Epidural anesthesia

Tarakad S Ramachandran MD (Dr. Ramachandran of SUNY Upstate Medical University has no relevant financial relationships to disclose.)
James G Greene MD PhD, editor. (Dr. Greene of Emory University School of Medicine has no relevant financial relationships to disclose.)
Originally released March 14, 1997; last updated August 3, 2015; expires August 3, 2018

Overview

Epidural anesthesia is practiced in virtually every clinical setting. Its safety and versatility have supported increasing use for more and varied therapies. Permanent neurologic complications related to neuraxial techniques are rare. Proper clinical setting, improved techniques, clinical acumen, and judicial use significantly improve the outcome. Combined epidural-general anesthesia and epidural-spinal anesthesia techniques have been widely used in many clinical settings with optimum benefit. Use of epidural anesthesia is safe in patients with myasthenia gravis.

Key points

 

• The American Society of Regional Anesthesia and Pain Medicine (ASRA) recommends that epidural catheters be removed with the international normalized ratio less than or equal to 1.4.

 

• It is possible to offer regional block to patients with inherited bleeding disorders provided their coagulation defects have normalized, either spontaneously or following adequate hemostatic cover.

 

• Epidural anesthesia procedures are mostly used in patients undergoing labor and delivery, and the frequency of neurologic complications is about the same in pregnant women compared to nonpregnant patients, though of greater severity in the nonpregnant group.

Historical note and terminology

Lumbar epidural anesthesia was first performed and described by Siccard and Cathelin in 1901 (Murphy 1986). It was used frequently in the early 1900s because of the relative safety compared to complications associated with general anesthesia at the time. Since then, epidural anesthesia has been regarded as a safe procedure, although some authors have suggested that neurologic complications, first reported in 1921, have been underreported (Usubiaga 1975; Dahlgren and Tornebrandt 1995; Yuen et al 1995).

Lumbar epidural anesthesia refers to the injection of an anesthetic or analgesic agent into the lumbar epidural space to induce anesthesia or analgesia of the lumbosacral spinal roots. The epidural space consists of the region between the dura and periosteum of the vertebral bodies. This space contains areolar tissue and the internal vertebral venous plexus. The epidural space is largest at the level of L2. The effect of epidural anesthesia after epidural injection of a specific dose of local anesthetic differs considerably among individuals. Factors affecting the distribution of neural blockade by local anesthetics in epidural anesthesia include age, height, weight and body mass index, pregnancy, dural surface area, choice of epidural insertion site, patient position and gravity, needle direction and catheter position, injection through needle versus injection through catheter, epidural catheter design, fractional versus single bolus injection, speed of injection, epidural pressure, pressure in adjacent body cavities, total dose, concentration versus volume, the anesthetic agent or agents used alone or in combination, and whether epidural anesthesia is used alone or with other forms of anesthesia or analgesia (Visser et al 2008).

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