Assemble equipment for epidural placement.
Explain procedure and reassure patient. Sedation as appropriate.
Patient positioning is critical for successful placement. Instruct the patient to round his/her back to facilitate epidural placement.
A. Assemble equipment for epidural including saline for loss of resistance syringe and local anesthetic for skin wheal. B.The patient should be instructed to sit with his/her back rounded in order to open the spaces between the spinous processes to facilitate epidural catheter placement.
The back should be sterile prepped widely around L4-5 interspace.
Place sterile drape. With sterile technique, palpate L4 spinous process (level of iliac crests). Inject local anesthetic wheal in the interspace.
C. The back should be widely sterile prepped with sterile prep solution. D. The L4 spinous process should be palpated (level with the top of the iliac crests) and a small local anesthetic wheal injected in the L4-5 interspace. Local anesthetic can be infiltrated deeper through the skin wheal. 2% lidocaine can be used.
LUMBAR EPIDURAL CATHETER PLACEMENT
The Tuohy epidural needle should be inserted midline.
Once the Tuohy is seated into interspinous ligament (1 to 2 cm), remove stylet.
E. The Tuohy needle should be inserted perpendicular to the back, midline, through the L4-5 interspace. F. Once the Tuohy needle has passed subcutaneous tissues and is firmly seated in ligament (a “crunching” sensation is felt), the stylet can be removed.
A saline-filled loss of resistance (LOR) syringe should be attached to the Tuohyneedle.
Apply gentle constant pressure to the plunger as the Tuohy needle is advanced through ligament by the non-dominant hand.
As ligamentum flavum is encountered an increase in resistance may be felt, followed by a sudden LOR. Stop.
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