Anaesthetists Handbook - MEDICAL EDUCATION at University ...

IndicationsEpidural anaesthesia and analgesia• Laparotomy for any reason• Midline vertical abdominal incision for any reason• Total knee replacement• Revision of total hip / knee• Nephrectomy• Cystectomy• Thoracotomy• Amputation of lower limb• Multiple rib fracturesIdeally the epidural should be sited preoperatively and its functionchecked before the operation commences.The epidural should be placed at an appropriate vertebral level i.e.thoracic epidural for abdominal incisions. The use of lumbar cathetersfor abdominal procedures is associated with a high failure rate.Ideally epidurals should be sited with the patient awake to reduce thepossibility of nerve or spinal cord damage.Awake insertion allows the anaesthetist to check the epidural prior toinduction and avoids the difficulty of a single anaesthetist monitoringan unconscious patient whilst also performing an epidural.Some anaesthetists and patients, however, prefer epidural insertionto be carried out once the patient is asleep.Management of hypotensionHypotension may be defined as an unacceptable reduction in systolicor mean arterial blood pressure. This is usually a fall of over 20%from preoperative values or systolic pressure below the levelexpected for the age and condition of the patient.The most common cause of hypotension in a surgical patient with anepidural is hypovolaemia. However, the local anaesthetic used in theepidural infusion can cause vasodilatation which can benefit thepatient by improving blood flow to anastomoses / grafts and reducingAnaesthetists Handbook January 2010 129