low thoracic epidural

[caligas]

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I am in a practice where I am required to do thoracic epidurals a few times a year for things like rib fractures or the rare open AAA. For me its not enough to stay slick. A colleague suggest simply doing low thoracic midline placement, which is not much different than a lumbar epidural, and thread the cath up higher and use dilaudid for improved spread. Any thoughts on this stategy? I suppose it might be of limited value for a higher rib fracture.

 

[GasEmDee]

It's not a reliable strategy if you are too far from the incision. The catheter frequently curls up around the level of needle placement. You'd have to use a high volume of local. Best thing is to have catheter placement at a level concordant with the incision.

Here's one strategy: Practice doing a paramedian technique at the lumbar level for your regular epidurals. You start with the needle slightly lateral, off midline, and below the space between the spinous processes. You then insert the needle, hit the transverse process, and then redirect the needle cephalad and medial until you find ligamentum flavum.

When it comes time to do thoracic epidurals, u can do the same approach, but because the thoracic vertebra are shorter, you start less below the space, and you angle less cephalad. I find this approach very reliable. In addition, the ligamentum flavum is thicker paramedian, so the likelihood of dural puncture is lower. Good luck!