Overview
Epidural anesthesia involves the injection of local anesthetic and/or opioids into the epidural space, which is the potential space between the ligamentum flavum and the dura mater. This provides analgesia and anesthesia for various surgical procedures and labor pain management.
Epidural anesthesia is a cornerstone of regional anesthesia practice, providing excellent pain control for labor, post-operative analgesia, and surgical anesthesia. It offers advantages over general anesthesia including reduced opioid requirements, better post-operative outcomes, and preservation of consciousness.
Learn more in our comprehensive RxDx Anesthesia Course
Indications
Pain relief during childbirth and delivery
Surgical anesthesia for cesarean delivery
Analgesia after major abdominal, thoracic, or orthopedic surgery
Management of chronic pain conditions
Analgesia for thoracic procedures
Anesthesia for lower extremity procedures
Analgesia for vascular procedures
Pain management in trauma patients
Contraindications
Absolute Contraindications
Relative Contraindications
📋 Equipment Checklist
Check off items as you gather them:
Pre-procedure Preparation
Preparation includes patient assessment (coagulation status, spine anatomy, neurological examination), equipment check (epidural kit, monitoring), informed consent, and understanding the anatomy of the epidural space and surrounding structures.Step-by-Step Procedure
Step 1: Patient Assessment
Assess patient for contraindications, perform neurological examination, check coagulation status, and obtain informed consent. Position patient in sitting or lateral position.
⚠️ Common Mistakes to Avoid:
- Inadequate assessment
- Missing contraindications
- Poor positioning
💡 Pro Tip:
Always check coagulation status and perform thorough neurological examination before procedure.
Step 2: Equipment Preparation
Prepare epidural kit, check all equipment, draw up local anesthetic, prepare loss of resistance syringe with saline or air.
⚠️ Common Mistakes to Avoid:
- Incomplete equipment check
- Wrong local anesthetic concentration
- Air embolism risk
💡 Pro Tip:
Use saline for loss of resistance to avoid air embolism. Check all equipment before starting.
Step 3: Sterile Technique
Perform sterile preparation with antiseptic solution, drape the area, and maintain strict aseptic technique throughout the procedure.
⚠️ Common Mistakes to Avoid:
- Inadequate sterile technique
- Poor skin preparation
- Contamination
💡 Pro Tip:
Maintain strict aseptic technique to prevent epidural abscess or meningitis.
Step 4: Needle Insertion
Insert Touhy needle through skin, subcutaneous tissue, and ligaments until loss of resistance is felt at the ligamentum flavum.
⚠️ Common Mistakes to Avoid:
- Wrong needle angle
- Too deep insertion
- Poor loss of resistance technique
💡 Pro Tip:
Use loss of resistance technique carefully. The epidural space is typically 4-6 cm from skin.
Step 5: Epidural Space Identification
Identify epidural space using loss of resistance technique. Confirm with negative aspiration for blood and CSF.
⚠️ Common Mistakes to Avoid:
- False loss of resistance
- Dural puncture
- Vascular puncture
💡 Pro Tip:
Always aspirate before injection. If blood or CSF is aspirated, do not inject local anesthetic.
Step 6: Catheter Insertion
Insert epidural catheter 3-5 cm into epidural space, secure catheter, and test dose with local anesthetic.
⚠️ Common Mistakes to Avoid:
- Catheter too deep
- Poor catheter securing
- No test dose
💡 Pro Tip:
Always give a test dose (3ml lidocaine 2% with epinephrine) to detect intrathecal or intravascular placement.
Step 7: Test Dose and Monitoring
Administer test dose, monitor for signs of intrathecal or intravascular injection, and begin continuous monitoring.
⚠️ Common Mistakes to Avoid:
- Skipping test dose
- Inadequate monitoring
- Ignoring warning signs
💡 Pro Tip:
Monitor for 5 minutes after test dose. Signs of intrathecal injection include rapid motor block and hypotension.
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Post-procedure Care
Post-procedure care includes monitoring for complications (hypotension, respiratory depression, neurological deficits), assessment of block level, management of side effects, and documentation of the procedure details.Complications & Management
| Complication | Incidence | Signs | Management | Prevention |
|---|---|---|---|---|
| Dural puncture | 1-2% | CSF flow, post-dural puncture headache, rapid motor block | Remove needle, consider intrathecal catheter, treat headache | Careful technique, proper needle positioning, avoid deep insertion |
| Epidural hematoma | <0.01% | Severe back pain, neurological deficits, bowel/bladder dysfunction | Emergency MRI, neurosurgical consultation, decompression | Check coagulation status, avoid in anticoagulated patients |
| Epidural abscess | <0.01% | Back pain, fever, neurological deficits, elevated WBC | Antibiotics, MRI, surgical drainage if needed | Strict aseptic technique, proper skin preparation |
| Hypotension | 10-30% | Decreased blood pressure, dizziness, nausea | IV fluids, vasopressors, Trendelenburg position | Preload with IV fluids, monitor blood pressure closely |
| Incomplete block | 5-15% | Patchy anesthesia, inadequate pain relief | Reposition catheter, supplement with local anesthetic | Proper catheter placement, adequate local anesthetic dose |
| Catheter migration | 3-8% | Loss of analgesia, catheter dislodgement | Replace catheter, secure properly | Proper catheter securing, adequate insertion depth |
Clinical Pearls
Always check coagulation status before epidural placement - safety first.
Use loss of resistance technique carefully - the epidural space is small.
Always give a test dose - it can prevent serious complications.
Monitor for complications continuously - especially in the first 24 hours.
Document procedure details including level, complications, and catheter position.
Practice sterile technique religiously - epidural abscess is devastating.
Be prepared for dural puncture - have a plan for post-dural puncture headache.
Check catheter position regularly - migration can occur during surgery.
Use appropriate local anesthetic concentration - higher concentration for surgery, lower for analgesia.
Epidural analgesia improves post-operative outcomes significantly.