Epidural administration

Short description: Medication injected into the epidural space of the spine

"Epidural" redirects here. For the anatomical site, see Epidural space. For other uses, see Epidural (disambiguation).

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.

ICD-9-CM| 03.90
MeSH| D000767
OPS-301 code| 8-910

[edit on Wikidata]

Epidural administration (from Ancient Greek ἐπί, "upon" + dura mater)[1] is a method of medication administration in which a medicine is injected into the epidural space around the spinal cord. The epidural route is used by physicians and nurse anesthetists to administer local anesthetic agents, analgesics, diagnostic medicines such as radiocontrast agents, and other medicines such as glucocorticoids. Epidural administration involves the placement of a catheter into the epidural space, which may remain in place for the duration of the treatment. The technique of intentional epidural administration of medication was first described in 1921 by the Spanish Aragonese military surgeon Fidel Pagés.

Epidural anaesthesia causes a loss of sensation, including pain, by blocking the transmission of signals through nerve fibres in or near the spinal cord. For this reason, epidurals are commonly used for pain control during childbirth and surgery, for which the technique is considered safe and effective, and is considered more effective and safer than giving pain medication by mouth or through an intravenous line. An epidural injection may also be used to administer steroids for the treatment of inflammatory conditions of the spinal cord. It is not recommended for people with severe bleeding disorders, low platelet counts, or infections near the intended injection site. Severe complications from epidural administration are rare, but can include problems resulting from improper administration, as well as adverse effects from medicine. The most common complications of epidural injections include bleeding problems, headaches, and inadequate pain control. Epidural analgesia during childbirth may also impact the mother's ability to move during labor. Very large doses of anesthetics or analgesics may result in respiratory depression.

An epidural injection may be administered at any point of the spine, but most commonly the lumbar spine, below the end of the spinal cord. The specific administration site determines the specific nerves affected, and thus the area of the body from which pain will be blocked. Insertion of an epidural catheter consists of threading a needle between bones and ligaments to reach the epidural space without going so far as to puncture the dura mater. Saline or air may be used to confirm placement in the epidural space. Alternatively, direct imaging of the injection area may be performed with a portable ultrasound or fluoroscopy to confirm correct placement. Once placed, medication may be administered in one or more single doses, or may be continually infused over a period of time. When placed properly, an epidural catheter may remain inserted for several days, but is usually removed when it is possible to use less invasive administration methods (such as oral medication).

## Contents

* 1 Uses
* 1.1 Pain relief during childbirth
* 1.2 Pain relief during other surgery
* 1.3 Others
* 2 Contraindications
* 3 Risks and complications
* 3.1 Medication-specific
* 4 Technique
* 4.1 Anatomy
* 4.2 Insertion
* 4.3 Use and removal
* 4.4 Combined spinal-epidural techniques
* 5 Recovery
* 6 History
* 7 Society and culture
* 8 References
* 9 Further reading
* 10 External links

## Uses

Epidural infusion pump with opioid (sufentanil) and anesthetic (bupivacaine) in a locked box

### Pain relief during childbirth

Epidural injections are commonly used to provide pain relief (analgesia) during childbirth.[2] This usually involves epidural injection of a local anesthetic and opioids, commonly called an "epidural". This is more effective than oral or intravenous (IV) opioids and other common modalities of analgesia in childbirth.[3] After an epidural is administered, the recipient may not feel pain, but may still feel pressure.[4] Epidural clonidine is rarely used but has been extensively studied for management of analgesia during labor.[5]

Epidural analgesia is considered a safer and more effective method of relieving pain in labor as compared to intravenous or oral analgesia. In a 2018 Cochrane review of studies which compared epidural analgesia with oral opioids, some advantages of epidural analgesia versus opioids included fewer instances of naloxone use in newborns, and decreased risk of maternal hyperventilation.[3] Some disadvantages of epidural analgesia versus opioids included longer labor durations, an increased need for oxytocin to stimulate uterine contractions, and an increased risk of fever, low blood pressure, and muscle weakness.[3]

However, the review found no difference in overall Caesarean delivery rates between epidural analgesia versus no analgesia. Additionally, there was no difference found on the immediate neonatal health of the child between epidural analgesia versus no analgesia. Furthermore, the occurrence of long-term backache was unchanged after epidural use.[3] Complications of epidural analgesia are rare, but may include headaches, dizziness, difficulty breathing and seizures for the mother. The child may experience a slow heartbeat, decreased ability to regulate temperature, and potential exposure to the drugs administered to the mother.[6]

There is no overall difference in outcomes based on the time the epidural is administered to the mother,[7] specifically no change in the rate of caesarean section, birth which must be assisted by instruments, and duration of labor. There is also no change in the Apgar score of the newborn between early and late epidural administration.[7] Epidurals other than low-dose ambulatory epidurals also impact the ability of the mother to move during labor. Movement such as walking or changing positions may help improve labor comfort and decrease the risk of complications.[8]

### Pain relief during other surgery

Epidural analgesia has been demonstrated to have several benefits after other surgeries, including decreasing the need for the use of oral or systemic opioids,[9] and reducing the risk of postoperative respiratory problems, chest infections,[10] blood transfusion requirements,[11] and myocardial infarctions.[12] Use of epidural analgesia after surgery in place of systemic analgesia is less likely to decrease intestinal motility which would occur with systemic opioid therapy through blockade of the sympathetic nervous system.[11][13] Some surgeries that spinal analgesia may be used in include lower abdominal surgery, lower limb surgery, cardiac surgery, and perineal surgery.[11][14][15]

