Thoracic Epidural

Last updated: February 9, 2026

Midline technique: Patient back arched forward, like a cat. Assess for spaces — lower scapula is T7. Aim for T5-T6. Just like a lumbar epidural, administer local anesthetic and then advance. No direct puncture epidurals, just standard epidurals. In terms of angulation, yes, the thoracic spinous processes are angled down, but account for the patient arched back. In practice, the needle may still be near-horizontal to the floor (with slight cephalad angulation). As the needle advances along the correct trajectory, resistance typically increases until the epidural space is reached.

Tape to the side opposite where surgery is.

Administer local anesthetic to check for level (T4 is the nipple for reference). Can give ropivacaine 0.2% 5 mL, or lidocaine 2% 5 mL. If using lidocaine, use the non-preservative formulation (such as the pink one). Check for level with temperature differentiation (ice cubes, alcohol swabs).

Inform APS. Order the epidural bag (fentanyl 2 mcg/mL and bupivacaine 0.05%), basal 6 mL/hr with demand 4 mL every 10 min (6/4/10). Get a cassette from the anesthesia tech and a bag from the pre-op area.

For perioperative pain control, either start the epidural bag or give local PRN as needed (for example, ropivacaine 0.2%, 5 mL aliquots).