Epidural

Question 1

Lobectomy using thoracic epidural, now has hypotension, bradycardia, desaturation (SpO 2 92%), upper limb parasthesia, oliguria

Differentials?

Why patient having bradycardia?

Management plan?

Factors affecting epidural efficiency?

Answer 1

1. High epidural block
2. Distributive shock 2 ry to epidural
3. Paralysis of intercostal muscles
4. Paralysis of diaphragm
5. Hemothorax or pneumothorax
6. Post-operative hypovolemic shock

High epidural block → blocking of the cardioaccelerator fibres (sympathetic fibres) from T1-T5 → unopposed parasympathetic action of the vagus nerve

• Call the operating consultant and anesthesia consultant
• Sit the patient upright
• 100% O2
• Stop any injections in the epidural catheter
• Rule out any concomitant hypovolemic shock
• Epinephrine, phenylephrine, metaraminol (inotropic agents)
• Atropine (chronotropic agent)

• Level of injection
• Dosage
• Type of medications
• Vasoconstrictors
• Posture
• Age, height, weight

Question 2

what are the medication used in epidural?

Why epidural in this case?

Alternative to epidural in this case?

How to test the level of the block?

What else besides ice packs?

Why we use temperature sensation?

Why temperature not pin-prink?

Answer 2

• local anesthetics like lidocaine and bupivacaine with an opioid like fentanyl

• Longer surgery(Early mobilization).
• Post-operative analgesia (Pain relief for longer periods)
• Improves outcomes (Decrease neurohormonal stress response)
Improved cough reflex and improves recovery

Catheter
Epidural space
Spinal cord
# Intercostal nerve block (ICNB)

Using temperature sensation (ice packs)

Ethyl chloride spray
Pain and temperature nerve fibers are similarly affected by local anesthetic drug

so change in temperature perception indicate the area where epidural is working.
Because of the arrangements of fibers, the motor fibers are the last to be affected

Painful, bleeding, possible infection

Question 3

How to differentiate high epidural block from hypovolemic shock?

Systemic effects of Epidural analgesia?

Who would you involve besides anaesthetist?

What signs and symptoms would tell you patient is getting worse?

Answer 3

Epidural
• Warm and pink peripheries (due to vasodilatation)
• Bradycardia

Hypovolemia
• Cold, clammy peripheries

• Tachycardia

• Hypotension: due to block of the sympathetic outflow causing peripheral vasodilatation
• Reduced CO due to a reduction in the VR
• Attenuation of the surgical stress response
• Reduction of FRC
• Reduction of post-operative DVT: due to a number of causes including the concomitant use of IV fluids used to support the arterial pressure.

Operating consultant

• ↓ BP
• ↓ HR
• ↓ O 2 Saturation
• Paresthesia
• Oliguria