A single-use epidural administration kit in sterile packaging

### Others

Main articles: Chemistry:Epidural steroid injection and Epidural blood patch

The injection of steroids into the epidural space is sometimes used to treat nerve root pain, radicular pain and inflammation caused by conditions such as spinal disc herniation, degenerative disc disease, and spinal stenosis.[16] The risk of complications from steroid administration is low and complications are usually minor. The specific drug, dose, and frequency of administration impacts the risk for and severity of complications. Complications of epidural steroid administration are similar to the side effects of steroids administered in other manners, and can include higher than normal blood sugar, especially in patients with type 2 diabetes.[16] An epidural blood patch consists of a small amount of a person's own blood is injected into the epidural space. This is done as a method of sealing a hole or leak in the epidural.[17] The injected blood clots at the site of the puncture, closes the leak, and modulates CSF pressure.[18][19] This may be used to treat post-dural-puncture headache and leakage of cerebrospinal fluid due to dural puncture, which occurs in approximately 1.5% of epidural analgesia procedures.[20]

## Contraindications

The use of epidural analgesia and anesthetic is considered safe and effective in most situations. Epidural analgesia is contraindicated in people who have complications such as cellulitis near the injection site or severe coagulopathy.[20] In some cases, it may be contraindicated in people with low platelets, increased intracranial pressure, or decreased cardiac output.[20] Due to the risk of disease progression, it is also potentially contraindicated in people with preexisting progressive neurologic disease.[20] Some heart conditions such as stenosis of the aortic or mitral valves are also a contraindication to the use of epidural administration, as is low blood pressure or hypovolemia.[16] An epidural is generally not used in people who are being administered anticoagulation therapy as it increases the risk of complications from the epidural.[16]

## Risks and complications

In addition to blocking nerves which carry pain signals, local anesthetics may block nerves which carry other signals, though sensory nerve fibers are more sensitive to the effects of the local anesthetics than motor nerve fibers. For this reason, adequate pain control can usually be attained without blocking the motor neurons, which would cause a loss of muscle control if it occurred. Depending on the drug and dose administered, the effects may last only a few minutes or up to several hours.[21] As such, an epidural can provide pain control without as much of an effect on muscle strength. For example, a woman in labor who is being administered continuous analgesia via an epidural may not have impairment to her ability to move. Larger doses of medication are more likely to result in side effects.[22] Very large doses of some medications can cause paralysis of the intercostal muscles and thoracic diaphragm responsible for breathing, which may lead to respiratory depression or arrest. It may also result in loss of sympathetic nerve input to the heart, which may cause a significant decrease in heart rate and blood pressure.[22] Obese people, those who have given birth prior, those with a history of opiate use, or those with cervical dilation of more than 7 cm are at a higher risk of inadequate pain control.[23]

If the dura is accidentally punctured during administration, it may cause cerebrospinal fluid to leak into the epidural space, causing a post-dural-puncture headache.[24] This occurs in approximately 1 in 100 epidural procedures. Such a headache may be severe and last several days, or rarely weeks to months, and is caused by a reduction in CSF pressure. Mild post-dural-puncture headaches may be treated with caffeine and gabapentin,[25] while severe headaches may be treated with an epidural blood patch, though most cases resolve spontaneously with time. Less common but more severe complications include subdural hematoma and cerebral venous thrombosis. The epidural catheter may also rarely be inadvertently placed in the subarachnoid space, which occurs in less than 1 in 1000 procedures. If this occurs, cerebrospinal fluid can be freely aspirated from the catheter, and this is used to detect misplacement. When this occurs, the catheter is withdrawn and replaced elsewhere, though occasionally no fluid may be aspirated despite a dural puncture.[26] If dural puncture is not recognized, large doses of anesthetic may be delivered directly into the cerebrospinal fluid. This may result in a high block, or, more rarely, a total spinal, where anesthetic is delivered directly to the brainstem, causing unconsciousness and sometimes seizures.[26]

Epidural administrations can also cause bleeding issues, including "bloody tap", which occurs in approximately 1 in 30–50 people.[27] This occurs when epidural veins are inadvertently punctured with the needle during the insertion. It is a common occurrence and is not usually considered a problem in people who have normal blood clotting. Permanent neurological problems from bloody tap are extremely rare, estimated at less than 0.07% of occurrences.[28] However, people who have a coagulopathy may have a risk of epidural hematoma, and those with thrombocytopenia might bleed more than expected. A 2018 Cochrane review found no evidence regarding the effect of platelet transfusions prior to a lumbar puncture or epidural anesthesia for participants that have thrombocytopenia.[29] It is unclear whether major surgery-related bleeding within 24 hours and the surgery-related complications up to 7 days after the procedure are affected by epidural use.[29]

Rare complications of epidural administration include formation of an epidural abscess (1 in 145,000)[30] or epidural hematoma (1 in 168,000),[30] neurological injury lasting longer than 1 year (1 in 240,000),[30] paraplegia (1 in 250,000),[31] and arachnoiditis.[32] Rarely, an epidural may cause death (1 in 100,000).[31] In circumstances where contraindications exist, there are numerous fascial plane blocks that may be provided instead of an epidural.[33]

### Medication-specific

If bupivacaine, a medication commonly administered via epidural, is inadvertently administered into a vein, it can cause excitation, nervousness, tingling around the mouth, tinnitus, tremor, dizziness, blurred vision, or seizures as well as central nervous system depression, loss of consciousness, respiratory depression and apnea. Bupivacaine intended for epidural administration has been implicated in cardiac arrests resulting in death when accidentally administered into a vein instead of the epidural space.[34][35] The administration of large doses of opioids into the epidural space may cause itching and respiratory depression.[36][37] The sensation of needing to urinate is often significantly diminished or completely absent after administration of epidural local anesthetics or opioids.[38] Because of this, a urinary catheter is often placed for the duration of the epidural infusion.[38]

In many women given epidural analgesia during labor oxytocin is also used to augment uterine contractions. In one study which examined the rate of breastfeeding two days following epidural anesthesia during childbirth, epidural analgesia used in combination with oxytocin resulted in lower maternal oxytocin and prolactin levels in response to breastfeeding on the second day following birth.[39] The lower maternal oxytocin level negatively affects the baby's feeding rooting reflex, decreasing the amount of milk produced. The consequence of these effects from epidural analgesia is higher weight loss.[40]

## Technique

### Anatomy

Sagittal section of the spinal column (not drawn to scale). Yellow: spinal cord; blue: pia mater; light blue: subarachnoid space; red: arachnoid; pink: dura mater; pale green: epidural space; taupe: vertebral bones; teal: interspinous ligaments.

