QUEEN’S UNIVERSITY

DEPARTMENT OF ANESTHESIOLOGY

SUBJECT: Epidural Catheter placement for post-operative pain management

NUMBER PAGE 1 of 6 ORIGINAL ISSUE 2003 10 01 REVIEW REVISION

Recommendation:

Level	Surgical Procedure/Site of Injury
T 6-7	Thoracic procedures; Rib fractures
T 7-8	Thoracoabdominal procedures ( 2 incisions)
T 7-8; T 8-9	Upper abdominal procedures; Nephrectomy;
T9-10	Mid and lower abdominal procedures
T10-11	AP resection; Pelvic pouch procedure

Landmarking

• Mark the level before prepping and draping - non-transparent drapes may make more difficult when applied – the area of epidural placement should be properly draped with the window of the drape over the interspace for placement;
• Helpful landmarks to find:
• T1 most prominent spinous process - mark every spinous process below to desired level - most reliable approach;
• T7 spinous process is located in projection of the line connecting lower scapular angles – note: it is possible to miscalculate one level up or down

Starting Epidural Analgesia: hints and tips from APMS

• If present with 3mL test dose, note bilateral epidural block prior to induction – if there is concern regarding placement, a proven bilateral block is helpful

• Bolus in OR prior to incision with 3-5ml of 0.25% bupivacaine (or local anesthetic of choice).

IF HEMODYNAMICALLY STABLE; NO MAJOR BLOOD LOSS IS ANTICIPATED; NOT SIGNIFICANTLY HYPOVOLEMIC ETC.

• Repeat as tolerated by hemodynamic status
• Start epidural solution at planned infusion rate.

• If the patient is unstable, but the use of epidural is desirable – give a bolus of hydromorphone 5-10 mcg/kg epidurally (usual dose 5mcg/kg).
• Anticipate and treat itching and nausea.
• Patients with Crohn's disease/Ulcerative colitis use higher concentration of local Bupivacaine 0.2% + 10-20mcg/ml of hydromorphone (stocked by pharmacy and available by request).
• If you suspect the epidural is not working in OR, hold SC heparin until assessed by APMS in the PAR. APMS will re-evaluate the placement and fix or replace the catheter.

Things to Remember

1. Epidural catheters should be placed in the middle of the dermatomes affected by surgery;
2. Small incisions do not necessarily prevent severe visceral pain;
3. Most centers recommend epidural analgesia for lower abdominal surgeries, except for uncomplicated simple hysterectomy and prostatectomy;
4. Thoracic epidurals should have no more than 5-7 cm and lumbar epidurals no more than 3-5 cm of catheter in the epidural space;
5. IT IS ALWAYS A GOOD AND SAFE PRACTICE TO TREAT EVERY BOLUS OF LOCAL ANESTHETIC AS A TEST DOSE:

FIRST GIVE 3ML WITH EPI 1:200 000 MIX: EVALUATE FOR INTRAVASCULAR TIP OF THE CATHETER LOCATION/MIGRATION, INTRATHECAL TIP OF THE CATHETER LOCATION/MIGRATION.

IF NO SIGNS OF TACHYCARDIA (INTRAVASCULAR) OR SPINAL

( INTRATHECAL) AFTER 3ML, GIVE THE REST OF THE DESIRED DOSE.

Note: b-blockers can mask tachycardia.

Documentation of Epidural Placement

The following points must be covered when documenting the placement of any epidural/paravertebral catheter:

• Needle type and size
• Patient position during placement
• Level of catheter placement
• Technique used to find space
• Depth of epidural space in centimeters
• CSF/Blood on placement and # of attempts
• Level of block to ice with test dose/ loading dose
• Depth catheter threaded to skin and taped
• Paresthesias

Sample charting:

Please note: this information is essential for use by the APMS/on call staff in troubleshooting epidural/paravertebral analgesic problems

