Epidural injection

After epidural injection, an opioid may transfer into the cerebrospinal fluid (CSF), into the blood or bind to epidural fat, the extent depending on their lipophilicity. After epidural administration, morphine passes slowly into the CSF. Sufentanil, which is highly lipid soluble, can be detected in the plasma within 2-5 minutes after epidural injection and part of the analgesic effect of the more lipid soluble opioids may be due to a supraspinal action amplifying the direct spinal action. Epidural fentanyl and sufentanil produce a more consistent and intense analgesia than morphine, with a faster onset. Flowever, the duration is short but this can be overcome by giving them by continuous epidural infusions. 

An ophthalmic preparation seems to be efficacious for conjunctival inflammation and to reduce pain after traumatic corneal abrasion. Gingival inflammation is reduced after administration of indomethacin oral rinse. Epidural injections produce a degree of pain relief similar to that achieved with methylprednisolone in postlaminectomy syndrome. 

Clinical use The indications for levobupivacaine include wound infiltration (0.25 % solution), nerve conduction block (0.25 - 0.5 %), spinal analgesia (0.5 %) and epidural anesthesia (0.5 to 0.75 %). For labour analgesia, lower concentrations of levobupivacaine are recommended when administered as epidural injection (0.125 to 0.25 % up to 25 mg) or infusion (0.25 %). The maximum dose for ilioinguinal or iliohypogastric block in children is 1.25 mg/kg/side (0.25 to 0.5 % solutions). For postoperative pain management, levobupivacaine can be applied epidurally in combination with the opioids fentanyl or morphine or with the a2-agonist clonidine. 

Wong, Ch. H., Dey, P., Yarmush, J., Wu, W.-H., Zbuzek, V.K. Nifedipine-induced analgesia after epidural injection in rats, Anesth. Analg. 1994, 79, 303-306. 

Probably the second most common and probably the most expensive form of chronic pain in industrialised societies behind headache. It can be acute or chronic and has many causes. It is sometimes treated with epidural injections or injections into joints. 

The myopathy usually develops gradually, without pain, and symmetrically. However, a single epidural injection of a glucocorticoid for lumbar radicular pain has caused Cushing s syndrome and myopathy (SEDA-20, 370 97). 

The effects of intrathecal administration, both wanted and unwanted, are still much debated (448). The question as to whether oral glucocorticoid therapy should be preferred to intrathecal injections is raised by the harmful effects that have sometimes occurred after the latter, although some of these may have been caused by irritative substances in the injection fluid (SEDA-6, 331). The same local glucocorticoid concentrations can probably be attained with fewer problems with oral administration. Epidural injection of glucocorticoids seems to be safer than intrathecal injection, but injection of high doses can cause the same systemic adverse effects as seen with oral treatment. Facial flushing and erythema after lumbar... 

A 42-year-old man had received 15 epidural injections of methylprednisolone 80 mg over 10 years. About 6 weeks after his last injection, he developed progressively worsening cloudy vision. He had bilateral posterior subcapsular cataracts and subsequently underwent bilateral cataract removal. 

Indomethacin enjoys the usual indications for use in rheumatic conditions and is particularly popular for gout and ankylosing spondylitis. In addition, it has been used to treat patent ductus arteriosus. Indomethacin has been tried in numerous small or uncontrolled trials for many conditions, including Sweet s syndrome, juvenile rheumatoid arthritis, pleurisy, nephrotic syndrome, diabetes insipidus, urticarial vasculitis, postepisiotomy pain, and prophylaxis of heterotopic ossification in arthroplasty, and many others. An ophthalmic preparation seems to be efficacious for conjunctival inflammation (alone and in combination with gentamicin) to reduce pain after traumatic corneal abrasion. Gingival inflammation is reduced after administration of indomethacin oral rinse. Epidural injections produce a degree of pain relief similar to that achieved with methylprednisolone in postlaminectomy syndrome. 

There are many types of steroid hormones in the body, such as the sex/gonadal hormones testosterone and estrogen, thyroid hormones, growth hormones, and stress hormones, which serve various normal functions. One type of steroid— corticosteroids or glucocorticoids—is secreted by the adrenal glands (located just above the kidneys). These steroids, particularly synthetic versions of them, have powerful antiinflammatory actions that help to relieve pain. They are often given as an epidural injection to relieve neck or back pain that results from a compressed or pinched nerve. They can also be injected directly into a joint to relieve pain caused by inflammation in conditions such as tendonitis (inflammation of the tendons), carpal tunnel syndrome, tennis elbow, bursitis (inflammation of sac-like cavities in tendons or muscles that allow them to slide easily over bone), or other joint pain. Professional athletes, who routinely experience one or more of these conditions, are often given local steroid injections. Frequently, the steroid is combined with a local anesthetic such as lidocaine. 

Total spinal anesthesia was suspected in a 46-year-old man who was found unconscious and apneic with no palpable cardiac output 20 minutes after a high thoracic (T2/3) epidural injection of 3 ml hdocaine 1% and 3 ml bupivacaine 0.125% (141). Following initial cardiopulmonary resuscitation he was admitted to the intensive care unit, where treatment included mechanical lung ventilation, thiamylal infusion, and cooling to a core temperature of 33-34 C. The thiamylal was withdrawn after 17 days and he was warmed and successfully extubated the next day. He was discharged after a further 4 months of rehabihtation with no relevant neurological consequences. 

