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Epidural - General Comments

• Optimal distance to thread: 3-5 cm into epidural space
• Before placing dressing, have the patient straighten back and stretch. This may draw the catheter deeper beneath the skin. If patients move after dressing placed, catheter will instead be pulled out of the epidural space.
• Use adhesive (Mastisol) prior to placing Tegaderm dressing. Consider placing a small, sterile gauze adjacent to the puncture site, to absorb moisture.
• Avoid any air pockets under dressing
• Secure edges of Tegaderm with 1 inch paper tape.
• Make sure to screw the Luer-lock connector onto the catheter as tightly as possible. Secure the catheter in a way to minimize traction at the connector (e.g., tape a loop of the catheter to the connector).
• Make sure the correct filter (0.20 micrometer sterilizing filter) is attached to the connector.

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Epidural - Adult
 

Incision	Epid Lvl	Bolus	Gtt cc/hr
Thoracic	T4-6	6-8	6-8
Upper abd	T6-8	6-8	6-8
Lower abd, pelvic	T8-10	8-12	8-12
Lower ext	L1-4	12-20	8-12

Duramorph Dose (mg)

Age (yr)	Lumbar	Thoracic
20-60	3-4	2-3
>60	2-2.5	1.5-3

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Epidural - Pediatric

Depth to space (mm) = 10 + 2age
Volume = 0.05 cc/kg/segment
Meds:
-Fentanyl 2mcg/Bupiv 0.1%
-MSO4/Bupiv
Max Doses: MSO4 = 8 mcg/kg/hr
      Bupiv = 0.4-0.5 mg/kg/hr
    (0.2 if age <6mo)

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Epidural - OB

"Fred's Brew"
=Bupiv 0.04%, Fent 1.7mcg/cc, Epi 1:600K

Mix:
Bupiv 0.25% 10cc
Epi 100mcg
Fentanyl 100mcg (2cc)
Pres free NS 48cc

Use:
Test with lido 1% 3cc
Bolus 5cc Brew x 3
Start gtt 15cc/hr

PCEA
Bupiv 0.125% with 2 µg/ml fentanyl
5 ml dose, 15-30 min lockout
Basal 6-10 ml/hr

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Epidurals - Infection

-Mild redness, no purulence: dressing changes with betadine swab, abx oint
-Purulence or signif local tenderness: d/c cath, culture tip and swab of site; follow q4hr neuro + temp checks; d/w surg; consider iv abx
-Deep infxn (signif back pain, severely infected site, new fever, neurologic changes): neurosurg consult, ?ID consult, MRI to r/o epidural abscess

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