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Epidural Anesthesia Epidural Anesthesia Epidural administration A freshly inserted lumbar epidural catheter. The site has been prepared with tincture of iodine, and the dressing has not yet been applied. Depth markings may be seen along the shaft of the catheter. Epidural administration (from Ancient Greek ἐπί, "on, upon" + dura mater) is a medical route of administration in which a drug such as epidural analgesia and epidural anaesthesia or contrast agent is injected into the epidural space around the spinal cord. The epidural route is frequently employed by certain physicians and nurse anaesthetists to administer local anaesthetic agents, and occasionally to administer diagnostic (e.g. radiocontrast agents) and therapeutic (e.g., glucocorticoids) chemical substances. Epidural techniques frequently involve injection of drugs through a catheter placed into the epidural space. The injection can result in a loss of sensation—including the sensation of pain—by blocking the transmission of signals through nerve fibres in or near the spinal cord. The technique of epidural anaesthesia was first developed in 1921 by Spanish military surgeon Fidel Pagés (1886–1923).[1] Difference from spinal anaesthesia Simulation of the insertion of an epidural needle between the spinous processes of the lumbar vertebrae. A syringe is connected to the epidural needle and the epidural space is identified by a technique to assess loss of resistance. When the epidural space is identified then the syringe is removed and the epidural catheter may be inserted into the epidural space through the needle. Local anaesthetic agents may be inserted through the epidural needle and catheter to provide pain relief. Epidural Anesthesia. Spinal anaesthesia is a technique whereby a local anaesthetic drug is injected into the cerebrospinal fluid. This technique has some similarity to epidural anaesthesia, and lay people often confuse the two techniques. Important differences include: To achieve epidural analgesia or anaesthesia, a larger dose of drug is typically necessary than with spinal analgesia or anaesthesia. The onset of analgesia is slower with epidural analgesia or anaesthesia than with spinal analgesia or anaesthesia, which also confers a more gradual decrease in blood pressure. An epidural injection may be performed anywhere along the vertebral column (cervical, thoracic, lumbar, or sacral), while spinal injections are more often performed below the second lumbar vertebral body to avoid piercing and consequently damaging the spinal cord. It is easier to achieve segmental analgesia or anaesthesia using the epidural route than using the spinal route. An indwelling catheter is more commonly placed in the setting of epidural analgesia or anaesthesia than with spinal analgesia or anaesthesia. Epidural medication administration can be continued post-operatively (and re- dosed intraoperatively) via a catheter, while spinal anesthesia is generally a single shot injection. Indications:- Injecting medication into the epidural space is primarily performed for analgesia. This may be performed using a number of different techniques and for a variety of reasons. Additionally, some of the side-effects of epidural analgesia may be beneficial in some circumstances (e.g., vasodilation may be beneficial if the subject has peripheral vascular disease). When a catheter is placed into the epidural space (see below) a continuous infusion can be maintained for several days, if needed. Epidural analgesia may be used: For analgesia alone, where surgery is not contemplated. An epidural injection or infusion for pain relief (e.g. in childbirth) is less likely to cause loss of muscle power, but can subsequently be conveniently augmented to be sufficient for surgery, if needed. As an adjunct to general anaesthesia. The anaesthetist may use epidural analgesia in addition to general anaesthesia. This may reduce the patient's requirement for opioid analgesics. This is suitable for a wide variety of surgery, for example gynaecological surgery (e.g. hysterectomy), orthopaedic surgery (e.g. hip replacement), general surgery (e.g. laparotomy) and vascular surgery (e.g. open aortic aneurysm repair). As a sole technique for surgical anaesthesia. Some operations, most frequently Caesarean section, may be performed using an epidural anaesthetic as the sole technique. This can allow the patient to remain awake during the operation. The dose required for anaesthesia is much higher than that required for analgesia. For post-operative analgesia, whether the epidural was employed as the sole anaesthetic, or in conjunction with general anaesthesia, during the operation. Analgesics are administered into the epidural space typically for a few days after surgery, provided a catheter has been