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Fast Fact and Concept #85: Epidural Analgesia

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Title: Fast Fact and Concept #85: Epidural Analgesia

Author(s): Gordon, Deb; Schroeder, Mark

Epidural analgesia with local anesthetics, opioids, or alpha agonists alone, or in combination, can provide superior regional analgesia over conventional systemic routes (IV or PO), with minimal systemic side effects (nausea, sedation, constipation). In palliative care, epidural analgesia may be appropriate for patients with regional pain (e.g. pelvic pain from cervical cancer) and/or patients who do not tolerate or obtain relief from oral/parenteral drugs and non-drug therapies. Drugs administered epidurally are distributed by three main pathways:

  1. diffusion through the dura into the CSF, then to the spinal cord or nerve roots;
  2. vascular uptake by the vessels in the epidural space into systemic circulation; and
  3. 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 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 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 60-90 minutes when morphine is used. If local anesthetic is used, the lockout interval should be at least 15 minutes to allow for peak effect of the supplemental local anesthetic dose.

In contrast to drugs administered systemically, drugs administered in the epidural space are extremely potent since the drug is delivered close to the site of action (opioid and alpha agonist receptors in the spinal dorsal horn or local anesthetic blockade of nerve roots). Therefore, frequent assessment of pain relief, side effects, and signs or symptoms of technical complications (catheter dislodgement, epidural hematoma or abscess, pump malfunction, etc.) are necessary every hour for the first 24 hours, then every 4 hours. Assess and document on the pain management flowsheet:

  1. patients pain rating using patient-specific pain scale (e.g. 0-10), both at rest and with activity
  2. level of sedation & respiratory rate, preferably by the same nurse during each shift
  3. side effects: pruritis, nausea, urinary retention, orthostatic hypotension, motor block
  4. sign of catheter insertion site infection or epidural abscess, e.g., back pain, tenderness, erythema, swelling, drainage, fever, malaise, neck stiffness, or motor block
  5. changes in sensory/motor function that may indicate an epidural hematoma including unexplained back pain, leg pain, bowel or bladder dysfunction, motor block

References:

Pasero C, Portenoy RK, McCaffery M. Opioid Analgesics. In Pain: Clinical Manual: 2nd Ed. Eds M. McCaffery & C. Pasero, Mosby, 1999, pp161-299.

Epidural Analgesia 3rd ed. A Self Directed Learning Module. Schroeder S, Gordon D, Deeren D, Ford M, Schroeder M. University of Wisconsin Hospital & Clinics, Madison, WI 2000.http://www.wisc.edu/trc/projects/pop/Epi-manual.pdf

Acknowledgement: The Fast Fact is adapted with permission from: Patient Controlled Epidural Analgesia (PCEA); Pain Management Fast Facts-5 Minute Inservice; University of Wisconsin Pain Team, D Gordon, RN.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing. Fast Facts and Concepts #85 . Epidural Analgesia. Gordon D and Schroeder, M, April 2003. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 3/2003

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)
Training: Fellows, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Nurses

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Addiction, Chronic non-malignant pain, Controlled substance regulations, Pain, Pain assessment, Pain treatment


The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).