Epidural Technique In Obstetric Anesthesia by Giorgio Capogna

Author:Giorgio Capogna
Language: eng
Format: epub
ISBN: 9783030453329
Publisher: Springer International Publishing

5.8 Paramedian Approach

This approach has been specifically thought of for the middle thoracic region, where the obliquity of the spinous process is extreme. Although the paramedian approach is not commonly used in the obstetric patient, it may be used as an alternative to the midline approach when the introduction of the needle through the interspace is deemed difficult, or in the case of patients who are difficult to position.

The different angle of penetration of the needle in the epidural space may be the reason for the technical advantages advocated for this approach, which include a small risk of accidental perforation of the dura mater, no tenting of the dura by the tip of the catheter, and the promotion of a straight course cephalad in the near midline for the epidural catheter [19].

Typical features of this approach include a larger target through the interlaminar space as well as the avoidance of the puncture of the supraspinous and interspinous ligaments.

Local anesthesia is obtained by making a 2 cm wheal lateral to the midline, and infiltrating the subcutaneous tissues, including the paraspinal muscles and periosteum of the laminae. This injection not only aims to produce analgesia, but it also serves to make a path for the epidural needle. The latter is inserted into the skin and directed towards the medial extremity of the lamina. As soon as this structure is contacted, the needle is gently maneuvered so that its bevel reaches the superior surface of the lamina and therefore engages the tough ligamentum flavum. The stylet is then removed and the syringe filled with saline is connected to the hub of the needle. The needle is then advanced slowly and constantly in the way previously described in the paragraph on midline approach, until sudden lack of resistance indicates that the epidural space has been entered.

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