Main article: Biology:Epidural space

An epidural is injected into the epidural space, inside the bony spinal canal but just outside the dura. In contact with the inner surface of the dura is another membrane called the arachnoid mater, which contains the cerebrospinal fluid. In adults, the spinal cord terminates around the level of the disc between L1 and L2, while in neonates it extends to L3 but can reach as low as L4.[16] Below the spinal cord there is a bundle of nerves known as the cauda equina or "horse's tail". Hence, lumbar epidural injections carry a low risk of injuring the spinal cord. Insertion of an epidural needle involves threading a needle between the bones, through the ligaments and into the epidural space without puncturing the layer immediately below containing CSF under pressure.[16]

### Insertion

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.

Epidural administration is a procedure which requires the person performing the insertion to be technically proficient in order to avoid complications. Proficiency may be trained using bananas or other fruits as a model.[41][42]

The person receiving the epidural may be seated, or lying on their side or stomach.[16] The level of the spine at which the catheter is placed depends mainly on the site of intended operation – based on the location of the pain. The iliac crest is a commonly used anatomical landmark for lumbar epidural injections, as this level roughly corresponds with the fourth lumbar vertebra, which is usually well below the termination of the spinal cord.[16] The Tuohy needle, designed with a 90-degree curved tip and side hole to redirect the inserted catheter vertically along the axis of the spine, may be inserted in the midline, between the spinous processes. When using a paramedian approach, the tip of the needle passes along a shelf of vertebral bone called the lamina until just before reaching the ligamentum flavum and the epidural space.[43]

Along with a sudden loss of resistance to pressure on the plunger of the syringe, a slight clicking sensation may be felt by the operator as the tip of the needle breaches the ligamentum flavum and enters the epidural space. Saline or air may be used to identify placement in the epidural space. A systematic review from 2014 showed no difference in terms of safety or efficacy between the use of saline and air for this purpose.[44] In addition to the loss of resistance technique, direct imaging of the placement may be used. This may be conducted with a portable ultrasound scanner or fluoroscopy (moving X-ray pictures).[45] After placement of the tip of the needle, a catheter or small tube is threaded through the needle into the epidural space. The needle is then withdrawn over the catheter. The catheter is generally inserted 4–6 cm into the epidural space, and is typically secured to the skin with adhesive tape, similar to an intravenous line.[46]

### Use and removal

If a short duration of action is desired, a single dose of medication called a bolus may be administered. Thereafter, this bolus may be repeated if necessary provided the catheter remains undisturbed. For a prolonged effect, a continuous infusion of medication may be used. There is some evidence that an automated intermittent bolus technique may provide better pain control than a continuous infusion technique even when the total doses administered are identical.[47][48][49] Typically, the effects of the epidural block are noted below a specific level or portion of the body, determined by the site of injection. A higher injection may result in sparing of nerve function in the lower spinal nerves. For example, a thoracic epidural performed for upper abdominal surgery may not have any effect on the area surrounding the genitals or pelvic organs.[50]

### Combined spinal-epidural techniques

For some procedures where both the rapid onset of a spinal anesthetic and the post-operative analgesic effects of an epidural are desired, both techniques may be used in combination. This is called combined spinal and epidural anesthesia (CSE). The spinal anesthetic may be administered in one location, and the epidural at an adjacent location. Alternatively, after locating the epidural space with the Tuohy needle, a spinal needle may be inserted through the Tuohy needle into the subarachnoid space.[16] The spinal dose is then given, the spinal needle withdrawn, and the epidural catheter inserted as normal. This method, known as the "needle-through-needle" technique, may be associated with a slightly higher risk of placing the catheter into the subarachnoid space.[51]

## Recovery

Epidural analgesia is generally well tolerated, with recovery time quick after administration is complete and the epidural is removed. The epidural catheter is usually removed when it is possible to safely switch to oral administration of medications, though catheters can safely remain in place for several days with little risk of bacterial infection,[52][53][54] particularly if the skin is prepared with a chlorhexidine solution.[55] Subcutaneously tunneled epidural catheters may be safely left in place for longer periods, with a low risk of infection or other complications.[56][57] Regardless of the length of use, the effects of a medicine administered epidurally, including numbness if used for analgesia, usually wear off within a few hours of the epidural being stopped, with full recovery of normal function within 24 hours.[58]

The use of epidural analgesia during a birth does not have any effect on whether a caesarean section must be performed during future births. Epidural analgesia during childbirth also generally has no negative effects on the long-term health of the mother or child.[3] Use of epidural analgesia versus oral analgesia or no analgesia has no effect on the normal length of hospital stay after childbirth, the only difference being that care must be performed around the epidural insertion site to prevent infection.[59] Following epidural analgesia used for gastrointestinal surgery, the time to recovery of normal gastrointestinal function is not significantly different from recovery time after intravenous analgesia.[60] The use of epidural analgesia during cardiac surgeries may shorten the amount of time a person requires ventilator support following surgery, but it is unknown whether it shortens the overall post-surgery hospital stay overall.[61]

## History

Spanish doctor Fidel Pagés visiting injured soldiers at the Docker Hospital in Melilla in 1909

The first record of an epidural injection is from 1885, when American neurologist James Corning of Acorn Hall in Morristown, New Jersey, used the technique to perform a neuraxial blockade. Corning inadvertently injected 111 mg of cocaine into the epidural space of a healthy male volunteer,[62] although at the time he believed he was injecting it into the subarachnoid space.[63] Following this, in 1901 Fernand Cathelin first reported intentionally blocking the lowest sacral and coccygeal nerves through the epidural space by injecting local anesthetic through the sacral hiatus.[20] The loss of resistance technique was first described by Achile Dogliotti in 1933, following which Alberto Gutiérrez described the hanging drop technique. Both techniques are now used to identify when the needle has correctly been placed in the epidural space.[64][20]

