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EPIDURAL ANALGESIA – CURRENT VIEWS AND APPROACHES

EPIDURAL ANALGESIA

Edited by Sotonye Fyneface-Ogan .

174 pages .
Open Access . 


The World Health Organization defines pain as “an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. According to Baszanger, “[p]ain is a person's private experience, to which no one else has direct access and cannot be reduced by objectification, it cannot, ultimately, be stabilized as an unquestionable fact that can serve as the basis of medical practice and thus organize relations between professional and lay persons”.
Therefore pain, whatever the source, must be treated. Epidural analgesia has been extensively used to relieve pain of some regions of the human body.
Epidural analgesia is now frequently used to carry out postoperative and labor analgesia. First described in 1901 by Corning, the exploration of the epidural space is technically demanding and requires a good knowledge of the relevant anatomy and contents of the space.
The use of this space for various purposes in obstetrics has improved over the years.
One publication by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia illustrates consistent improvement of knowledge in this area. Epidural analgesia is produced with the use of low dose local anesthetics (such as bupivacaine, ropivacaine, lidocaine, levobupivacaine), opioids, or alpha agonists alone, or in combination. It is known to provide superior regional analgesia over conventional systemic routes (intravenous or enteral), with minimal systemic side effects (nausea, sedation, constipation). In low doses these local anesthetics produce more sensory block and with less motor block. However the aim of striking a difficult balance between the lowest motor block possible (to facilitate labour and vaginal delivery, and even allow ambulation) and an optimal analgesia could be a challenging one. Local anesthetic concentrations as low as 0.0625% bupivacaine have been used with fentanyl 20 micrograms for epidural analgesia for labor.
Generally speaking, agents injected into the epidural space are distributed by three main pathways: diffusion through the dura into the cerebrospinal fluid (CSF), then to the spinal cord or nerve roots; vascular uptake by the vessels in the epidural space into systemic circulation; and uptake by the fat in the epidural space, creating a drug depot from which the drug can eventually enter the CSF or the systemic circulation.

Epidural analgesia is a commonly employed technique of providing pain relief during labor. The number of parturients given intrapartum epidural analgesia is reported to be over 50% at many institutions in the United States and United Kingdom. While this figure is much lower in some developed countries, intrapartum epidural analgesia is almost non-existent in many parts of low resource countries as a result of the dearth of manpower and equipment. A survey of obstetric anesthesia in the United States indicated that the percentage of women given intrapartum epidural analgesia increased from 22% in 1981 to 51% in 1992 at hospitals performing at least 1,500 deliveries annually. The increased availability of epidural analgesia and the favorable experiences of women who have had painless labor with epidural block have reshaped the expectations of pregnant women entering labor.
Although epidural analgesia is the most widely used method of pain relief in childbirth it does not mean that the method is free of complications or contraindications, but these are considered to be of minor importance and a generally infrequent event. In general, the gains outweigh the losses and epidurals are now
regarded as a safe method for both mothers and babies. 
Pain from labor or otherwise does not involve only the patient, or the expectant mother, but their families and relations as well as the professionals who assist the patient and who give sense and meaning to the pain of others through compassion, acknowledgement and admiration; sentiments that the sufferer perceives and analyses as part of the meaning of such suffering, and which finally legitimizes it or not, gives it meaning or not, and therefore makes it seem “useful” or not. Pain must be relieved no matter the gender or the age!
Epidural analgesia has been well-known to confer excellent pain relief and complete dynamic analgesia leading to a substantial reduction in the surgical stress response. It provides favorable effects on coagulation and homeostasis, as well as on cardiorespiratory, gastrointestinal and immune functions, all these potential positive influences being theoretically translated into an improved quality of patient recovery.
Epidural analgesia can be administered by intermittent boluses (by a clinician or by patient controlled epidural analgesia (PCEA) using an appropriate pump); continuous infusion; or a combination thereof. PCEA is used to supplement a basal rate, to allow a patient to manage breakthrough pain in order to meet their individual analgesic requirements. Like Intravenous Patient Controlled Analgesia (IV PCA), PCEA can provide more timely pain relief, more control for the patient, and convenience for both the patient and nurse to reduce the time required to obtain and administer required supplemental boluses. Unlike IV PCA, the lockout interval of PCEA varies widely based on the lipid solubility of the opioid administered, from 10 minutes with fentanyl to 60 to 90 minutes when morphine is used. If local anesthetic is used, the lockout interval is taught to be at least 15 minutes to allow for peak effect of the supplemental local anesthetic dose.

