Ischemic pain mandating unconventional position for epidural placement

Positioning has always been a special and important concern for any regional anesthetic technique. The standard positions recommended for epidural anesthesia include lateral decubitus, sitting and prone. We report a special situation where we employed the standing position for placing epidural catheter. A 40-year-old man presented with severe ischemic pain of right lower limb due to near total thrombosis of right common iliac artery. He was scheduled for peripheral angiogram and referred to us for pain management as his pain was not permitting him to sit or lie down. Epidural analgesia was planned for managing the pain in the catheterization laboratory and for any other possible management intervention later. As the patient was not tolerating any position other than standing because of severe pain, we placed the lumbar epidural catheter in the standing position and quickly activated the analgesia in the supine position. Patient had good pain relief immediately and an infusion was commenced. Safety and comfort are the major issues to be addressed, while positioning for any procedure. Standing position was chosen for this particular case as it was the only comfortable position for the patient and the safety was not compromised.