In 1921 Fidel Pagés, a military surgeon from Spain, developed the technique of "single-shot" lumbar epidural anesthesia,[65] which was later popularized by Italian surgeon Achille Mario Dogliotti.[66] Later, in 1931 Eugen Aburel described using a continuous epidural catheter for pain relief during childbirth.[67][64] In 1941, Robert Hingson and Waldo Edwards recorded the use of continuous caudal anesthesia using an indwelling needle,[68] following which they described the use of a flexible catheter for continuous caudal anesthesia in a woman in labor in 1942.[69] In 1947, Manuel Curbelo described placement of a lumbar epidural catheter,[70] and in 1979, Behar reported the first use of an epidural to administer narcotics.[71]

## Society and culture

Some people continue to be concerned that women who are administered epidural analgesia during labor are more likely to require a cesarean delivery, based on older observational studies.[72] However, evidence has shown that the use of epidural analgesia during labor does not have any statistically significant effect on the necessity to perform a cesarean delivery. A 2018 Cochrane review found no increase in the rate of Caesarean delivery when epidural analgesia was employed.[3] However, epidural analgesia does lengthen the second stage of labor by 15 to 30 minutes, which may increase the risk a delivery must be assisted by instruments.[73][74]

In the United States in 1998, it was reported that over half of childbirths involved the use of epidural analgesia,[75] and by 2008 this had increased to 61% of births.[76] In the United Kingdom, epidurals have been offered through the National Health Service for all women during childbirth since 1980. By 1998, epidural analgesia was used in the UK for almost 25% of childbirths.[77] In Japan, most childbirths take place in primary or secondary hospitals in which epidural analgesia is not offered.[78]

In some developed countries, over 70% of childbirths involve epidural analgesia.[79] Other studies have shown that minority women and immigrants are less likely to receive epidural analgesia during childbirth.[80] Even in countries with universal healthcare coverage such as Canada, socioeconomic factors such as race, financial stability, and education influence the rate at which women receive epidural analgesia.[81] One survey in 2014 found that over half of pregnant women in a Nigerian antenatal clinic (79.5%) did not know what epidural analgesia was or what it was used for, while 76.5% of them would utilize epidural analgesia if offered after it was explained to them.[82]

