Quick Facts

Indications

Epidural blocks are indicated for various surgical procedures and pain management:

• Cesarean section
• Thoracic surgery
• Abdominal surgery
• Lower limb surgery
• Post-operative pain control
• Analgesia for traumatic injury
  • Rib fractures
  • Pelvic fractures
  • Lower extremity fractures

Absolute Contraindications

• Patient refusal
• Allergy to local anesthetic
• Infection at the site of placement
• Elevated intracranial pressure
• Severe coagulopathy
• Severe aortic stenosis
• Pre-existing spinal cord damage

Relative Contraindications

• History of spinal surgery
• Aortic stenosis
• Anticoagulants
• Certain neurological disorders
• Inability to maintain position for procedure

Procedure

Technique [add video]

1. Apply monitors (SpO₂ and NIBP)
2. Assist patient in sitting neuraxial position
3. Position patient on the side of the bed, rounding the back out in a “mad cat” or “shrimp” position
4. Locate iliac crests and palpate vertebral interspaces
5. Mark the intended insertion site (often L3–4 or L4–5)
6. Prepare for procedure:
   • Using sterile technique, open the epidural kit on the mayo stand or epidural cart
   • Apply sterile gloves
   • Clean the back with sterile betadine solution (allow drying time)
   • Draw up 3 ml of 1% lidocaine and attach a 25g needle
   • Draw up 5 ml of test dose
   • Draw up saline into the loss of resistance syringe, leaving a bubble of airSaline is not necessary, but will prevent pneumocephalus if air is accidentally injected into the spinal space
   • Place a sterile drape with an opening around the block placement site

Block placement

1. Perform a local anesthetic skin wheel (with about 2 ml of 2% lidocaine) at the block placement site
2. Introduce the Tuohy needle (initially 2.5–3 cm deep, possibly more with high BMI patients)
3. Remove the stylet from the Tuohy needle
4. Attach the loss of resistance syringe
5. Advance slightly cephalad (depth will depend on patient size)
   Typically, “loss of resistance” occurs around 3–9 cm, depending on the patient’s size
6. Always brace your left hand on the patient’s back to secure the needle position
7. Keep continuous pressure on the LOR syringe as you slowly advance through the layers of tissue:
   • Subcutaneous tissue
   • Supraspinous ligament
   • Intraspinous ligament
   • Ligamentum flavum “pop” *This is where we feel “loss of resistance”
8. Once you feel the “pop” of the ligamentum flavum, do not advance any further as you are now in the epidural space
9. The epidural space is considered a potential space; it will open with the injection of fluid
10. Consider injecting the remaining saline from the LOR syringe to open the space
11. Remove the LOR syringe, keeping the back of your left hand braced against the patient’s back while holding the Tuohy needle in place

DETERMINING DEPTH OF EPIDURAL SPACE

1. Take note of the remaining cm marks on the needle
2. Subtract the number of remaining cm’s (outside the skin) from 9 cm (total length of the Tuohy) to determine the cm depth of the epidural space
3. Insert and advance the epidural catheter through the Tuohy needle, feeding it 3–5 cm past the depth of the Tuohy

TEST DOSING

1. Carefully remove the Tuohy needle while keeping the catheter in place
2. Attach an alligator clamp to the catheter
3. Aspirate to assess for any blood or CSF in the catheter (if either is present, remove the catheter and start over at another level)
4. Administer 2 cc of test dose [1.5% Lidocaine/1:200,000 epinephrine] and observe for signs of intravascular or subdural injection
5. If no signs of intravascular or subdural injection are observed, proceed with the loading dose
6. The loading dose is usually 5–10 cc of epidural infusion solution
   • Depends on patient factors, labor status, height, provider preference
7. Assist the patient into the supine position (with left uterine displacement if pregnant)

Confirmation Steps

• If the test dose is intravascular, the patient will experience tinnitus, a metallic taste in the mouth (effects of the local anesthetic), and increased HR and BP (effects of the epinephrine)
• If the test dose is subdural, the patient will experience extreme heaviness and immobility in the lower extremities
• Within a few minutes of the test dose, the patient may notice a warm/tingling sensation in their legs, as though they are “falling asleep.” This is a good sign that the epidural is working
• After 30 minutes, the epidural level should be at the level of the umbilicus (T10)
• “Testing” of the epidural level may be accomplished with a cold object such as an alcohol swab or ice cube
• Epidurals work by gravity, so side-lying positions will cause the medication to bathe the nerves on the dependent side

Documentation Requirements

• Epidural kit lot number and expiration date
• Sterile measures taken
• Patient position during and after block placement
• Level of block placement
• Number of attempts
• Needle types used
• Level of sensory blockade obtained
• Any complications

Quick Resources

References