INDICATIONS

1. ▪ Postop: thoracotomy, laparotomy, procedures on hips and lower extremities

2. ▪ Acute: chest & lower extremity trauma, sickle cell crisis

3. ▪ Chronic: regional pain syndrome of lower extremities, pain from malignancy

PRE-PROCEDURAL ASSESSMENT

1. ▪ Contraindications: history of bleeding disorder, spine abnormalities, previous spine surgery

2. ▪ Informed consent

3. ▪ Check for kyphoscoliosis or infection at sight of intended epidural placement.

4. ▪ Detailed neurological exam to detect preexisting neuro deficits

PROCEDURAL MANAGEMENT

1. ▪ Usually performe dunder general anesthesia in lateral decubitus position with adequate monitoring; if awake, sitting position may be used

2. ▪ Caudal approach in neonate and young in fants; direct lumbar or thoracic puncture in older children

3. ▪ Sterile prep and drape; operator wears sterile gloves, hat and mask

4. ▪ Tuohy or Crawford needle, loss of resistance to saline or air

5. ▪ Thread catheter 3–5 cm into epidural space.

6. ▪ Aspirate for CSF or blood, administer test dose: lidocaine with epinephrine 0.1 mL/kg (max 3 mL) to rule out intravascular/intrathecal placement. Look for T wave amplitude elevation, tachycardia, hypertension, lower extremity weakness (conscious pts).

7. ▪ Start epidural infusion in OR. Bolus prior to infusion. Supplement with IV opioids as needed.

8. ▪ Children <8 yrs rarely develop hypotension; treat with fluids and/or vasopressors.

POST-PROCEDURAL CONCERNS

1. ▪ Examine pt for adequacy of sensory block, particularly if complaining of pain.

2. ▪ Bolus with or without increasing hourly infusion rate may be used to improve analgesia.

3. ▪ Monitor cardiorespiratory parameters and pain scores on regular schedule.

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