15 Anesthetic Management for Epiduroscopy Epiduroscopy is a procedure that requires careful anesthetic management. Although the instrumentation involved in this procedure is a small fiberoptic endoscope, the size of the endoscope is much larger than instruments usually introduced into the epidural space. This can lead to significant complications if care is not taken when directing the instrument. A properly sedated patient is the key to avoiding complications. Too deep of an anesthetic can lead to the patient being unable to verbalize when the scope may be causing damage to critical structures. Too light of an anesthetic can lead to patient movement, making it difficult and potentially more dangerous to maneuver the scope in the epidural space. Patients selected for epiduroscopy have had pain for longer than 3 months and have failed a variety of traditional treatments, including interventional procedures such as epidural steroid injections. Conscious sedation is often provided for interventional procedures. Many of these patients have also failed medication management options, potentially including moderate- to high-dose opioid therapy. This leads to challenging intraoperative management of these patients. It is critical to perform a thorough preoperative evaluation of patients scheduled for epiduroscopy. History taking should include the following: • Review of previous anesthetic records: • Airway evaluation: • Medication use: • Medical comorbidities: • Surgical changes: Physical examination should focus on the following: • Neurologic examination including sensation, strength, and reflexes to be tested postoperatively in order to test for any compromise. • Respiratory status including oxygen supplementation, continuous positive airway pressure device use, predisposition for obstructive sleep apnea, reactive airway disease, and chronic obstructive pulmonary disease.1,2,3 • Cardiac evaluation for any clicks, murmurs, or gallops indicative of new or worsening cardiac disease. • Musculoskeletal and integumentary examination to evaluate for any skin changes or ulcers that may be present, especially at the operative site, of which the pain physician must be made aware. Epiduroscopy requires prolonged prone positioning ( • Preoperative and intraoperative evaluation should be made of all pressure points.4,5,6 • Soft padding must be applied to all of these pressure points. • The patient should be asked about comfort at these points prior to any significant sedative or opioid administration. • Appropriately sized prone head pillows should be selected based on patient head circumference and review of previous records. Patients should be secured to the bed to minimize the risk of significant patient movement: • Arms are typically flexed 90 degrees at the shoulder and elbow should be on arm boards.7,8,9 • Care must be taken to avoid nerve compression at the elbow with foam pads.
15.1 Introduction
15.2 Preoperative Evaluation
Previous sedative medications used and patient response.
Hemodynamic response to various medication classes.
Oxygen supplementation required during previous cases.
Postanesthesia care unit status including postanesthetic recovery score and any unusual occurrences.
Any particular pressure points that required extra padding in the prone position.
Type of head pillow required for patient comfort during the procedure.
Mallampati score.
Respiratory status in supine, seated, and prone positions.
Ease of previous airway device placement including endotracheal tube or supraglottic device such as a laryngeal mask airway.
Removable appliances such as dentures or bridges.
Opioid use and dosing, including last dose.
Benzodiazepine use, which is common due to the high prevalence of anxiety among patients with chronic pain.
Psychoactive medication use such as selective serotonin reuptake inhibitors and tricyclic antidepressants.
Allergies to medications and responses.
Properly controlled hypertension is critical to minimize the potential risk of bleeding in the epidural space.
Diabetic control may limit the use of corticosteroids by the interventional pain physician during the procedure.
Diabetic autonomic neuropathy can lead to abnormal cardiovascular responses to stimulation and anesthetic medications.
Coronary artery or peripheral vascular disease may preclude the use of certain sedative medications, which have a more pronounced effect on hemodynamics.
Chronic liver disease may affect biotransformation of anesthetic medications, leading to increased likelihood of accumulation.
Chronic kidney disease leads to decreased clearance; dose adjustments must be made and some medications should be avoided entirely.
Previous cervical, thoracic, or lumbar surgery may lead to special considerations when patient positioning is determined.
Previous limb surgery or lymph node dissection may limit the available sites for intravenous access and sphygmomanometry.
15.3 Patient Positioning
Fig. 15.1) and, as such, all appropriate precautions should be taken:
Neupsy Key
Fastest Neupsy Insight Engine