## References

1. ↑ Epidural (3rd ed.), Oxford University Press, September 2005, http://oed.com/search?searchType=dictionary&q=Epidural, retrieved 1 November 2020 (Subscription or UK public library membership required.)
2. ↑ Schrock, SD; Harraway-Smith, C (1 March 2012). "Labor analgesia". American Family Physician 85 (5): 447–54. PMID 22534222.
3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 "Epidural versus non-epidural or no analgesia in labour". The Cochrane Database of Systematic Reviews 2018 (5). 2018. doi:10.1002/14651858.CD000331.pub4. PMID 29781504.
4. ↑ Buckley, Sarah (2014-01-24). "Epidurals: risks and concerns for mother and baby". Midwifery Today with International Midwife (Mothering No.133) (81): 21–3, 63–6. PMID 17447690. http://sarahbuckley.com/epidurals-risks-and-concerns-for-mother-and-baby#ref. Retrieved April 18, 2014.
5. ↑ "Epidural clonidine: a review of its pharmacology and efficacy in the management of pain during labour and postoperative and intractable pain". CNS Drugs 6 (6): 474–497. 1996. doi:10.2165/00023210-199606060-00007.
6. ↑ "Anesthesia". Harvard University Press. http://search.credoreference.com/content/entry/hupwh/anesthesia/0?searchId=9b195ee2-c732-11e3-b874-0aea1e3b2a47&result=1.
7. ↑ 7.0 7.1 "Early versus late initiation of epidural analgesia for labour.". The Cochrane Database of Systematic Reviews 2014 (10). October 9, 2014. doi:10.1002/14651858.CD007238.pub2. PMID 25300169.
8. ↑ "Safe, healthy birth: what every pregnant woman needs to know". J Perinat Educ 18 (3): 48–54. 2009. doi:10.1624/105812409X461225. PMID 19750214.
9. ↑ "Efficacy of postoperative epidural analgesia: a meta-analysis". JAMA 290 (18): 2455–63. 2003. doi:10.1001/jama.290.18.2455. PMID 14612482.
10. ↑ "The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials". Anesth Analg 86 (3): 598–612. 1998. doi:10.1097/00000539-199803000-00032. PMID 9495424.
11. ↑ 11.0 11.1 11.2 Oxford handbook of anaesthesia. Oxford: Oxford University Press. 2006. p. 1038. ISBN 978-0-19-856609-0.
12. ↑ "Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis". Anesth Analg 93 (4): 853–8. 2001. doi:10.1097/00000539-200110000-00010. PMID 11574345.
13. ↑ "The effect of epidural analgesia on postoperative outcome after colorectal surgery". Colorectal Disease 9 (7): 584–98; discussion 598–600. 2007. doi:10.1111/j.1463-1318.2007.1274.x. PMID 17506795.
14. ↑ Guay, Joanne; Kopp, Sandra (2019-03-01). "Epidural analgesia for adults undergoing cardiac surgery with or without cardiopulmonary bypass". The Cochrane Database of Systematic Reviews 2019 (3). doi:10.1002/14651858.CD006715.pub3. ISSN 1469-493X. PMID 30821845.
15. ↑ Salicath, Jon H.; Yeoh, Emily Cy; Bennett, Michael H. (2018-08-30). "Epidural analgesia versus patient-controlled intravenous analgesia for pain following intra-abdominal surgery in adults". The Cochrane Database of Systematic Reviews 8 (10). doi:10.1002/14651858.CD010434.pub2. ISSN 1469-493X. PMID 30161292.
16. ↑ 16.0 16.1 16.2 16.3 16.4 16.5 16.6 16.7 16.8 Schneider, Byron; Zheng, Patricia; Mattie, Ryan; Kennedy, David J. (2 August 2016). "Safety of epidural steroid injections". Expert Opinion on Drug Safety 15 (8): 1031–1039. doi:10.1080/14740338.2016.1184246. PMID 27148630.
17. ↑ Tubben, Robert E.; Murphy, Patrick B. (2018), "Epidural Blood Patch", StatPearls (StatPearls Publishing), PMID 29493961, https://www.ncbi.nlm.nih.gov/books/NBK482336/, retrieved 2018-10-31
18. ↑ White, Benjamin; Lopez, Victor; Chason, David; Scott, David; Stehel, Edward; Moore, William (2019-03-28). The lumbar epidural blood patch: A Primer. Applied Radiology. 48 (2): 25–30.
19. ↑ Nath, Gita; Subrahmanyam, Maddirala (2011). "Headache in the parturient: Pathophysiology and management of post-dural puncture headache" (in en). Journal of Obstetric Anaesthesia and Critical Care 1 (2): 57. doi:10.4103/2249-4472.93988. ISSN 2249-4472. https://www.joacc.com/text.asp?2011/1/2/57/93988.
20. ↑ 20.0 20.1 20.2 20.3 20.4 20.5 "Epidural analgesia for labor: Current techniques". Local and Regional Anesthesia 3: 143–53. 2010. doi:10.2147/LRA.S10237. PMID 23144567.
21. ↑ "The effect of local anesthetic agents on afferent and motor nerve impulses in the frog". Archives Internationales de Pharmacodynamie et de Therapie 237 (2): 255–66. February 1979. PMID 485692.
22. ↑ 22.0 22.1 "Procedural sedation: A review of sedative agents, monitoring, and management of complications". Saudi Journal of Anaesthesia 5 (4): 395–410. October 2011. doi:10.4103/1658-354X.87270. PMID 22144928.
23. ↑ "Inadequate pain relief with labor epidurals: a multivariate analysis of associated factors". Int J Obstet Anesth 18 (1): 10–4. January 2009. doi:10.1016/j.ijoa.2007.10.008. PMID 19046867.
24. ↑ Oxford handbook of anaesthesia. Oxford: Oxford University Press. 2006. p. 20. ISBN 978-0-19-856609-0.
25. ↑ Basurto, Ona (15 July 2015). "Drugs for treating headache after a lumbar puncture". The Cochrane Database of Systematic Reviews (The Cochrane Library) 2015 (7). doi:10.1002/14651858.CD007887.pub3. PMID 26176166. PMC 6457875. https://www.cochrane.org/CD007887/SYMPT_drugs-treating-headache-after-lumbar-puncture. Retrieved 16 November 2018. "Caffeine proved to be effective in decreasing the number of people with PDPH and those requiring extra drugs (2 or 3 in 10 with caffeine compared to 9 in 10 with placebo). Gabapentin, theophylline and hydrocortisone also proved to be effective, relieving pain better than placebo".
26. ↑ 26.0 26.1 "Negative aspiration for cerebral fluid does not assure proper placement of epidural catheter.". AANA J 60 (3): 301–3. 2002. PMID 1632158.
27. ↑ "Soft catheters reduce the risk of intravascular cannulation during epidural block—a retrospective analysis of 1,117 cases in a medical center". Kaohsiung J. Med. Sci. 28 (7): 373–6. 2012. doi:10.1016/j.kjms.2012.02.004. PMID 22726899.
