epidural administration epidural administration epidural administration (from ancient greek ἐπί, , upon" + dura mater) 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. in the united states, over 50% of childbirths involve the use of epidural anesthesia. "epidural" redirects here. for the anatomical site, see epidural space. for other uses, see epidural (disambiguation). epidural administrationa freshly inserted lumbar epidural catheter. the site has been prepared with tincture of iodine, and the dressing has not yet been applied. depth markings may be seen along the shaft of the catheter.icd-9-cm03.90meshd000767ops-301 code8-910 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. the technique is considered safe and effective for providing pain relief during childbirth and surgery, 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 platelets, 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 side effects of the medicines administered. 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 the use of less invasive administration methods (such as taking medication by mouth) is a viable alternative. uses epidural infusion pump with opioid (sufentanil) and anesthetic (bupivacaine) in a locked box pain relief during childbirth epidural injections are commonly used to provide pain relief (analgesia) during childbirth. this usually involves epidural injection of a local anesthetic and opioids, commonly called an "epidural". this is more effective than oral or intra venal (iv) opioids and other common modalities of analgesia in childbirth. after an epidural is administered, a woman may not feel pain, but may still feel pressure. epidural clonidine is rarely used but has been extensively studied for management of analgesia during labor. epidural analgesia is considered a safer and more effective method of relieving pain in labor as compared to intravenous or oral analgesia. in a 2018 cochrane review of studies which compared epidural analgesia with oral opiates, some advantages of epidural analgesia included better efficacy, fewer instances of naloxone use in newborns, and decreased risk of maternal hyperventilation. some disadvantages of epidurals included an increase in the number of caesarian sections required due to fetal distress, a longer labor, increased need for oxytocin to stimulate uterine contractions, an increased risk of low blood pressure and muscle weakness, as well as fever. however, the review found no difference in overall caesarean delivery rates, and no evidence of negative effects to the baby soon after birth. furthermore, the occurrence of long-term backache was unchanged after epidural use. complications of epidural analgesia are rare, but may include headaches, dizziness, difficulty breathing and seizures for the mother. the child may experience a slow heartbeat, decreased ability to regulate temperature, and potential exposure to the drugs administered to the mother. there is no overall difference in outcomes based on the time the epidural is administered to the mother, specifically no change in the rate of caesarean section, birth which must be assisted by instruments, and duration of labor. there is also no change in the apgar score of the newborn between early and late epidural administration. epidurals other than low-dose ambulatory epidurals also impact the ability of the mother to move during labor. movement such as walking or changing positions may help improve labor comfort and decrease the risk of complications. pain relief during other surgery epidural analgesia has been demonstrated to have several benefits after other surgeries, including decreasing the need for the use of oral or systemic opioids, and reducing the risk of postoperative respiratory problems, chest infections, blood transfusion requirements, and myocardial infarctions. use of epidural analgesia after surgery in place of systemic analgesia is less likely to decrease intestinal motility which would occur with systemic opioid therapy through blockade of the sympathetic nervous system. some surgeries that spinal analgesia may be used in include lower abdominal surgery, lower limb surgery, cardiac surgery, and perineal surgery. others main articles: epidural steroid injection and epidural blood patch the injection of steroids into the epidural space is sometimes used to treat nerve root pain, radicular pain and inflammation caused by conditions such as spinal disc herniation, degenerative disc disease, and spinal stenosis. the risk of complications from steroid administration is low and complications are usually minor. the specific drug, dose, and frequency of administration impacts the risk for and severity of complications. complications of epidural steroid administration are similar to the side effects of steroids administered in other manners, and can include higher than normal blood sugar, especially in patients with type 2 diabetes. an epidural blood patch consists of a small amount of a person's own blood is injected into the epidural space. this is done as a method of sealing a hole or leak in the epidural. the injected blood clots at the site of the puncture, closes the leak, and modulates csf pressure. this may be used to treat post-dural-puncture headache and leakage of cerebrospinal fluid due to dural puncture, which occurs in approximately 1.5% of epidural analgesia procedures. contraindications 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. in some cases, it may be contraindicated in people with low platelets, increased intracranial pressure, or decreased cardiac output. due to the risk of disease progression, it is also potentially contraindicated in people with preexisting progressive neurologic disease. 