MockCC24 Epidural

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Stem: Patient had lobectomy, epidural at level of T3/T4. Post-op hypotension, bradycardia & O₂ sat of 92%

Differentials?

High epidural block
Distributive shock 2° to epidural
Paralysis of intercostal muscles
Paralysis of diaphragm

Why patient having bradycardia / How epidural interferes with cardiovascular regulatory mechanism?

High epidural block + blocking of the cardioaccelerator fibres (sympathetic fibres) from T1–T5 → unopposed parasympathetic action of the vagus nerve

Which fibres will be affected causing VD?

C fibres

Factors affecting epidural efficiency?

Type of medications
Dosage
Level of injection
Posture
Age, height, weight

What are the medications used in epidural?

Local anaesthetic e.g. bupivacaine and/or lidocaine
Analgesics: e.g. opioids like fentanyl
they may be given in combination in order to decrease the required dose of local anaesthetic

How to test the level of the block? Why?

Using temperature sensation (cold spray e.g. Ethyl chloride)

Why temperature not pin-prick?

Painful
Bleeding
Possible infection

Why epidural in this case?

Early mobilization
Pain relief for longer periods
Decrease neurohormonal stress response - Improved cough reflex

How to differentiate high epidural block from hypovolemic shock?

Epidural
-Warm peripheries
-Bradycardia
Hypovolemia
-Cold peripheries
-Tachycardia

Management plan?

Call the operating consultant and anaesthesia consultant
Sit the patient upright
100% O₂
Stop any injections in the epidural catheter
Rule out any concomitant hypovolemic shock
Epinephrine, phenylephrine, metaraminol (inotropic agents)
Atropine (chronotropic agent)

How can epidural affect respiration?

Paralysis of intercostal muscles
Paralysis of diaphragm
Lead to shallow respiration & increase CO₂ and respiratory failure

isurg

MockCC24 Epidural