28. ↑ "Incidence of neurologic complications related to thoracic epidural catheterization". Anesthesiology 86 (1): 55–63. 1997. doi:10.1097/00000542-199701000-00009. PMID 9009940.
29. ↑ 29.0 29.1 Estcourt, Lise J; Malouf, Reem; Hopewell, Sally; Doree, Carolyn; Van Veen, Joost (2018-04-30). Cochrane Haematological Malignancies Group. ed. "Use of platelet transfusions prior to lumbar punctures or epidural anaesthesia for the prevention of complications in people with thrombocytopenia" (in en). Cochrane Database of Systematic Reviews 2018 (4). doi:10.1002/14651858.CD011980.pub3. PMID 29709077.
30. ↑ 30.0 30.1 30.2 "Epidurals and risk: it all depends". http://www.medicine.ox.ac.uk/bandolier/band159/b159-3.html.
31. ↑ 31.0 31.1 Oxford handbook of anaesthesia. Oxford: Oxford University Press. 2006. p. 21. ISBN 978-0-19-856609-0.
32. ↑ "Obstetric epidurals and chronic adhesive arachnoiditis". Br J Anaesth 92 (1): 109–20. January 2004. doi:10.1093/bja/aeh009. PMID 14665562.
33. ↑ Pawa, Amit; King, Christopher; Thang, Christopher; White, Leigh (February 2023). "Erector spinae plane block: the ultimate 'plan A' block?". British Journal of Anaesthesia 130 (5): 497–502. doi:10.1016/j.bja.2023.01.012. PMID 36775671.
34. ↑ "Successful Use of a 20% Lipid Emulsion to Resuscitate a Patient after a Presumed Bupivacaine-related Cardiac Arrest". Anesthesiology 105 (7): 217–8. 2006. doi:10.1097/00000542-200607000-00033. PMID 16810015.
35. ↑ Mulroy MF (2002). "Systemic toxicity and cardiotoxicity from local anesthetics: incidence and preventive measures.". Reg Anesth Pain Med 27 (6): 556–61. doi:10.1053/rapm.2002.37127. PMID 12430104.
36. ↑ "A dose-response study of intrathecal morphine: efficacy, duration, optimal dose, and side effects". Anesthesia & Analgesia 67 (11): 1082–8. 1988. doi:10.1213/00000539-198867110-00011. PMID 3189898.
37. ↑ "Delayed respiratory arrest after epidural hydromorphone". Anaesthesia 42 (4): 404–6. 1987. doi:10.1111/j.1365-2044.1987.tb03982.x. PMID 2438964.
38. ↑ 38.0 38.1 "Postoperative urinary retention: anesthetic and perioperative considerations". Anesthesiology 110 (5): 1139–57. May 2009. doi:10.1097/ALN.0b013e31819f7aea. PMID 19352147.
39. ↑ "Effects of Intrapartum Oxytocin Administration and Epidural Analgesia on the Concentration of Plasma Oxytocin and Prolactin, in Response to Suckling During the Second Day Postpartum". Breastfeed Med 4 (2): 71–82. 2009. doi:10.1089/bfm.2008.0002. PMID 19210132.
40. ↑ "Epidural Analgesia With or Without Oxytocin, but Not Oxytocin Alone, Administered During Birth Disturbs Infant Pre-feeding and Sucking Behaviors and Maternal Oxytocin Levels in Connection With a Breastfeed Two Days Later". Frontiers in Neuroscience 15. 2021. doi:10.3389/fnins.2021.673184. PMID 34267623.
41. ↑ "A simple epidural simulator: a blinded study assessing the 'feel' of loss of resistance in four fruits.". Eur J Anaesthesiol 30 (7): 405–8. 2013. doi:10.1097/EJA.0b013e328361409c. PMID 23749185.
42. ↑ Leighton BL (1989). "A greengrocer's model of the epidural space.". Anesthesiology 70 (2): 368–9. doi:10.1097/00000542-198902000-00038. PMID 2913877.
43. ↑ Nagel, Sean J.; Reddy, Chandan G.; Frizon, Leonardo A.; Holland, Marshall T.; Machado, Andre G.; Gillies, George T.; Howard, Matthew A. (October 2018). "Intrathecal Therapeutics: Device Design, Access Methods, and Complication Mitigation: INTRATHECAL THERAPEUTICS REVIEW". Neuromodulation: Technology at the Neural Interface 21 (7): 625–640. doi:10.1111/ner.12693. PMID 28961351.
44. ↑ Antibas, Pedro L; do Nascimento Junior, Paulo; Braz, Leandro G; Vitor Pereira Doles, João; Módolo, Norma SP; El Dib, Regina (2014-07-17). "Air versus saline in the loss of resistance technique for identification of the epidural space". Cochrane Database of Systematic Reviews 2015 (7). doi:10.1002/14651858.cd008938.pub2. ISSN 1465-1858. PMID 25033878.
45. ↑ "Ultrasound-guided epidural catheter insertion in children". Anesthesia & Analgesia 101 (2): 333–9, table of contents. 2005. doi:10.1213/01.ANE.0000156579.11254.D1. PMID 16037140.
46. ↑ "The optimal distance that a multiorifice epidural catheter should be threaded into the epidural space". Anesth Analg 81 (2): 301–4. 1995. doi:10.1097/00000539-199508000-00016. PMID 7618719.
47. ↑ "Automated regular boluses for epidural analgesia: a comparison with continuous infusion". Int J Obstet Anesth 14 (4): 305–9. 2005. doi:10.1016/j.ijoa.2005.05.004. PMID 16154735.
48. ↑ "A randomized comparison of programmed intermittent epidural bolus with continuous epidural infusion for labor analgesia". Anesthesia & Analgesia 102 (3): 904–9. 2006. doi:10.1213/01.ane.0000197778.57615.1a. PMID 16492849.
49. ↑ "A comparison of a basal infusion with automated mandatory boluses in parturient-controlled epidural analgesia during labor". Anesthesia & Analgesia 104 (3): 673–8. 2007. doi:10.1213/01.ane.0000253236.89376.60. PMID 17312228.
50. ↑ "Is urinary drainage necessary during continuous epidural analgesia after colonic resection?". Reg Anesth Pain Med 25 (5): 498–501. 2000. doi:10.1053/rapm.2000.9537. PMID 11009235.
51. ↑ Simmons, Scott W; Dennis, Alicia T; Cyna, Allan M; Richardson, Matthew G; Bright, Matthew R (10 October 2019). "Combined spinal-epidural versus spinal anesthesia for caesarean section". Cochrane Database of Systematic Reviews 10 (10). doi:10.1002/14651858.CD008100.pub2. PMID 31600820.
52. ↑ "Bacterial colonization and infection rate of continuous epidural catheters in children". Anesth Analg 86 (4): 712–6. 1998. doi:10.1097/00000539-199804000-00007. PMID 9539589.
53. ↑ "Epidural catheter colonization is not associated with infection". Surgical Infections 3 (4): 359–65. 2002. doi:10.1089/109629602762539571. PMID 12697082.
54. ↑ "Bacterial colonization of epidural catheters used for short-term postoperative analgesia: microbiological examination and risk factor analysis". Anesthesiology 108 (1): 130–7. 2008. doi:10.1097/01.anes.0000296066.79547.f3. PMID 18156891.
