lumbar spine pushed out towards you, and iliac crests parallel to the shoulders

• Palpate the superior iliac crests (hip bones) that create Tuffier’s Line.

  • Parallel thumbs should meet to join at the L4 vertebrae, so now walk over it to feel the L3-L4 interspace

  • Be cautious marking the skin, as skin can move while vertebrae do not (false image)

  • If more obese, skin folds can form a divet that guides you to were to insert your needle

• Ensure everyone is wearing a mask and scrub cap

5. Preparation of Equipment

• Place the tray on your dominant side and open it

• Don sterile gloves

• Open the betadine/chloroprep cleaning solution

  • Chloroprep works by friction

  • Betadine works by drying

    • **Go from inner to outer circle, with handle pointed down to prevent dripping of the chloroprep/betadine onto your gloves, which could cause neurotoxicity if introduced into the spine

• Drape the back

6. Kit Preparation

• While cleaning solution dries, prepare your kit supplies in a sequential manner:

  1. Draw up 3 mL 1% Lidocaine with a filter needle in the 3 mL syringe; then switch out to the smallest 22 G needle. Loosen the cap.

  2. Inspect the epidural Touhy needle to confirm the stylet is in place and loosen the cap. The curved tip prevents dural puncture.

     1. This is a 10 cm marked needle. Will lead the epidural catheter into a cephalad direction.

  3. Draw up 2 mL normal saline with a filter needle into the loss of resistance syringe; lay it flat to avoiding liquid exiting the tip. No needle attached.

  4. Prepare a test dose of 3 mL 1.5% Lidocaine with 1:200,000 Epinephrine (5 mcg/mL; total is 45 mg lidocaine and 15 mcg epinephrine) with a filter needle into the largest syringe. No needle attached.

  5. Remove the catheter from its wrapper

7. Procedure

• Blot any excess betadine with a sterile 4x4 gauze (no wiping needed for chloroprep).

• Using the nondominant hand (over the sterile drape), palpate the iliac crest and reconfirm desired site (L3-4 interspace).

• Maintain placement by keeping two fingers or a thumb at the confirmed spot.

• Warn the patient, and then inject the small 3 mL syringe immediately superior to your finger marker and make a good skin wheal in all planes; insert it deeper to function as a seeker needle to confirm you are in the interspace (not meeting bone).

  • Remove but keep the finger marker in place

• ***Instruct the patient to communicate any sensations of paresthesias (electrical shock feeling) and immediately stop if encountered

• They may now feel pressure, but it should not be sharp pain d/t the numbing of previous lidocaine syringe. Into the previously created hole, insert the Touhy needle with the bevel facing up and slightly angled cephalad.

• You will go through the supraspinous ligament then advance until it is seated into the interspinous ligament (there should be NO pop, just a feeling of increased resistance and able to now hold a 90 degree angle without dropping if it is let go)

• Remove the stylet and connect the loss of resistance syringe

• Using a two-hand technique, insert cm by cm until loss of resistance is achieved (using loss of resistance technique)

8. Loss of Resistance and Catheter Placement

• Upon achieving loss of resistance, inject the saline to verify entry into the epidural space and open it up

  • Caution: If uncertain about resistance loss, avoid continuous insertion to reduce risk of postdural headache; just test catheter threading instead

  • ********If appropriate, this is when you would do the spinal part of a combined spinal-epidural procedure

• Notate the depth

  • Measure the depth by counting back from the needle hub and subtracting that number from 10; mentally add 5 cm to determine the depth to mark at skin surface you will need later on.

• Begin threading the catheter in to 15 cm marking at the hub window

  • Advise the patient they may feel a NORMAL brief electric shock as the catheter brushes against nerve roots

  • If resistance is encountered during catheter threading, request the patient to take a deep breath to open up the epidural space.

  • Avoid excessive catheter placement to minimize risk of kinking or knotting.

• Remove the Touhy needle while providing gentle forward pressure to the catheter to ensure it stays at the 15 cm marking upon removal of the needle

  • Do not do this in one large motion, as the end of the catheter will touch a nonsterile part of the bed

• Pull the catheter carefully back to get to the correct depth at skin surface you counted that is needed in a previous step

9. Test Dose

• Insert end of the epidural catheter into the alligator clip and then attach the primed filter

• Check the latest vital signs.

• Attach test dose syringe and aspirate gently; if no CSF or blood is noted, proceed with injection of test dose while vigilantly monitoring for symptoms of intravascular or intrathecal injection.

  • Signs of complications:

    • Intravascular: An increase in heart rate by over 20 BPM within 30-60 seconds of injection and other s/s of LAST (e.g., metallic taste, tinnitus, circomoral numbness); withdraw the catheter and attempt re-insertion at another level if appropriate.

    • Intrathecal (dural puncture): Signs of rapid/severe motor/sensory blockade, cannot use this catheter and attempt re-insertion at another level if appropriate. You have also caused a postdural puncture headache.

• If test dose is negative, then secure catheter to the patients back (downward small loop and then over the shoulder)

• Inject appropriate bolus of LA after aspirating again and adding appropriate adjuvents or starting continuous gtt PRN.

10. Patient Positioning

• Quickly maneuver the patient into the proper position for the necessary block/level

• Check developing level with alcohol swab first at shoulder for comparison, then toes up until desired level is properly blocked

  • autonomic loss first (hypotension, warmth through blocking of B fibers), then sensory (decreased touch/pain through blocking of C/A-delta fibers), then motor/proprioception (through blocking of A-alpha fibers)

11. Safety

• Continue monitoring VSS and maintain CV/airway

• Monitor for symptoms of high spinal block:

  • Includes excess sensory and motor block associated with loss of consciousness, typically occurring within 3 minutes post-local anesthetic injection.

  • Treatment:

    • Initially position patient in a head-down position or flex neck.

    • If symptoms persist, prioritize airway maintenance, possibly requiring intubation, and support circulation with sympathomimetics and IVFs