3. Epidural Placement Flashcards
what is the 1% lidocaine in the epidural kit for?
drawn up in 3mL syringe used for skin wheel
what is in the test dose lidocaine?
1.5% lidocaine and epi 1:200,000
what is the test dose lidocaine drawn up in?
20mL syringe
what is the test dose of lidocaine used for?
initial bolus of epidural local anesthetic right after the catheter is placed.
what is the purpose of the test dose?
to make sure the catheter isn’t in:
intrathecal
intravascular
how can you diagnose that the catheter is intrathecal?
immediate numbing of the legs
profound sympathectomy
how can you diagnose that the catheter is intravascular
immediate increase in HR and BP
tinnitus, metallic taste, numbness in mouth
what is the glass syringe used for?
(saline and air) loss of resistance technique when attached to the tuohy needle
what is an alternative to the glass loss of resistance syringe
plastic syringe with only air in it
what is the benefit of using saline in your loss of resistance syringe?
you can see the air bubble compressing in the syringe
what is the disadvantage for using saline in the loss of resistance syringe?
harder to diagnose a wet tap because the saline coming out of tuohy may be mistaken for CSF
If you do wet tap what will the CSF most likely do?
spray out of the tuohy needle
what is false loss of resistance
can be felt when off midline and enters paraspinous muscles
how do you know if it was a false loss of resistancE?
because you will have difficulty threading the epidural catheter
what is the cc amount of test dose?
5mL
what is a withdrawal filter
attached to syringe prior to drawing up local, filters out glass particles
what is the alternative to the withdrawal filter?
filter needle
what can you use if you forget to use a filter needle on the local?
injectate filter
attachef onto syringe
what syringe do you draw up the 1% lidocaine?
3mL syringe with 18ga (purple) needle
what needle do you use to inject the 1% lidocaine for the skin wheel?
25ga needle (blue)
what is the 22ga (grey) needle used for?
trick question, we don’t know
could be used as alternative to the skin wheel local
where do you put your needles on the epidural tray?
stick needles into the needle holder (red and has styroform inside)
prevents from recapping needle
what is the name and gauge of the epidural needle
tuohy needle
17ga
what is the tuohy needle used for
attached to loss of resistance needle to find epidural space
the catheter is threaded through this needle
how long is the tuohy needle?
11cm
how many cm markings does the tuohy needle have?
8cm
what detail of the tuohy needle decreases the chance of dural puncture?
the tip of the needle is curved
what way should the bevel be pointed at?
upward
what does left hand do during epidural?
placed against pts back and advances the needle
what does the right hand do during epidural?
hold pressure on loss of resistance needle
why do you only advance the needle with the left hand?
advancing with only one hand decreases the likelihood of wet tap
what is the first thick mark on the epidural catheter?
5cm from distal tip
what are the two consecutive thick marks on the epidural catheter?
10cm from distal tip
what is the thick black bar on the epidural catheter?
11cm AND 12 cm from the distal tip
what are the three consecutive thick marks on the epidural catheter?
15cm away from distal tip
what piece allows the catheter to be hooked up to an infusion pump?
snaplock adapter attached at proximal end of catheter
how much of the catheter should be in the epidural space?
5cm
problem with threading catheter <5cm
more likely to pull out and stop working
problem with threading catheter >5cm
increased likelihood of one sided block
when the catheter is to the ___cm mark at the hub of the tuohy then it will be 5cm in the epidural space?
16cm
how do you determine how fas the tuohy needle has been inserted?
look at the portion sticking out and count backward from 8
what is the average depth from the skin to the epidural space?
4.5-5.5cm
what is the range the depth from the skin to the epidural space could be?
3-9cm
if the tuohy needle has been removed can the catheter be advanced further into the epidural space?
no
only withdrawn
if the epidural space was 3cm deep what should the catheter read at the skin>?
8cm at the skin
should you remove the catheter while it is still threaded through the tuohy? why or why not?
no because it could potentially shear off some of the catheter into the epidural space
why should you insert the catheter further than the 16cm mark at the hub?
because when pulling the tuohy out it has the tendency to come out slightly, it ensures that 5cm are still in the epidural space
what is the angle of the tuohy needle insertion for lumbar epidurals?
perpendicular
because the spinous processes are perpendicular to the skin
what is the angle of the tuohy needle insertion for the thoracic epidurals?
slightly cephalad
because the spinous process are slightly slanted downward in the thoracic region
what do you do if you apirate blood from the epidural catheter?
withdrawn 1cm, flushed and aspirated again
repeated (if necessary) as long as 3cm remain in epidural space
which is the easiest approach? midline or paramedian?
midline
paramedian approach
bigger interspaces but more advanced approach
taylor approach
paramedian approach at L4-L5
what approach offers the largest interspace possible?
taylor approach
what are the two main complications with epidurals?
unintentional intrathecal administration (high spinal) unilateral block (catheter inserted too far)
how can a unilateral epidural block be treated?
withdrawing catheter 1-2cm
patient lay on side that hurts
remove catheter and start over
steps to epidural placement (19)
- Open the kit
- Drop a plastic syringe (optional) and 2 sterile tegaderm on the field
- Put on sterile gloves
- Prep the patient
- Apply the sterile drape
- Draw up everything while waiting for the betadine to dry
- Wipe off the betadine with gauze at the area of needle insertion
- Make a skin wheel with 1% lidocaine
- Insert the Tuohy needle to ≈ 3cm mark
- Connect the glass or plastic LOR syringe to the Tuohy needle
- Guide the Tuohy needle into the epidural space with the loss of resistance technique
- Remove the loss of resistance syringe
- Insert the epidural catheter to the 16cm mark at the Hub of the Tuohy needle
- Remove the Tuohy needle from the patient’s back
- Pull the catheter back to the appropriate marking at the skin
- Attach the epidural “snaplock adapter”
- Give test dose through the injectate filter after properly aspirating
- Secure the epidural catheter against the patient’s back with tegaderm
- Throw the epidural catheter over the patient’s should and allow the nurse to connect the catheter to the epidural pump
