1. Preparation

2a. Inject Local Anesthetic

2b. Insert Tuohy Needle

2c. Thread Epidural Catheter

2d. Remove Tuohy Needle

2. Epidural Administration

3. Confirmation of Placement and Test Dose Administration

4. Securing the Epidural Catheter

Heated Intraperitoneal Chemotherapy (HIPEC) coupled with cytoreduction is increasingly being used to treat isolated peritoneal dissemination of intra-abdominal malignancies. Cytoreductive surgery (CRS) is initially performed using either a conventional open or laparoscopic approach. CRS includes removal of the main tumor, excision of any other visible tumors, peritonectomy, omentectomy, and intestinal resections, if necessary. Following CRS, a chemotherapeutic solution is administered at a temperature of 40 to 41.5°C. Infusing chemotherapy immediately following CRS facilitates a uniform distribution of the solution throughout the entire peritoneal cavity. This strategy prevents localized spread that may arise from postoperative adhesion formation, ensuring that peritoneal surfaces are exposed to a concentrated chemotherapy dose while minimizing systemic toxicity.

This high-risk surgical procedure induces substantial hemodynamic and metabolic changes. Therefore, it requires a careful and detailed approach to the administration of anesthesia. Furthermore, hemodynamic status and cardiac function should be continuously evaluated with advanced hemodynamic monitoring. Besides primary disease and complexity of surgery, it has shown that the type and amount of fluids administered during surgery, possible blood transfusions, and the choice of anesthetic agents directly influence the outcomes experienced by patients.

<h4>CHAPTER 1</h4>

<p>A little cleaning solution here.
And - we're doing an epidural for you right now.
So...
For his HIPEC case -
all right, we're typically putting the epidural at the T9 to T10.
After wide skin prep -
Dr. Wu will put a plastic drape on the back.
A little plastic drape coming on your back.</p>

<h4>CHAPTER 2</h4>

<p>You're going to feel a little numbing medicine.
This will be a little pinch and burn.
Okay, so Dr. Wu will start with some local anesthetic.
He's someone who has very tensile skin.
Just some numbing medicines, okay?
Some more numbing medicine here.
Perfect.
All right.</p>

<p>You may feel some pressure in the back.
Keep in the middle.
So now Dr. Wu is using the 17 guage Tuohy needle.
Yeah. Yeah.
When it goes through...
The sub-q skin - you can go a little bit more if you engage.
Yeah. Yeah.
Square it.
A little bit.
I'm in there now. Okay.
So we're going to engage at the ligamentum flavum.
Okay.
A little bit tighter? Not yet.
It's a little bit tighter. A little bit tighter?
It looks tighter now.
So we're at the ligamentum flavum.
Okay, we can adjust our needle a little bit.
We use lots of resistance to saline.
Yeah. So you can see the change of the resistance.</p>

<p>Don't move - you're doing great.
So we lost at the 5?
That's - 8, 7.
So this is 8, 7, 6, probably 5.
We're trying to thread in the catheter.
It's threading easy? Yeah, I think so.
Very easy. Okay.</p>

<p>So then, we're going to remove
the epidural needle.
It's okay, that's enough. Okay. That's it.
So the epidural needle is out.
Okay? Needle is out. You can relax.</p>

<h4>CHAPTER 3</h4>

<p>Just a little piece of plastic here.
Okay, you have just a small catheter out of your back.
We just need to test it, and then secure it.
Okay? So what Dr. Wu will do is pull back the epidural catheter.
We'll leave 5 cm at the epidural space. So, we leave at -
11? Yeah. Because 15, 14, 13 -
12, and - a little bit more.
Okay. And then we'll give what we call the test dose, which is...
All right, so we're going to
test our epidural. We're going to
aspirate first - make sure that no CSF comes back.
Negative aspiration.
Okay, so that's what we call the negative aspirations, and then we'll inject
3 cc of 1.5% of lidocaine with epinephrine.
We look at the patient's heart rate.
Let us know if you feel any weird side effects.
Any kind of weird numbness or metallic taste in your mouth,
weird sensations in your legs, ringing in the ears.
We don't expect any of that to happen, but if it does, let us know.
Everything is perfect. You're doing really well.
Okay?
No change of heart rate.
And then we're going to check the blood pressures.
Yeah.</p>

<h4>CHAPTER 1</h4>

<p>Now we're going to secure the epidural catheter.
So that depends on drying it a bit.
Okay.</p>


Watch this video of a preoperative epidural placed at T9-T10 in advance of HIPEC with cytodreduction.

DOI
Publication Date	2024/02/02
Article ID	218.1
Production ID	0218.1
Volume	2024
Issue	218.1
https://doi.org/10.24296/jomi/218.1

Epidural at T9-T10: Preoperative for HIPEC Surgery

Procedure Outline

Table of Contents

1. Preparation

2. Epidural Administration

3. Confirmation of Placement and Test Dose Administration

4. Securing the Epidural Catheter