Tag Archives: epidural

Tunnelled epidural catheter

Additional kit:

Abbocath

Scalpel

18G (‘green’) needle & syringe

 

Procedure:

After insertion of epidural, withdrawn Thouhy by 1-2 cm so that it remains in patient but outside of epidural space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

Apply dressing

Thoracic epidural tips for lateral / GA

– 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

 

Radical Cystectomy Recipe

Issues:

Long/major-op
Laparotomy – usually umbilicus to pubis, may be longer
Potential major blood loss
Anastomoses
Prolonged ileus

Recipe:
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

Dex/paracetamol
Des
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.
Ondansetron
Alternative:
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