Management of Ineffective Epidural During Surgery Under General Anesthesia

Introduction to Epidural Failure

• The American Society of Anesthesiologists recommends abandoning the epidural and relying on general anesthetic with systemic analgesia if the epidural is clearly not working despite multiple test doses, as further attempts to salvage it intraoperatively are futile and potentially dangerous 1

Characteristics of Epidural Failure

• Epidural failure is characterized by no sensory block, no motor block, and negative hemodynamic response, with the catheter likely misplaced outside the epidural space 1
• The absence of tachycardia during abdominal incision under adequate general anesthesia confirms the general anesthesia is working, but does not validate epidural function 1

Immediate Intraoperative Management

• The American College of Surgeons recommends removing or ignoring the epidural catheter for the remainder of the case, deepening the general anesthetic with volatile agents and/or IV anesthetics as needed, and using systemic opioids for intraoperative analgesia 1, 2
• Consider IV lidocaine infusion as an alternative analgesic adjunct with anti-inflammatory properties, with a recommended dose of 1.5 mg/kg bolus, then 2 mg/kg/h 2, 3

Postoperative Analgesia Planning

• The American Pain Society recommends planning alternative postoperative pain management, including multimodal systemic analgesia with IV opioids via PCA, scheduled acetaminophen, and NSAIDs or COX-2 inhibitors if no contraindications 2, 3
• Continue IV lidocaine infusion into the postoperative period if initiated, and consider ketamine as an adjunct for opioid-sparing effects 2, 3

Alternative Regional Techniques

• The American Society of Regional Anesthesia and Pain Medicine recommends considering TAP blocks or wound infiltration catheters with continuous local anesthetic infusion as alternative regional techniques for postoperative analgesia 3

Common Pitfalls and Prevention

• Incorrect initial placement using loss of resistance technique is the most common cause of epidural failure, and operator inexperience significantly increases failure rates 1
• Test the epidural before induction of general anesthesia with cold/pinprick testing to confirm sensory block, and verify bilateral sensory block to at least T10 level for abdominal surgery 4

Documentation and Follow-up

• Document the epidural failure clearly in the anesthetic record, remove the catheter at the end of surgery or early postoperative period, and inform the surgical team that postoperative analgesia will be systemic rather than epidural-based 1, 3