Epidural Troubleshooting Guide

Problem	Possible Cause	Action
Pump alarming “High Pressure”	Tubing or catheter kinked	Ensure tubing straight - follow tubing from pump to patient. Restart pump/attempt bolus
	Spike not fully in solution bag	Push spike into bag. Restart pump/attempt bolus
	Cassette not fully latched	Clamp tubing – unlock and unlatch cassette – re-latch cassette and lock pump. Restart pump/ attempt bolus
	Filter clogged	Change filter and restart pump/attempt bolus
	Catheter kinked inside blue and black connector	Aseptically remove and reapply connector. Restart pump/attempt bolus
	Catheter kinked under dressing	CHECK PTT/INR, PLATELET COUNT, LAST DOSE OF ANTI-COAGULANT (check Medication Record and with RN – timing as per ASRA guidelines). Untape Catheter to skin and check for kinks. Pull catheter back 1-2 cm. Retape, restart pump/attempt bolus.
	Unknown	Attempt bolus with 3-5 mL syringe – turn patient on side and attempt bolus.
	Catheter out	Check Anesthetic Record for original placement. If catheter is obviously out of the epidural space, remove the rest of the way.
	Cannot be fixed!	CHECK PTT/INR, PLATELET COUNT, LAST DOSE OF ANTI-COAGULANT (check Medication Record and with RN – timing as per ASRA guidelines). Hold anti-coagulants and leave APMS day staff to remove catheter
Unilateral sensory block	Catheter migrated through nerve root foramina/ too much catheter in space	CHECK PTT/INR, PLATELET COUNT, LAST DOSE OF ANTI-COAGULANT (check MAR and with RN – timing as per ASRA guidelines). Remove dressing and withdraw catheter to leave 2-3 cm in space and retape. Note: following catheter manipulation, it is advisable to treat the first bolus as a test dose – the addition of epinephrine (1:200,000) and monitoring of heart rate may be required. Bolus epidural with Bupivacaine .25% if hemodynamically stable – may need to be immediately available for 20-30 minutes.
Poor block coverage	Inadequate block size	Bolus epidural with 5-7 mL pump solution and increase rate.
	Adequate sensory block but inadequate density	Bolus epidural with 5-7 mL bupivacaine .25%. If positive response to bolus, change solution to bupivacaine 2 mg/mL & hydromorphone 10 mcg/mL
	Prior chronic opioid use	Change epidural solution to bupivacaine 1 mg/mL & hydromorphone 20 mcg/mL
Patient confusion/ hallucinations/ significant pruritus or nausea/ drowsiness	Opioid sensitivity/ dose too high	Decrease epidural infusion rate if block surplus to requirements or change solution to bupivacaine 1.25 mg/mL at same rate.
Hemodynamic Instability	Presence of sympathectomy a problem	If no contraindications to fluid bolus, give 500-1000mL crystalloid to compensate for the sympathectomy. Change epidural solution to hydromorphone 20 mcg/mL or 40 mcg/mL at 2-3 mL/hr and titrate to effect.
Lower Extremity Motor Block	Catheter placed in low thoracic or lumbar region/ block size too large ** high alert for signs of hematoma – see below	T11 and lower – high incidence of motor block Ø Stop infusion until block begins to recede – must be some movement on motor block in first hour to rule out developing hematoma – if suspicious see “Risk for hematoma” below Ø Q1H neuro-checks until receded Ø Once receded – decrease rate or change to PCEA or, if bupivacaine > .1% change to bupivacaine .1% Ø Consider changing to opioid only if motor block troublesome and catheter essential
Risk for epidural abscess Ø Neutropenic Ø And CRF Ø Elderly Ø Febrile/bacteremic/ septicemia Ø Diabetes Mellitus	Presence of new back pain +/- neurological deficits, superficial skin infection, fever, nuchal rigidity, unexplained septic state	CHECK PTT/INR, PLATELET COUNT, LAST DOSE OF ANTI-COAGULANT (check MAR and with RN – timing as per ASRA guidelines). Aspirate catheter with 3cc syringe – send aspirate for C&S. Remove catheter – send tip for C&S. Inform patient of suspected problem! Arrange MRI/ immediate neurosurgical consult, neurovital signs and long term anti-biotic therapy.
Risk for epidural hematoma Ø Diabetes Ø Elderly Ø CRF Ø Concomitant use of dalteparin, IV heparin, coumadin Ø ITP	Presence of new back pain +/- neurological deficits	Stop epidural infusion. CHECK PTT/INR, PLATELET COUNT, LAST DOSE OF ANTI-COAGULANT (check MAR and with RN – timing as per ASRA guidelines). Stop anti-coagulants if necessary and reverse if possible. Aspirate as much blood as possible from catheter with 3cc syringe. Arrange immediate neurosurgical consult and MRI. Note: permanent neurological damage may occur if not drained in 8 hours

Continuous Peripheral Regional Block Troubleshooting Guide

Problem	Possible cause	Action
Pain/ no sensory block despite bolus	Catheter no longer near or in sheath	Connect catheter to Stimuplex and stimulate at 5 mAmp – if still stimulating nerve distribution, bolus 10 mL from pump then restart infusion. If cannot confirm with stimulation, bolus with 10 mL bupivacaine 0.5% + epi 1:200,000. If cannot resolve problem, stop infusion and leave catheter for APMS – start PCA-IV or other opioid for pain control.

APMS recommendation for the initiation of femoral blocks, lumbar plexus blocks

Bolus Bupivacaine 0.5% 20-40 mL after catheter placement ( if a GA is planned) or after surgery ( if spinal/epidural anesthesia was used for the case) , then start bupivacaine 0.125% at 8-10 mL/hr not to exceed 0.5 mg/kg/hr. Be advised that boluses doses and infusion rates must be adjusted if more than one block infusion is applied (i.e. bilateral TKA)