inserted. Through the use of a patient-controlled epidural analgesia (PCEA) infusion pump, a patient can supplement an epidural infusion with occasional supplemental doses of the infused medication through the epidural catheter. For the treatment of back pain. Injection of analgesics and steroids into the epidural space may improve some forms of back pain. See below. For the treatment of chronic pain or palliation of symptoms in terminal care, usually in the short- or medium-term. The epidural space is more difficult and risky to access as one ascends the spine (because the spinal cord gains more nerves as it ascends and fills the epidural space leaving less room for error), so epidural techniques are most suitable for analgesia anywhere in the lower body and as high as the chest. They are (usually) much less suitable for analgesia for the neck, or arms and are not possible for the head (since sensory innervation for the head arises directly from the brain via cranial nerves rather than from the spinal cord via the epidural space.) Contraindications While the use of epidural analgesia and anesthetic is considered safe and effective, there are some contraindications to the use of such procedures. Absolute contraindications include:[2] patient refusal safety concerns including inadequate equipment, experience, or appropriate supervision severe hematologic coagulopathy infection near the site of injection Relative contraindications include:[2] low platelets without abnormal bleeding progressive neurologic disease (as neuraxial analgesia may further disease progression) increased ICP (due to possibility of dural puncture, CSF leakage, and consequent pressure on the brainstem) decreased but stable cardiac output (e.g. aortic stenosis) hypovolemia (as neuraxial analgesia decreases systemic vascular resistance) remote infection distant to injection site Side effects In addition to blocking the nerves which carry pain, local anaesthetic drugs in the epidural space will block other types of nerves as well, in a dose-dependent manner. Depending on the drug and dose used, the effects may last only a few minutes or up to several hours. Epidural analgesia typically involves using the opiates fentanyl or sufentanil, with bupivacaine or one of its congeners. Fentanyl is a powerful opioid with a potency 80 times that of morphine and side effects common to the opiate class. Sufentanil is another opiate, 5 to 10 times more potent than Fentanyl. Bupivacaine is markedly toxic if inadvertently given intravenously, causing excitation, nervousness, tingling around the mouth, tinnitus, tremor, dizziness, blurred vision, or seizures, followed by central nervous system depression: drowsiness, loss of consciousness, respiratory depression and apnea. Bupivacaine has caused several deaths by cardiac arrest when epidural anaesthetic has been accidentally inserted into a vein instead of the epidural space.[3][4] Sensory nerve fibers are more sensitive to the effects of the local anaesthetics than motor nerve fibers.[5] This means that an epidural can provide analgesia while affecting muscle strength to a lesser extent. For example, a labouring woman may have a continuous epidural during labour that provides good analgesia without impairing her ability to move. If she requires a Caesarean section, she may be given a larger dose of epidural local anaesthetic. The larger the dose used, the more likely it is that side effects will be evident.[6] For example, very large doses of epidural anaesthetic can cause paralysis of the intercostal muscles and thoracic diaphragm (which are responsible for breathing), and loss of sympathetic nerve input to the heart, which may cause a significant decrease in heart rate and blood pressure.[6] This may require emergency intervention, which may include support of the airway and the cardiovascular system. The sensation of needing to urinate is often significantly diminished or even abolished after administration of epidural local anaesthetics and/or opioids.[7] Because of this, a urinary catheter is often placed for the duration of the epidural infusion.[7] People with continuous epidural infusions of local anaesthetic solutions typically ambulate only with assistance, if at all, in order to reduce the likelihood of injury due to a fall. Large doses of epidurally administered opioids may cause troublesome itching, and respiratory depression.[8][9][10][11] Complications These include: failure to achieve analgesia or anaesthesia occurs in about 5% of cases, while another 15% experience only partial analgesia or anaesthesia. If analgesia is inadequate, another epidural may be attempted. o The following factors are associated with failure to achieve epidural analgesia/anaesthesia:[12] . Obesity . Multiparity . History
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