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:
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:
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
Purpose: Instructional Aid, Self-Study Guide, Teaching
|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|
ACGME Competencies: Medical Knowledge, Patient Care
Keyword(s): Addiction, Chronic non-malignant pain, Controlled substance regulations, Pain, Pain assessment, Pain treatment
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