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Epidural administration
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== Risks and complications == In addition to blocking nerves which carry pain signals, local anesthetics may block nerves which carry other signals, though [[sensory nerve|sensory nerve fibers]] are more sensitive to the effects of the local anesthetics than [[motor nerve|motor nerve fiber]]s. 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.<ref>{{cite journal|vauthors=Stark P|date=February 1979|title=The effect of local anesthetic agents on afferent and motor nerve impulses in the frog|journal=Archives Internationales de Pharmacodynamie et de Therapie|volume=237|issue=2|pages=255–66|pmid=485692}}</ref> 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.<ref name=":1">{{cite journal|vauthors=Tobias JD, Leder M|date=October 2011|title=Procedural sedation: A review of sedative agents, monitoring, and management of complications|journal=Saudi Journal of Anaesthesia|volume=5|issue=4|pages=395–410|doi=10.4103/1658-354X.87270|pmc=3227310|pmid=22144928 |doi-access=free }}</ref> Very large doses of some medications can cause paralysis of the [[intercostal muscle]]s 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.<ref name=":1" /> [[Obese]] people, those who have [[multiparity|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.<ref name="Agaram2009">{{cite journal | vauthors = Agaram R, Douglas MJ, McTaggart RA, Gunka V | title = Inadequate pain relief with labor epidurals: a multivariate analysis of associated factors | journal = Int J Obstet Anesth | volume = 18 | issue = 1 | pages = 10–4 | date = January 2009 | pmid = 19046867 | doi = 10.1016/j.ijoa.2007.10.008 }}</ref> 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.<ref name="Allman20">{{cite book|title=Oxford handbook of anaesthesia|vauthors=Wilson IH, Allman KG|publisher=Oxford University Press|year=2006|isbn=978-0-19-856609-0|location=Oxford|page=20}}</ref> 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,<ref name="Cochrane database 2015">{{cite journal |url=https://www.cochrane.org/CD007887/SYMPT_drugs-treating-headache-after-lumbar-puncture|title=Drugs for treating headache after a lumbar puncture|issue=7|pages=CD007887|last=Basurto |first= Ona | date=15 July 2015 |journal=The Cochrane Database of Systematic Reviews |volume=2015 |publisher=The Cochrane Library |access-date=16 November 2018 |quote=Caffeine proved to be effective in decreasing the number of people with PDPH and those requiring extra drugs (2 or 3 in 10 with caffeine compared to 9 in 10 with placebo). Gabapentin, theophylline and hydrocortisone also proved to be effective, relieving pain better than placebo|doi=10.1002/14651858.CD007887.pub3|pmid=26176166|pmc=6457875}}</ref> 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.<ref name="Troop1992">{{cite journal|vauthors=Troop M|year=2002|title=Negative aspiration for cerebral fluid does not assure proper placement of epidural catheter.|journal=AANA J|volume=60|issue=3|pages=301–3|pmid=1632158}}</ref> 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]].<ref name="Troop1992" /> Epidural administrations can also cause bleeding issues, including "bloody tap", which occurs in approximately 1 in 30–50 people.<ref name="pmid22726899">{{cite journal|vauthors=Shih CK, Wang FY, Shieh CF, Huang JM, Lu IC, Wu LC, Lu DV| year=2012|title=Soft catheters reduce the risk of intravascular cannulation during epidural block—a retrospective analysis of 1,117 cases in a medical center|journal=Kaohsiung J. Med. Sci.|volume=28|issue=7|pages=373–6|doi=10.1016/j.kjms.2012.02.004|pmid=22726899|doi-access=free}}</ref> 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.<ref name="pmid9009940">{{cite journal|vauthors=Giebler RM, Scherer RU, Peters J|year=1997|title=Incidence of neurologic complications related to thoracic epidural catheterization|journal=Anesthesiology|volume=86|issue=1|pages=55–63|doi=10.1097/00000542-199701000-00009|pmid=9009940|doi-access=free}}</ref> 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 transfusion]]s prior to a [[lumbar puncture]] or epidural anesthesia for participants that have [[thrombocytopenia]].<ref name=":4" /> 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.<ref name=":4">{{cite journal|last1=Estcourt|first1=Lise J|last2=Malouf|first2=Reem|last3=Hopewell|first3=Sally|last4=Doree|first4=Carolyn|last5=Van Veen|first5=Joost|date=2018-04-30|editor-last=Cochrane Haematological Malignancies Group|title=Use of platelet transfusions prior to lumbar punctures or epidural anaesthesia for the prevention of complications in people with thrombocytopenia|journal=Cochrane Database of Systematic Reviews|volume=2018|issue=4 |pages=CD011980|language=en|doi=10.1002/14651858.CD011980.pub3|pmid=29709077|pmc=5957267}}</ref> Rare complications of epidural administration include formation of an [[epidural abscess]] (1 in 145,000)<ref name="ox">{{cite web|url=http://www.medicine.ox.ac.uk/bandolier/band159/b159-3.html|title=Epidurals and risk: it all depends|archive-url=https://web.archive.org/web/20120218151943/http://www.medicine.ox.ac.uk/bandolier/band159/b159-3.html|archive-date=18 February 2012|url-status=dead|df=mdy-all}}</ref> or [[epidural hematoma]] (1 in 168,000),<ref name="ox" /> neurological injury lasting longer than 1 year (1 in 240,000),<ref name="ox" /> [[paraplegia]] (1 in 250,000),<ref name="Allman21">{{cite book|title=Oxford handbook of anaesthesia|vauthors=Wilson IH, Allman KG|publisher=Oxford University Press|year=2006|isbn=978-0-19-856609-0|location=Oxford|page=21}}</ref> and [[arachnoiditis]].