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  • Superior pain relief when compared with IV PCA, subcutaneous and oral analgesics
  • Superior static and dynamic (mechanical) analgesia and hence improved mechanical DVT prophylaxis
  • Improved mobilization and physical rehabilitation
  • Improved pulmonary function
  • Earlier return of postoperative bowel function
  • Increased extremity perfusion due to vasodilatation and reduced platelet aggregation
  • Reduced risk of complications related to immobility
  • No evidence of decreased cognitive dysfunction in elderly patients

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  • Coagulopathy: functional platelet abnormalities; platelets <80,000; elevated PT, PTT, and INR. Antiplatelet medications. See chapter 119 for more information
  • Sepsis, local, or systemic infection
  • Surgeons often request no regional analgesia when there is a concern of possible compartment syndrome (e.g., tibial plateau fracture). However, there is no evidence in the literature to support the claim that diagnosis could be delayed by regional analgesia

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  • Check all connections, tubing, and pump function
  • Check catheter insertion and measurement at the skin (a transparent dressing makes this easier). Determine if catheter has pulled out of the epidural space
  • Aspirate the epidural catheter for blood or cerebrospinal fluid (CSF)
    • If blood return, the epidural catheter can be pulled back 0.5–1 cm and reaspirated
    • If CSF return, remove epidural and consider epidural catheter replacement
  • Consider rebolusing the epidural after the catheter has been pulled back and aspirate is negative

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Test dose with 3 mL 1.5% lidocaine with epinephrine 1:200,000

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  • If there is an increase in heart rate (≥10 bpm) or blood pressure (SBP increase by ≥15 mm Hg), or an increase in T-wave amplitude by more than 25%, the catheter is likely intravascular
  • If there is profound sensory or motor block in the abdomen and extremities within 5 minutes, the catheter is in the subarachnoid space
  • If there is an abdominal sensory level (for a lumbar placement), the catheter is in the epidural space. That is not always obtained with such a small dose
  • Please note: subarachnoid and epidural placements are often associated with a drop in blood pressure following test dose administration

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The more hydrophilic the opioid, the more cephalad spread will be seen, with the risk of respiratory depression.

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Table Graphic Jump Location
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Opioids
FentanylLipophilic2–5 μg/mL
HydromorphoneIntermediate10–30 μg/mL
MorphineHydrophilic
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Local Anesthetics
Bupivacaine0.0625–0.125–0.25%
Ropivacaine0.125–0.2–0.25%
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Fentanyl/bupivacaine:

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Fentanyl 2 μg/bupivacaine 0.125%Fentanyl 5 μg/bupivacaine 0.125%
Fentanyl 2 μg/bupivacaine 0.0625%Fentanyl 5 μg/bupivacaine 0.0625%
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Fentanyl/ropivacaine:

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Fentanyl 2 μg/ropivacaine 0.125%Fentanyl 5 μg/ropivacaine 0.125%
Fentanyl 2 μg/ropivacaine 0.25%Fentanyl 5 μg/ropivacaine 0.25%
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  • Spread depends on volume; typically the volume that will block 1 lumbar dermatome will block only 0.7 thoracic dermatome and 2 cervical dermatomes: 1L = 0.7T = ...

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