Patient-Controlled Epidural Analgesia/Continuous Epidural Catheters

Although useful for management of many types of pain, the most common indication for epidural catheter placement is for management of labor pain. High lumbar and thoracic epidural catheter placement has gained increasing popularity in recent years for the management of postoperative pain. The technique is most commonly employed for procedures in which a thoracic or an extensive abdominal incision is anticipated. Absolute contraindications for epidural catheter placement include patient refusal, uncorrected hypovolemia, increased intracranial pressure, local infection at the planned site of insertion, and patient allergy to amide/ester local anesthetics. Relative contraindications include coagulopathy, an uncooperative patient, severe anatomic abnormalities of the spine, sepsis, and hypertension. The advantages include attenuation of the sympathetic response to surgical stimulation and pain; effects on the cardiovascular, respiratory, and gastrointestinal systems; thromboprotective effects; and possibly limitation of tumor spread. The risks of epidural catheter placement include epidural hematoma, infection, nerve or spinal cord injury, dural puncture, or respiratory or cardiovascular depression from a high block. Epidural opioids provide analgesia without causing motor or sympathetic blockade. Epidurally administered local anesthetics may result in decreased postoperative ileus, nausea, vomiting, and sedation, which can be associated with opioids. Local anesthetics and opioids act additively or synergistically and, when used together, can lead to a reduction in the dose of each drug.