Guidelines for
Thoracic Epidural Analgesia Placement & Perioperative Management

Pisini: May 2014



Thoracic epidural placement



Landmarks are used to approximate the puncture site to the intended segment



Recommended placement for specific surgical procedure




Because of the extreme caudad angulation of the thoracic spinous processes, a conventional midline approach to the thoracic epidural space can be difficult.


A paramedian approach is highly recommended to place the needle consistently at thoracic epidural segments above T11.


Paramedian Approach




Schematic of thoracic epidural catheter placement using transverse and posterior views of drawings of the thoracic spine. Hustead (or Tuohy) needle with the bevel directed cephalad is introduced perpendicular to the anesthetized skin approximately 1 cm lateral to the spinous process of the targeted segment and advanced until the ipsilateral lamina or medial transverse process is contacted. If lamina is not contacted, avoid advancing the needle laterally, which will place the needle in the paravertebral space. Note the needle depth to the lamina (A). Withdraw the needle back to skin (B). Readvance the needle slightly medially without a change in cephalocaudad direction (C).With advancement, lamina again should be contacted (D). Slight medial revisions of the needle are performed until the needle contacts bone at a slightly more superficial (_2–5 mm) depth than the original depth (A) of the lateral lamina. This suggests the epidural needle tip is midline at the junction of the lamina and spinous process. If the needle contacts bone much shallower than the original depth of the lateral lamina (1 cm or greater), it is likely the needle has contacted the posterior part of the spinous process and the angle is too medial. If this is the case, the needle should be withdrawn and repositioned slightly more lateral. After the correct medial angle is determined, the needle is withdrawn and advanced with the same medial angle but in small increments cephalad to the same depth as in D (E). If bone is contacted, direct the needle slightly more cephalad and advance. If bone is no longer contacted and the depth exceeds the depth previously noted, the epidural needle stilette is removed and loss-of-resistance technique is begun (F).


Thoracic Epidural Analgesia in Acute Pain Medicine

Anesthesiology 2011; 115:181– 8 184 S. C. Manion and T. J. Brennan






Epidural needle/catheter markings




Epidural placement note



Epidural test dose prior to induction

Š       Recommend max test dose 3cc of 1.5% lido with epi.

Š       Recommend documenting a sensory level prior to induction.






StatLock Stabilization Devices





 Perioperative management:  This is variable and often case specific, dependent on individual patient hemodynamic status.  Options include:


Trouble shooting possible non-functioning epidural


Epidural Infusion




Chronic opioid tolerant patient


Dr. Weigel




Local anesthetic only epidural with IV PCA



Adjunct: Epidural clonidine:  In opioid tolerant patients and pediatric population consider augmenting pain relief by adding clonidine. 



Trouble shooting mechanical/pump problems