Epidural analgesia has been found to be very useful for postoperative pain relief in paediatric patients. Some of the numerous benefits include earlier ambulation, rapid weaning from ventilators, reduced time spent in a catabolic state, and lowered circulating stress hormone levels. Specific protocols and guidelines tailored to suit the pediatric patients can increase the success of placement, optimize the efficacy of analgesia and increase overall safety. These specific epidural protocols are directed at how to confirm correct catheter placement, which type of age-specific infusion to use and how much is safe, and how to treat side effects. Epidural analgesia is useful as part of a multimodal approach to acute and chronic pain management in children. The single S+ isomers, ropivacaine and levobupivacaine, are the drugs of choice in pediatric practice. The reduced cardiac and central nervous system toxicity, and less motor blockade, suggest that these agents may be more beneficial, particularly in infants and neonates. The maximum suggested dosage for racemic bupivacaine (0.2mg/kg/h for infants and neonates, 0.4 mg/kg/ h for older children) has led to improved safety of continuous epidural infusions. 
The administration of pharmacologic active agents to geriatric patients is complicated by the adverse conditions imposed by the aging process such as diminished functional activity, decreased metabolic rate, decreased function of liver and kidneys, increased sensitivity to anoxia and loss of blood, and increased drug sensitivity is likewise increasing in importance. Epidural analgesia has been found to reduce the intravenous opioid requirements in the geriatric population following surgeries of thoracic, upper abdominal, lower abdominal region.
Generally, epidural analgesia is time-consuming; it requires specific technical skills, pharmacological abilities and professional surveillance. Clearly, epidural analgesia is not devoid of risks and failures may occur.

Sotonye Fyneface-Ogan B.Med.Sc, M.B;B.S, PgDA, FWACS
Senior Lecturer
Head of Department of Anesthesiology
Faculty of Clinical Sciences
College of Health Sciences
University of Port Harcourt,
Port Harcourt,
Nigeria




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CONTENTS OF THE BOOK :




 1 Anatomy and Clinical Importance of the Epidural Space 1 Sotonye Fyneface-Ogan

 2 Local Anaesthetic Epidural Solution for Labour: About Concentrations and Additives 13 Christian Dualé and Martine Bonnin

 3 Patient-Controlled Analgesia After Major Abdominal Surgery in the Elderly Patient 27 Viorel Gherghina, Gheorghe Nicolae, Iulia Cindea, Razvan Popescu and Catalin Grasa

 4 Epidural Analgesia for Perioperative Upper Abdominal Surgery 43 Arunotai Siriussawakul and Aticha Suwanpratheep

 5 The Impact of Epidural Analgesia on Postoperative Outcome After Major Abdominal Surgery 55 Iulia Cindea, Alina Balcan, Viorel Gherghina, Bianca Samoila, Dan Costea, Catalin Grasa and Gheorghe Nicolae

 6 Epidural Analgesia in Labour from a Sociological Perspective – A Case Analysis of Andalusia, Spain 73 Rafael Serrano-del-Rosal, Lourdes Biedma-Velázquez and José Mª García-de-Diego

 7 Actualities and Perspectives in Continuous Epidural Analgesia During Childbirth in Romania 95 Virgil Dorca, Dan Mihu, Diana Feier, Adela Golea and Simona Manole

 8 Combined Spinal Epidural Anesthesia and Analgesia 115 Dusica Stamenkovic and Menelaos Karanikolas

 9 Contraindications – Hemorrhage and Coagulopathy, and Patient Refusal 135 Bahanur Cekic and Ahmet Besir





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Published by: younes younes - Tuesday, March 26, 2013

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