55. ↑ "Chlorhexidine versus povidone iodine in preventing colonization of continuous epidural catheters in children: a randomized, controlled trial". Anesthesiology 94 (2): 239–44. 2001. doi:10.1097/00000542-200102000-00012. PMID 11176087.
56. ↑ "Tunneled epidural catheters for prolonged analgesia in pediatric patients". Anesth Analg 92 (6): 1432–8. 2001. doi:10.1097/00000539-200106000-00016. PMID 11375820.
57. ↑ "Subcutaneous tunneling of caudal catheters reduces the rate of bacterial colonization to that of lumbar epidural catheters". Anesthesia & Analgesia 99 (3): 689–93, table of contents. 2004. doi:10.1213/01.ANE.0000130023.48259.FB. PMID 15333395.
58. ↑ "Epidural" (in en). UK National Health Service. 11 March 2020. https://www.nhs.uk/conditions/epidural/.
59. ↑ Cassanova, Robert (2018). Beckmann and Ling's obstetrics and gynecology (8th ed.). Philadelphia: Wolters Kluwer. pp. 120–126. ISBN 978-1-4963-5309-2.
60. ↑ Shi, W.-Z.; Miao, Y.-L.; Yakoob, M. Y.; Cao, J.-B.; Zhang, H.; Jiang, Y.-G.; Xu, L.-H.; Mi, W.-D. (September 2014). "Recovery of gastrointestinal function with thoracic epidural vs. systemic analgesia following gastrointestinal surgery: Analgesia and gastrointestinal function". Acta Anaesthesiologica Scandinavica 58 (8): 923–932. doi:10.1111/aas.12375. PMID 25060245.
61. ↑ Jakobsen, Carl-Johan (March 2015). "High Thoracic Epidural in Cardiac Anesthesia: A Review". Seminars in Cardiothoracic and Vascular Anesthesia 19 (1): 38–48. doi:10.1177/1089253214548764. PMID 25201889.
62. ↑ Corning, JL (1885). "Spinal anaesthesia and local medication of the cord". New York Medical Journal 42: 483–5.
63. ↑ Marx, GF (1994). "The first spinal anesthesia. Who deserves the laurels?". Regional Anesthesia 19 (6): 429–30. PMID 7848956.
64. ↑ 64.0 64.1 "One hundred years of epidural anaesthesia—the men behind the technical development". International Congress Series 1242: 203–212. December 2002. doi:10.1016/s0531-5131(02)00770-7.
65. ↑ Pagés, F (1921). "Anestesia metamérica" (in es). Revista de Sanidad Militar 11: 351–4.
66. ↑ "Research and clinical observations on spinal anesthesia: with special reference to the peridural technique". Current Researches in Anesthesia & Analgesia 12 (2): 59–65. 1933.
67. ↑ "Eugen Bogdan Aburel (1899–1975). The pioneer of regional analgesia for pain relief in childbirth". Anaesthesia 37 (6): 663–9. June 1982. doi:10.1111/j.1365-2044.1982.tb01279.x. PMID 6178307.
68. ↑ "Continuous caudal anesthesia in obstetrics". American Journal of Surgery 57 (3): 459–64. 1942. doi:10.1016/S0002-9610(42)90599-3.
69. ↑ "Continuous Caudal Analgesia in Obstetrics". Journal of the American Medical Association 121 (4): 225–9. 1943. doi:10.1001/jama.1943.02840040001001.
70. ↑ Martinez Curbelo, M (1949). "Continuous peridural segmental anesthesia by means of a ureteral catheter". Current Researches in Anesthesia & Analgesia 28 (1): 13–23. doi:10.1213/00000539-194901000-00002. PMID 18105827.
71. ↑ Behar, M; Olshwang, D; Magora, F; Davidson, J (1979). "Epidural morphine in treatment of pain". The Lancet 313 (8115): 527–529. doi:10.1016/S0140-6736(79)90947-4. PMID 85109.
72. ↑ "Risk of cesarean delivery with elective induction of labour at term in nulliparous women". Obstet Gynecol 94 (4): 600–607. 1999. doi:10.1016/S0029-7844(99)00377-4. PMID 10511367.
73. ↑ "Rates of caesarean section and instrumental vaginal delivery in nulliparous women after low concentration epidural infusions or opioid analgesia: systematic review". BMJ 328 (7453): 1410. June 2004. doi:10.1136/bmj.38097.590810.7C. PMID 15169744.
74. ↑ "A multicenter randomized controlled trial comparing patient-controlled epidural with intravenous analgesia for pain relief in labor". Anesthesia & Analgesia 99 (5): 1532–8; table of contents. November 2004. doi:10.1213/01.ANE.0000136850.08972.07. PMID 15502060.
75. ↑ Vincent RD, Jr; Chestnut, DH (15 November 1998). "Epidural analgesia during labor.". American Family Physician 58 (8): 1785–92. PMID 9835854.
76. ↑ ﻿Epidural and Spinal Anesthesia Use During Labor: 27-state Reporting Area, 2008﻿ (Report). Centers for Disease Control and Prevention. 6 April 2011. https://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_05.pdf. Retrieved 1 November 2020.
77. ↑ Burnstein, R.; Buckland, R.; Pickett, J. A. (July 1999). "A survey of epidural analgesia for labour in the United Kingdom: Epidural analgesia for labour in the UK". Anaesthesia 54 (7): 634–640. doi:10.1046/j.1365-2044.1999.00894.x. PMID 10417453.
78. ↑ Suzuki, R; Horiuchi, S; Ohtsu, H (September 2010). "Evaluation of the labor curve in nulliparous Japanese women.". American Journal of Obstetrics and Gynecology 203 (3): 226.e1–6. doi:10.1016/j.ajog.2010.04.014. PMID 20494329.
79. ↑ Bucklin, BA; Hawkins, JL; Anderson, JR; Ullrich, FA (September 2005). "Obstetric anesthesia workforce survey: twenty-year update.". Anesthesiology 103 (3): 645–53. doi:10.1097/00000542-200509000-00030. PMID 16129992.
80. ↑ Glance, LG; Wissler, R; Glantz, C; Osler, TM; Mukamel, DB; Dick, AW (January 2007). "Racial differences in the use of epidural analgesia for labor.". Anesthesiology 106 (1): 19–25. doi:10.1097/00000542-200701000-00008. PMID 17197841.
81. ↑ Liu, N; Wen, SW; Manual, DG; Katherine, W; Bottomley, J; Walker, MC (March 2010). "Social disparity and the use of intrapartum epidural analgesia in a publicly funded health care system.". American Journal of Obstetrics and Gynecology 202 (3): 273.e1–8. doi:10.1016/j.ajog.2009.10.871. PMID 20045506.
82. ↑ Okojie, NQ; Isah, EC (October 2014). "Perception of Epidural Analgesia for Labour Among Pregnant Women in a Nigerian Tertiary Hospital Setting". Journal of the West African College of Surgeons 4 (4): 142–62. PMID 27182515.