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. an epidural is generally not used in people who are being administered anticoagulation therapy as it increases the risk of complications from the epidural. risks and complications in addition to blocking nerves which carry pain signals, local anesthetics may block nerves which carry other signals, though sensory nerve fibers are more sensitive to the effects of the local anesthetics than motor nerve fibers. for this reason, adequate pain control can usually be attained without blocking the motor neurons, which would cause a loss of muscle control if it occurred. depending on the drug and dose administered, the effects may last only a few minutes or up to several hours. as such, an epidural can provide pain control without as much of an effect on muscle strength. for example, a woman in labor who is being administered continuous analgesia via an epidural may not have impairment to her ability to move. larger doses of medication are more likely to result in side effects. very large doses of some medications can cause paralysis of the intercostal muscles and thoracic diaphragm responsible for breathing, which may lead to respiratory depression or arrest. it may also result in loss of sympathetic nerve input to the heart, which may cause a significant decrease in heart rate and blood pressure. obese people, those who have given birth prior, those with a history of opiate use, or those with cervical dilation of more than 7 cm are at a higher risk of inadequate pain control. if the dura is accidentally punctured during administration, it may cause cerebrospinal fluid to leak into the epidural space, causing a post-dural-puncture headache. this occurs in approximately 1 in 100 epidural procedures. such a headache may be severe and last several days, or rarely weeks to months, and is caused by a reduction in csf pressure. mild post-dural-puncture headaches may be treated with caffeine and gabapentin, while severe headaches may be treated with an epidural blood patch, though most cases resolve spontaneously with time. less common but more severe complications include subdural hematoma and cerebral venous thrombosis. the epidural catheter may also rarely be inadvertently placed in the subarachnoid space, which occurs in less than 1 in 1000 procedures. if this occurs, cerebrospinal fluid can be freely aspirated from the catheter, and this is used to detect misplacement. when this occurs, the catheter is withdrawn and replaced elsewhere, though occasionally no fluid may be aspirated despite a dural puncture. if dural puncture is not recognized, large doses of anesthetic may be delivered directly into the cerebrospinal fluid. this may result in a high block, or, more rarely, a total spinal, where anesthetic is delivered directly to the brainstem, causing unconsciousness and sometimes seizures. epidural administrations can also cause bleeding issues, including "bloody tap", which occurs in approximately 1 in 30–50 people. this occurs when epidural veins are inadvertently punctured with the needle during the insertion. it is a common occurrence and is not usually considered a problem in people who have normal blood clotting. permanent neurological problems from bloody tap are extremely rare, estimated at less than 0.07% of occurrences. however, people who have a coagulopathy may have a risk of epidural hematoma, and those with thrombocytopenia might bleed more than expected. a 2018 cochrane review found no evidence regarding the effect of platelet transfusions prior to a lumbar puncture or epidural anesthesia for participants that have thrombocytopenia. it is unclear whether major surgery-related bleeding within 24 hours and the surgery-related complications up to 7 days after the procedure are affected by epidural use. rare complications of epidural administration include formation of an epidural abscess (1 in 145,000) or epidural hematoma (1 in 168,000), neurological injury lasting longer than 1 year (1 in 240,000), paraplegia (1 in 250,000), and arachnoiditis, rarely, an epidural may cause death (1 in 100,000). in circumstances where contraindications exist, there are numerous fascial plane blocks that may be provided instead of an epidural. medication-specific if bupivacaine, a medication commonly administered via epidural, is inadvertently administered into a vein, it can cause excitation, nervousness, tingling around the mouth, tinnitus, tremor, dizziness, blurred vision, or seizures as well as central nervous system depression, loss of consciousness, respiratory depression and apnea. bupivacaine intended for epidural administration has been implicated in cardiac arrests resulting in death when accidentally administered into a vein instead of the epidural space. the administration of large doses of opioids into the epidural space may cause itching and respiratory depression. the sensation of needing to urinate is often significantly diminished or completely absent after administration of epidural local anesthetics or opioids. because of this, a urinary catheter is often placed for the duration of the epidural infusion. in many women given epidural analgesia during labor oxytocin is also used