18G (‘green’) needle & syringe
After insertion of epidural, withdrawn Thouhy by 1-2 cm so that it remains in patient but outside of epidural space
Small nick in skin adjacent to epidural needle, on side of which epidural catheter is to be tunnelled
Local anaesthetic using green needle in subcut plane laterally
Apply a slight curve in abbocath needle
Then local anaesthetic using abbocath
Exit at exit site of epidural catheter. Use plastic tube to apply tension to skin to help this. Do not exit too far away otherwise will struggle with dressing.
Cut off proximal wide part of abbocath
Pass epidural catheter through abbocath
Then remove abbocath
Pull back epidural to correct position
Then pull through tunnel
Glue the two skin incisions
– POSITION WELL
– count up from L2/3 and also down from C7 spinous process (major prominence in neck) to identify level
– if under GA try 3 different spaces before resorting to para-median approach as patient is not awake to be a marker of danger
– maintain thumb of non-needling hand on spinous process above space
– feed epidural to that natural curve tends to take it cephelad
– tunnel catheter (less movement, earlier marker of infection):
- nick in skin prior to needling
- feed 16G gelco sub-dermally in lateral direction approx 5cm
- cut off end obliquely
- pass through catheter without touching skin
- CAREFUL NOT TO CUT EPIDURAL CATHETER
– PM @ LGH
Laparotomy – usually umbilicus to pubis, may be longer
Potential major blood loss
Xmatch 4 units/fluid warmer/cell salvage
Large bore IV
Awake epidural @ T10. Test does 3ml of mix (of 20ml 0.25% levobupivicaine + 100mcg/2ml fentanyl)
GA/ETT ( – 2mcg/ml fentanyl, less propofol)
Asleep art line/CVC +/- CO monitor
Just before KTS: Top-up epidural with 5ml mix/5ml H20/5ml mixRun epidural infusion 0.125% l-bupivicaine + 2mcg/ml fentanyl 4-8ml/hr.
At end bolus 5 ml of epidural infusion.
Run remi intra-op then epidural at end/extubation
Adv: can switch off if major haemorrhage to avoid hypotension
Dis: May be difficult to wean remi->epidural and establish post-op analgesia reliably
Loading dose for analgesia. 15-20ml of 0.1% l-bupivicaine + 2mcg/ml fentanyl. Volume (not concentration/dose) is the key!
Top-up for C-section. 20ml made of 18ml 2% lignocaine, 2ml 8.4% NaHCO3, 0.1ml of 1:1000 adrenaline + 50-100mcg fentanyl.
3mg of diamorphine (in 8ml) towards the end.
If topping up epidural for c-section (cat 2 so time available) then…
– if it just does not work at all. Remove and do full dose spinal, with thoracic wedge to prevent rostral spread
– low height*/patchy. Remove and do CSE with 1-1.5ml in spinal
*try patient on left lateral with trendelenburg