Volume of Local Anesthetic for Epidural Steroid Injections
For epidural steroid injections, the typical volume of local anesthetic ranges from 3-5 ml for thoracic epidurals (maximum 10 ml) and 5-15 ml for lumbar epidurals, with dosing based on patient weight and injection site. 1
Specific Volume Guidelines by Epidural Location
Thoracic Epidural
- Bupivacaine 0.25%: 0.2-0.3 ml/kg (maximum 10 ml) initially 1
- Levo-bupivacaine 0.25%: 0.2-0.3 ml/kg (maximum 10 ml) initially 1
- Ropivacaine 0.2%: 0.2-0.3 ml/kg 1
Lumbar Epidural
- Bupivacaine 0.25%: 0.5 ml/kg (maximum 15 ml) initially 1
- Levo-bupivacaine 0.25%: 0.5 ml/kg (maximum 15 ml) initially 1
- Ropivacaine 0.2%: 0.5 ml/kg (maximum 15 ml) initially 1
Administration Technique
The FDA recommends the following administration technique for epidural injections:
- Incremental dosing: Administer in 3-5 ml increments with sufficient time between doses to detect toxic manifestations 2
- Frequent aspiration: Perform before and during injection to avoid intravascular injection 2
- Test dose: Use a test dose containing epinephrine (10-15 mcg) to detect unintended intravascular injection 2
Safety Considerations
Maximum Dosage
- The lowest effective dose should be used to avoid high plasma levels and serious adverse effects 2
- For bupivacaine 0.25%: Maximum 1 ml/kg (2.5 mg/kg) 3
- For ropivacaine 0.2%: Maximum 1.5 ml/kg (3 mg/kg) 3
Monitoring Requirements
- Continuous monitoring of cardiovascular and respiratory vital signs during and after injection 2
- Monitoring of patient's state of consciousness 2
- Resuscitative equipment and drugs should be immediately available 2
Common Pitfalls to Avoid
- Rapid injection: Avoid rapid injection of large volumes; use incremental dosing 2
- Inadequate aspiration: Failure to aspirate before and during injection increases risk of intravascular injection 2
- Omitting test dose: Test doses help detect unintended intravascular or intrathecal injection 2
- Excessive volume: Using volumes greater than recommended increases risk of high spinal block or systemic toxicity 2
Special Populations
- Elderly/debilitated patients: Reduce doses based on age and physical status 2
- Patients with cardiac/liver disease: Require dose reduction 2
- Children: The European Society for Paediatric Anaesthesiology provides weight-based dosing guidelines 1
For optimal safety and efficacy in epidural steroid injections, the volume of local anesthetic should be carefully selected based on the injection site, patient characteristics, and the specific local anesthetic used.