<ref name="Rice2004">{{cite journal | vauthors = Rice I, Wee MY, Thomson K | title = Obstetric epidurals and chronic adhesive arachnoiditis | journal = Br J Anaesth | volume = 92 | issue = 1 | pages = 109–20 | date = January 2004 | pmid = 14665562 | doi = 10.1093/bja/aeh009 | citeseerx = 10.1.1.532.6709 }}</ref> Rarely, an epidural may cause death (1 in 100,000).<ref name="Allman21" /> In circumstances where contraindications exist, there are numerous fascial plane blocks that may be provided instead of an epidural.<ref>{{cite journal |last1=Pawa |first1=Amit |last2=King |first2=Christopher |last3=Thang |first3=Christopher |last4=White |first4=Leigh |title=Erector spinae plane block: the ultimate 'plan A' block? |journal=British Journal of Anaesthesia |date=February 2023 |volume=130 |issue=5 |pages=497–502 |doi=10.1016/j.bja.2023.01.012|pmid=36775671 |s2cid=256805767 |doi-access=free }}</ref> ===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.<ref name="Rosenblatt2006">{{cite journal|vauthors = Rosenblatt MA, Abel M, Fischer GW, Itzkovich CJ, Eisenkraft JB |s2cid=40214528|year=2006|title=Successful Use of a 20% Lipid Emulsion to Resuscitate a Patient after a Presumed Bupivacaine-related Cardiac Arrest|journal=Anesthesiology|volume=105|issue=7|pages=217–8|pmid=16810015|doi=10.1097/00000542-200607000-00033|doi-access=free}}</ref><ref name="Mulroy2002">{{cite journal|author=Mulroy MF|year=2002|title=Systemic toxicity and cardiotoxicity from local anesthetics: incidence and preventive measures.|journal=Reg Anesth Pain Med|volume=27|issue=6|pages=556–61|pmid=12430104|doi=10.1053/rapm.2002.37127|s2cid=36915462}}</ref> The administration of large doses of opioids into the epidural space may cause [[pruritus|itching]] and respiratory depression.<ref name="Jacobson1988">{{cite journal|vauthors=Jacobson L, Chabal C, Brody MC|year=1988|title=A dose-response study of intrathecal morphine: efficacy, duration, optimal dose, and side effects|journal= Anesthesia & Analgesia|volume=67|issue=11|pages=1082–8|doi=10.1213/00000539-198867110-00011|pmid=3189898|doi-access=free}}</ref><ref name="Wust1987">{{cite journal|vauthors=Wüst HJ, Bromage PR|year=1987|title=Delayed respiratory arrest after epidural hydromorphone|journal=Anaesthesia|volume=42|issue=4|pages=404–6|doi=10.1111/j.1365-2044.1987.tb03982.x|pmid=2438964|s2cid=37237552|doi-access=free}}</ref> The sensation of needing to urinate is often significantly diminished or completely absent after administration of epidural local anesthetics or opioids.<ref name=":2">{{cite journal|vauthors=Baldini G, Bagry H, Aprikian A, Carli F|date=May 2009|title=Postoperative urinary retention: anesthetic and perioperative considerations|journal=Anesthesiology|volume=110|issue=5|pages=1139–57|doi=10.1097/ALN.0b013e31819f7aea|pmid=19352147|doi-access=free}}</ref> Because of this, a [[urinary catheterization|urinary catheter]] is often placed for the duration of the epidural infusion.<ref name=":2" /> In many women given epidural analgesia during labor oxytocin is also used to augment uterine contractions. In one study which examined the rate of breastfeeding two days following epidural anesthesia during childbirth, epidural analgesia used in combination with oxytocin resulted in lower maternal oxytocin and prolactin levels in response to breastfeeding on the second day following birth.<ref name="Jonas2009">{{cite journal|vauthors=Jonas K, Johansson LM, Nissen E, Ejdebäck M, Ransjö-Arvidson AB, Uvnäs-Moberg K|year=2009|title=Effects of Intrapartum Oxytocin Administration and Epidural Analgesia on the Concentration of Plasma Oxytocin and Prolactin, in Response to Suckling During the Second Day Postpartum|journal=Breastfeed Med|volume=4|issue=2|pages=71–82|doi=10.1089/bfm.2008.0002|pmid=19210132}}</ref> The lower maternal oxytocin level negatively affects the baby’s feeding rooting reflex, decreasing the amount of milk produced. The consequence of these effects from epidural analgesia is higher weight loss.<ref name="Takahashi2021">{{cite journal|vauthors=Takahashi Y, Uvnäs-Moberg K, Nissen E, Lidfors L, Ransjö-Arvidson AB, Jonas W|year=2021|title=Epidural Analgesia With or Without Oxytocin, but Not Oxytocin Alone, Administered During Birth Disturbs Infant Pre-feeding and Sucking Behaviors and Maternal Oxytocin Levels in Connection With a Breastfeed Two Days Later|journal=Frontiers in Neuroscience|volume=15|doi=10.3389/fnins.2021.673184|doi-access=free |pmid=34267623|pmc=8276259 }}</ref>
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