## Further reading

* Boqing Chen and Patrick M. Foye, UMDNJ: New Jersey Medical School, Epidural Steroid Injections: Non-surgical Treatment of Spine Pain, eMedicine: Physical Medicine and Rehabilitation (PM&R), August 2005. Also available online.
* "The effects of epidural analgesia on labor, maternal, and neonatal outcomes: a systematic review". Am J Obstet Gynecol 186 (5 Suppl Nature): S69–77. 2002. doi:10.1067/mob.2002.121813. PMID 12011873.
* "Does epidural analgesia prolong labor and increase risk of cesarean delivery? A natural experiment". Am J Obstet Gynecol 185 (1): 128–34. 2001. doi:10.1067/mob.2001.113874. PMID 11483916.

## External links

* MedlinePlus Encyclopedia

* v
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Anesthesia and anesthesiology

Types|

* General
* Sedation
* Twilight anesthesia
* Local
* Topical
* Intercostal nerve block
* Neuraxial blockade
* Spinal
* Epidural
* Dental
* Inferior alveolar nerve

Techniques|

* Airway management
* Anesthesia provision in the US
* Arterial catheter
* Bronchoscopy
* Capnography
* Dogliotti's principle
* Drug-induced amnesia
* Intraoperative neurophysiological monitoring
* Nerve block
* Penthrox inhaler
* Tracheal intubation

Scientific principles|

* Blood–gas partition coefficient
* Concentration effect
* Fink effect
* Minimum alveolar concentration
* Second gas effect

Measurements|

* ASA physical status classification system
* Baricity
* Bispectral index
* Entropy monitoring
* Fick principle
* Goldman index
* Guedel's classification
* Mallampati score
* Neuromuscular monitoring
* Thyromental distance

Instruments|

* Anaesthetic machine
* Anesthesia cart
* Boyle's machine
* Gas cylinder
* Laryngeal mask airway
* Laryngeal tube
* Medical monitor
* Odom's indicator
* Relative analgesia machine
* Vaporiser
* Double-lumen endotracheal tube
* Endobronchial blocker

Complications|

* Emergence delirium
* Allergic reactions
* Anesthesia awareness
* Local anesthetic toxicity
* Malignant hyperthermia
* Perioperative mortality
* Postanesthetic shivering
* Postoperative nausea and vomiting
* Postoperative residual curarization

Subspecialties|

* Cardiothoracic
* Critical emergency medicine
* Geriatric
* Intensive care medicine
* Obstetric
* Oral sedation dentistry
* Pain medicine

Professions|

* Anesthesiologist
* Anesthesiologist assistant
* Nurse anesthetist
* Operating department practitioners
* Certified Anesthesia Technician
* Certified Anesthesia Technologist
* Anaesthetic technician
* Physicians' assistant (anaesthesia)

History|

* ACE mixture
* Helsinki Declaration for Patient Safety in Anaesthesiology
* History of general anesthesia
* History of neuraxial anesthesia
* History of tracheal intubation

Organizations|

* American Association of Nurse Anesthetists
* American Society of Anesthesia Technologists & Technicians
* American Society of Anesthesiologists
* Anaesthesia Trauma and Critical Care
* Association of Anaesthetists of Great Britain and Ireland
* Royal College of Anaesthetists
* Association of Veterinary Anaesthetists
* Australian and New Zealand College of Anaesthetists
* Australian Society of Anaesthetists
* International Anesthesia Research Society

* Category
* Outline

* v
* t
* e

Routes of administration, dosage forms

Oral|

| Digestive
tract (enteral)|

| Solids|

* Pill
* Tablet
* Capsule
* Pastille
* Time release technology
* Osmotic delivery system (OROS)

|
|

Liquids|

* Decoction
* Elixir
* Electuary
* Emulsion
* Extended-release syrup
* Effervescent powder or tablet
* Herbal tea
* Hydrogel
* Molecular encapsulation
* Powder
* Softgel
* Solution
* Suspension
* Syrup
* Syrup Concentrate for dilution and/or addition of carbonated water
* Tincture

Buccal (sublabial),
sublingual|

| Solids|

* Orally disintegrating tablet (ODT)
* Film
* Lollipop
* Sublingual drops
* Lozenges
* Effervescent buccal tablet
* Chewing gum

|

Liquids|

* Mouthwash
* Toothpaste
* Ointment
* Oral spray

Respiratory
tract|

| Solids|

* Smoking device
* Dry-powder inhaler (DPI)

|
|

Liquids|

* Anaesthetic vaporizer
* Vaporizer
* Nebulizer
* Metered-dose inhaler (MDI)

Gas|

* Oxygen mask and Nasal cannula
* Oxygen concentrator
* Anaesthetic machine
* Relative analgesia machine

Ophthalmic,
otologic, nasal]]|

* Nasal spray
* Ear drops
* Eye drops
* Ointment
* Hydrogel
* Nanosphere suspension
* Insufflation
* Mucoadhesive microdisc (microsphere tablet)

Urogenital|

* Ointment
* Pessary (vaginal suppository)
* Vaginal ring
* Vaginal douche
* Intrauterine device (IUD)
* Extra-amniotic infusion
* Intravesical infusion

Rectal (enteral)|

* Ointment
* Suppository
* Enema
* Solution
* Hydrogel
* Murphy drip
* Nutrient enema

Dermal|

* Ointment
* Topical cream
* Topical gel
* Liniment
* Paste
* Film
* DMSO drug solution
* Electrophoretic dermal delivery system
* Hydrogel
* Liposomes
* Transfersome vesicles
* Cream
* Lotion
* Lip balm
* Medicated shampoo
* Dermal patch
* Transdermal patch
* Contact (rubbed into break in the skin)
* Transdermal spray
* Jet injector

Injection,
infusion<br />(into tissue/blood)

| Skin|

* Intradermal
* Subcutaneous
* Transdermal implant

|
|

Organs|

* Intracavernous
* Intravitreal
* Intra-articular injection
* Transscleral

Central nervous system|

* Intracerebral
* Intrathecal
* Epidural

Circulatory,
musculoskeletal|

* Intravenous
* Intracardiac
* Intramuscular
* Intraosseous
* Intraperitoneal
* Nanocell injection
* Patient-controlled analgesia pump
* PIC line

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