Epidural anesthesia and analgesia provide versatile, titratable neural blockade for surgical anesthesia, labor analgesia, and postoperative pain management. The technique involves catheter placement in the epidural space, allowing continuous or intermittent dosing. Understanding the anatomy, pharmacology of epidural agents, and management of complications is essential for safe and effective epidural practice.
Loss of resistance to saline or air identifies the epidural space at the ligamentum flavum
Test dose: lidocaine 1.5% with 1:200,000 epinephrine (3 mL) — rules out intravascular and intrathecal placement
Labor epidural: bupivacaine 0.0625–0.125% + fentanyl 2 mcg/mL at 8–12 mL/hr via PIEB or continuous infusion
Surgical epidural: 2% lidocaine with epi or 0.5% bupivacaine, 1–2 mL per segment to block
Epidural hematoma risk increases with anticoagulation; follow ASRA guidelines for neuraxial timing
Programmed intermittent epidural boluses (PIEB) provide better labor analgesia with less total local anesthetic consumption compared to continuous epidural infusion. PIEB creates more uniform spread of local anesthetic in the epidural space.
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