What type of epidural is used for pain management?

Types of Epidural Analgesia for Pain Management

For pain management, thoracic or lumbar epidural analgesia using a continuous infusion of local anesthetic (typically bupivacaine 0.1-0.2% or ropivacaine 0.2%) combined with an opioid (fentanyl or morphine) is the most effective approach. 1

Epidural Medication Combinations

The most common epidural combinations for pain management include:

• Local anesthetic + opioid: This combination works synergistically to relieve pain, with the local anesthetic providing sensory block and the opioid enhancing analgesia.

  • Typical combinations:
    • Bupivacaine 0.1-0.2% with fentanyl (3-5 mcg/ml) 2
    • Ropivacaine 0.2% with fentanyl (2-4 mcg/ml) 3
    • Bupivacaine 0.1-0.2% with morphine (0.1-0.25 mg/ml) 1, 4

• Triple combination: Some cases benefit from adding an alpha-2 adrenergic agonist:

  • Local anesthetic + opioid + clonidine (enhances analgesia but may increase hypotension) 4

Delivery Methods

1. Continuous infusion: Most common method for ongoing pain management

   • Typical infusion rates: 6-14 ml/hour (12-28 mg/hour) 3
   • Maximum thoracic epidural infusion rate: 10 ml/hour 5

2. Patient-controlled epidural analgesia (PCEA):

   • Background infusion plus patient-controlled boluses
   • Typical settings: 5 ml/hour continuous with 5 ml bolus doses and 15-40 minute lockout 5, 6

3. Intermittent bolus dosing: Less common for chronic pain management

Epidural Location Based on Pain Site

• Thoracic epidural: Preferred for thoracic, upper abdominal, or rib fracture pain 1, 5

  • Placement typically at T5-T10 level
  • Higher risk of hypotension compared to lumbar placement 1

• Lumbar epidural: Used for lower abdominal, pelvic, or lower extremity pain 1

  • Placement typically at L2-L4 level

Concentration and Volume Considerations

• For surgical anesthesia: Higher concentrations (0.5-0.75% bupivacaine or ropivacaine) 3
• For pain management: Lower concentrations (0.1-0.2% bupivacaine or ropivacaine) 3
• For labor pain: Very low concentrations (0.0625-0.125% bupivacaine with opioid) 7

Specific Clinical Applications

Cancer Pain Management

For refractory cancer pain, epidural administration of opioids with local anesthetics is recommended when:

• Pain is inadequately controlled despite escalating systemic opioid doses
• Systemic opioids cause intolerable side effects
• Life expectancy exceeds 6 months (for implantable systems) 1

Post-surgical Pain

• Thoracic epidural with bupivacaine 0.1-0.2% plus fentanyl for thoracic/upper abdominal surgery 1
• Lumbar epidural with ropivacaine 0.2% at 6-14 ml/hour for lower abdominal/pelvic surgery 3

Trauma Pain (e.g., Rib Fractures)

• Thoracic epidural with bupivacaine/fentanyl or bupivacaine/morphine 1
• Reduces opioid consumption and delirium in older patients with rib fractures 1

Common Pitfalls and Considerations

1. Hypotension: Most common side effect, especially with thoracic epidurals

   • Monitor blood pressure closely
   • May require vasopressors to offset this effect 1, 5

2. Motor block: Can limit mobilization, especially with higher concentrations

   • Use lower concentrations (0.1-0.2%) for pain management to minimize motor effects 1

3. Respiratory depression: Risk increases with higher doses of epidural opioids

   • Monitor respiratory rate and sedation level
   • Higher risk with morphine than fentanyl 1

4. Urinary retention: Common side effect, especially with lumbar epidurals

5. Failure rate: Approximately 14.6% failure to identify epidural space 1

6. Duration limitations: For continuous infusions, FDA recommends not leaving catheters in place for more than 72 hours 3

Contraindications

• Infection at insertion site
• Coagulopathy or anticoagulant therapy (relative contraindication)
• Patient refusal
• Sepsis
• Severe hypovolemia

For optimal outcomes, epidural analgesia should be managed by a skilled pain management team with appropriate monitoring capabilities 1.