Taga K, Tomita M, Watanabe I, Sato K, Awamori K, Fujihara H, Shimoji K. Complete recovery of consciousness in a patient with decorticate rigidity following cardiac arrest after thoracic epidural injection. Br J Anaesth 2000 85(4) 632. ... 

GRAS listed. Accepted for use as a food additive in Europe. Included in the FDA Inactive Ingredients Guide (dental solutions epidural injections, IM, IV, and SC injections, inhalations, ophthalmic preparations, oral solutions, nasal, otic, rectal, and topical preparations). Included in parenteral and nonparenteral medicines licensed in the UK. Included in the Canadian List of Acceptable Non-medicinal Ingredients. 

Local anesthetics are used in the clinical situation to interrupt the nociceptive process at one or more points between the peripheral, high-threshold nociceptor and the cerebral cortex, by blocking transduction by infiltration at the site of injury or incision by preventing transmission in afferent myelinated A 8 and unmyelinated C fibers by blockade of peripheral nerves or nerve plexuses or by epidural injection. 

Le Blanc P H 1992 Regional anesthesia In Robinson N E (ed) Current therapy in equine medicine, 3rd edn. Saunders, Philadelphia, PA, pp. 25-28 Le Blanc P H, Caron J P, Patterson J S et al 1988 Epidural Injection of xylazine for perineal analgesia in horses. Journal of the American Veterinary Medical Association 193 1405-1408... 

As stated previously, contaminated products injected directly into the bloodstream or instilled into the eye cause the most serious problems. Intrathecal and epidural injections are potentially hazardous procedures. In practice, epidural injections are frequently given through a bacterial filter. Injectable and ophthalmic solutions are often simple solutions and provide Gram-negative opportunist pathogens with sufficient nutrients to multiply during storage if contaminated, a bioburden of 106 CFU as well as the production of endotoxins should be expected. Total parenteral nutrition fluids, formulated for individual patients ... 

Intraspinal and epidural injections are given under certain circumstances to have a local effect, either as anaesthesia or to treat infection of the central nervous system. For... 

Some medical conditions require the extended presence of a corticoid at the site of inflammation. One treatment for the pain from spinal stenosis or degenerative disk disease comprises epidural injection of a long-lasting corticoid. Depo Medrol , a solution of 6a-prednisolone (9-1) in a special vehicle, is one of the drugs often used for that purpose. Once injected, the solution forms a depot at the site of administration the drug slowly diffuses from that depot, leading to the sustained presence of the anti-inflammatory compound. 

E. Clinical Use The local anesthetics are most commonly used for minor surgical procedures. Local anesthetics are also used in spinal anesthesia and to produce autonomic blockade in ischemic conditions. Slow epidural infusion at low concentrations has been used successfully for postoperative analgesia (in the same way as epidural opioid infusion Chapter 31). Repeated epidural injection in anesthetic doses may lead to tachyphylaxis, however. 

Sharrock, N.E. Mather, L.E. Go, G. Sculco, T.P. Arterial and pulmonary arterial concentrations of the enantiomers of bupivacaine after epidural injection in elderly patients. Anesth. Analg. 1998, 86, 812-817. 

Mazoit IX, Benhamou D, Veillette Y, Samii K. Clonidine and or adrenaline decrease ligno-caine plasma peak concentration after epidural injection. Br J Clin Pharmacol (1996) 42, 242-5. 

Giaufre E, Bruguerolle B, Morisson-Lacombe G, Rousset-Rouviere B. Influence of midazolam on the plasma concentrations of mepivacaine after lumbar epidural injection in children. 

In retrospect, it was realized that the drugs given by the caudal route had been accidentally administered into the intrathecal space, namely an ectatic lumbosacral dural sac, which had been overlooked in the initial MRI scan. This case highlights the importance of looking for lumbosacral dural anomahes before planning caudal epidural injections in adults such anomalies should be regarded as contraindications for caudal epidural analgesia. 

In a double-blind, double-dummy, sham-control-led study including 168 total knee arthroplasty patients, subjects were assigned to receive DepoDur 30 mg, DepoDur 20 mg, or sham epidural injection, to compare DepoDur with morphine PCA. DepoDur patients experienced less pain and required less opioid rescue as compared to morphine PCA patients [5]. 

Ketamine is a rapidly acting anesthetic and analgesic. It can be given intravenously, intramuscularly, nasally, orally, rectally, epidurally, spinally, and topically. The initial anesthetic response if given intravenously is seen after 30-40 seconds, while a response after intramuscular administration is seen after 3-4 minutes. Nasal administration results in a response after 8-12 minutes. Analgesic effects after intramuscular, oral, and epidural injection are 10-15, within 30, and within 15-30 minutes, respectively. 

Bioavailability of ketamine is 90-93% after intramuscular injection, 16% after oral administration, and 77% after epidural injection. Protein binding of ketamine is 47%, and it is initially distributed to highly perfused tissues such as brain, heart, and the lungs. There the concentration can reach up to five times the plasma concentration. Redistribution is similar to thiopental. The distribution half-life after intravenous administration is 7 tol7 minutes, and the volume of distribution is 2 to 3 L/kg. 

Acute transient hiccups after epidural injection of levobupivacaine have been described [28 ]. 

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