Epidural administration
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 Spanish military surgeon Fidel Pagés.
"Epidural" redirects here. For the anatomical site, see Epidural space. For other uses, see Epidural (disambiguation).
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).
Contraindications[edit]
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]
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Recovery[edit]
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]
Society and culture[edit]
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]
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