Guidelines for Epidural Therapy in the Trauma Patient
Indications
Any patient with flail chest, 3 or more rib fractures resulting in splinting or clinical concern for compromised pulmonary status should be considered for epidural therapy. Page APS at #9031 for a consult request.
Contraindications
- Coagulation:
Placement: For consideration of epidural placement, the patient must have no coagulopathy or thrombocytopenia. They should be off of antiplatelet and anticoagulant medications in accordance with institutional guidelines.1 Maintenance of therapy: Prophylactic anticoagulation must be done in accordance with ASRA guidelines (Lovenox not to exceed 40 mg daily) or heparin 5,000 units BID or TID. 2 Epidural therapy is contraindicated in patients who will need systemic or therapeutic anticoagulation. Removal: epidural removal will be coordinated by the Acute Pain Service (APS). Removal is contraindicated in patients with thrombocytopenia.
- Infection:
Active systemic infection or evidence of bacteremia contraindicate epidural placement. Evidence of bacteremia with an indwelling catheter requires removal of catheter due to increased risk of abscess formation. Skin breakdown at catheter insertion site also contraindicate placement of an epidural. If any evidence of superficial skin infection develop while the catheter is in place, it will be removed at the discretion of APS.
- Sedation/Neurological Status:
Placement: during neuraxial block the needle and catheter are placed in close proximity to the spinal cord and its surrounding structures; the dura and nerve root. It is critical that a patient is able to communicate any change in neurological status or new sensation at this time. Placement of epidural catheters in heavily sedated patients has resulted in devastating neurological complication and for this reason a patient must be able to communicate during the procedure. If they are intubated, sedation should be weaned and the patient should be able to cooperate with the procedure.
New neurologic defect that requires ongoing neuro checks are considered a contraindication to epidural placement. Maintenance: patient must be alert enough to follow neuro commands and indicate efficacy of epidural therapy.
- Hemodynamic:
Epidural therapy is contraindicated in the following clinic situations:
- Hypotension
- Need for vasopressor infusion
- Unstable hemodynamic status
- Critical Aortic Stenosis
- Positioning/patient anatomy/chronic medical condition:
Epidurals can be placed with the patient in the sitting or lateral position. The patient should be free of trauma that would preclude them from remaining in this position for duration of the placement (about 20 min. in most cases). Uncooperative patients are a contraindication to epidural placement given the proximity of the needle to the spinal cord during placement. Patient must have a clear C-spine prior to placement of epidural.
History of severe scoliosis, neural tube defect, advanced peripheral neuropathy or advanced neurodegenerative disease is a contraindication to epidural therapy.
Intracranial mass or bleed with elevated ICP is an absolute contraindication to epidural therapy.
- NPO status:
Patient must be NPO (solids 8 hrs. clears 2 hrs.) prior to epidural placement.
- Pain well controlled:
If chest wall pain is well controlled at the time of APS consult and the patient is performing well with Incentive Spirometry, the risk of neuraxial analgesia may outweigh the benefits. Pain may be due to other sources and with this clinical picture an epidural would not be indicated.
Duration of Therapy: By epidural catheter day 5 a plan should be in place for alternative analgesia. If the patient continues to benefit from therapy, and there are no concerns for infection at the entry site of the catheter or evidence of meningitis, therapy may continue for up to 72 hrs. more. No epidural catheter should be extended beyond catheter day 7. For record keeping purposes, the day a catheter is placed is considered catheter day 1.
