Pediatric Atlas of Ultrasound and Nerve Stimulation-Guided Regional Anesthesia
Editors: Tsui, Suresh
Publisher: Springer
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Most anesthesiologists find the paramedian approach to be the most effective technique for thoracic epidural placement. This technique involves the following steps (Fig. 5):
- Insert the epidural needle 0.5–2 cm (e.g., one to two finger-breadths distance) lateral to the spinous process of the vertebra. Note: Use the patient’s finger as measurement of the distance lateral to the spinous process.
- Advance the needle perpendicular to the skin until it contacts the lamina.
- Redirect the needle approximately 15° medially to “walk off” the lamina.
- Angle the needle cephalad, and continue the “walk off” technique to locate the epidural space.
Note: As shown in Fig. 6, steps 2 and 3 must be performed separately, as the epidural space may be missed if the needle is “walked off” diagonally (i.e., medial and cephalad angulation at the same time).
Fig. 5 Paramedian approach for thoracic epidural placement in a spine model. (Top) Insert needle lateral to spinous process and perpendicular to the skin to contact the lamina. (Middle) Redirect the needle approximately 15° medially to “walk off” the lamina. (Bottom) Angulate the needle cephalad while maintaining needle 15° medially, and continue to “walk off” to reach the epidural space.
Fig. 6 Common mistakes: with simultaneous medial and cephalad angulation, the epidural space may be missed as the needle is “walked off” diagonally onto the spinous process or lamina of the spinal level above.
Pediatric Atlas of Ultrasound and Nerve Stimulation-Guided Regional Anesthesia
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