Clearly it's better to do them awake... while under GA you loose your best monitor. But what about that post gastric bypass panniculectomy or ex-lap that turns into a huge incision in the patient that could benefit from an epidural vs. pca? I do them all the time in peds (epi under ga) but rarely in adults. What is the standard (if any) in private practice? Preemptive epidural based on surgeons that are likely to make a bigger whack? Or.. wait until they wake up in the pacu and then place it- academic style? Do you have the time to do that when you are running 3-4 rooms?