What are the guidelines for administering a casual epidural (peridural anesthesia) for pain management?

Epidural Anesthesia Administration Guidelines

Epidural anesthesia (peridural anesthesia) should be administered using fluoroscopic guidance when available, with dilute concentrations of local anesthetics combined with opioids to minimize motor block while providing effective analgesia. 1

Patient Selection and Timing

Obstetric Patients

• Offer neuraxial analgesia on an individualized basis regardless of cervical dilation, including to patients in early labor (less than 5 cm dilation) when the service is available 1
• Reassure patients that neuraxial analgesia does not increase the incidence of cesarean delivery 1
• Consider early insertion of a neuraxial catheter for complicated parturients with obstetric indications (twin gestation, preeclampsia) or anesthetic indications (anticipated difficult airway, obesity) to reduce the need for general anesthesia if emergent procedures become necessary 1

Surgical Patients

• Equipment, facilities, and support personnel in the labor and delivery operating suite should be comparable to those in the main operating suite 1
• For postoperative pain management after major abdominal surgery, thoracic epidural anesthesia/analgesia should be considered, particularly for abdominal aortic aneurysm surgery 1
• Thoracic epidural analgesia should be considered for patients with traumatic rib fractures 1

Technical Approach and Drug Selection

Catheter Placement Technique

• Position the patient in sitting or lateral decubitus position with shoulders and back flexed to open interlaminar spaces 2
• Identify the target level using anatomical landmarks (counting down from C7 prominence or up from iliac crest) 2
• Perform sterile skin preparation and drape the area 2
• Infiltrate skin and deeper tissues with local anesthetic 2
• Insert the epidural catheter 3-5 cm into the epidural space and secure to skin with adhesive dressing 2

Medication Protocols

For Labor Analgesia:

• Initial dose: 2 mg/mL (0.2%) ropivacaine, 10-20 mL (20-40 mg total), onset 10-15 minutes 3
• Continuous infusion: 2 mg/mL (0.2%) at 6-14 mL/hour (12-28 mg/hour) 3
• Median dose of 21 mg per hour administered over median delivery time of 5.5 hours has been well tolerated 3

For Surgical Anesthesia:

• Lumbar epidural for surgery: 5 mg/mL (0.5%) at 15-30 mL (75-150 mg), or 7.5 mg/mL (0.75%) at 15-25 mL (113-188 mg) 3
• Cesarean section: 5 mg/mL (0.5%) at 20-30 mL (100-150 mg) or 7.5 mg/mL (0.75%) at 15-20 mL (113-150 mg) 3
• Thoracic epidural for surgery: 5 mg/mL (0.5%) at 5-15 mL (25-75 mg) or 7.5 mg/mL (0.75%) at 5-15 mL (38-113 mg) 3

For Postoperative Pain:

• Continuous infusion: 2 mg/mL (0.2%) at 6-14 mL/hour (12-28 mg/hour) for both lumbar and thoracic epidural 3
• Cumulative doses up to 770 mg over 24 hours have been well tolerated 3
• Continuous epidural infusion at rates up to 28 mg per hour for 72 hours have been well tolerated (2016 mg total plus surgical dose of 100-150 mg) 3

Optimizing Analgesia Quality

• Use dilute concentrations of local anesthetics with opioids to produce as little motor block as possible 1
• When continuous epidural infusion of local anesthetic is selected, add an opioid to reduce the concentration of local anesthetic, improve quality of analgesia, and minimize motor block 1
• Low-dose mobile epidural techniques (combined spinal-epidural or low-dose infusion) reduce instrumental vaginal delivery rates compared to traditional epidural (42.7-42.9% vs 35.1% normal vaginal delivery) 4

Safety Protocols and Verification

Pre-Administration Requirements

• Use an adequate test dose (3-5 mL of short-acting local anesthetic solution containing epinephrine) prior to induction of complete block 3
• Repeat the test dose if the patient is moved in a manner that could displace the epidural catheter 3
• Allow adequate time for onset of anesthesia following administration of each test dose 3

Verification of Placement

• Assess for bilateral sensory changes after administration of local anesthetic 2
• Ensure no signs of intravascular injection (tachycardia, hypertension) or intrathecal injection (rapid onset of dense motor block, hypotension) 2
• Use pencil-point spinal needles instead of cutting-bevel spinal needles to minimize risk of post-dural puncture headache 1

Aspiration Prophylaxis (Obstetric Patients)

• Before surgical procedures (cesarean delivery, postpartum tubal ligation), consider timely administration of nonparticulate antacids, H2-receptor antagonists, and/or metoclopramide 1
• Solid foods should be avoided in laboring patients 1
• Patients undergoing elective surgery should undergo 6-8 hour fasting period for solids depending on fat content 1

Complications and Management

Common Complications

• Dural puncture occurs in approximately 1.7% of cases 5
• Success rate of epidural anesthesia is approximately 84.6%, with failure rate of 4.7% 5
• Resources for treatment of potential complications (failed intubation, inadequate analgesia/anesthesia, hypotension, respiratory depression, local anesthetic systemic toxicity, pruritus, vomiting) should be available 1

Serious Adverse Events

• Serious adverse events occur more often than previously thought, with incidence rates differing in specific perioperative patient populations 6
• Epidural analgesia for obstetric purposes is considered well tolerated in young, healthy women, with permanent neurological damage occurring seldomly 6
• For perioperative and chronic pain treatment, careful patient selection is critical 6

Contraindications and Special Considerations

• Do not use for intra-articular infusions following arthroscopic procedures due to reports of chondrolysis 3
• Patients with infections, coagulopathy, or very short life expectancy are not appropriate candidates 1
• Patients in poor general condition due to aging, heart conduction block, advanced liver disease, or severe renal dysfunction require special attention and dosage adjustment 3

Alternative Approaches

• Consider alternative regional blocks such as paravertebral or erector spinae plane blocks as first-line options for thoracic procedures due to lower risk profile 2
• If epidural placement is unsuccessful, consider alternative approaches including paravertebral block or erector spinae plane block 2
• Combined spinal-epidural techniques may be used to provide effective and rapid onset of analgesia for labor 1

Duration and Monitoring

• Single-injection spinal opioids provide time-limited analgesia; if labor duration is anticipated to be longer than analgesic effects or if operative delivery is possible, consider a catheter technique instead 1
• Continuous infusion bottles should not be left in place for more than 24 hours 3
• Any solution remaining from an opened container should be discarded promptly 3
• Clinical experience supports the use of epidural infusions for up to 72 hours 3