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Epidural blockade is one of the most useful and versatile
procedures in modern anesthesiology. It is unique in that it can be placed
at virtually any level of the spinal spine, allowing more flexibility in its
application to clinical practice. It is more versatile than spinal
anesthesia, giving the clinician the opportunity to provide anesthesia and
analgesia, as well as enabling diagnosis and treatment of chronic disease
syndromes. It can be used to supplement general anesthesia, decreasing the
need for deep levels of general anesthesia, therefore providing a more
hemodynamically stable operative course and faster emergence from general anesthesia.
It provides better postoperative
pain control and more rapid recovery from surgery. When combined with spinal
anesthesia in a technique called a CSE (combined spinal-epidural),
benefits of both techniques can be combined and shortcomings of each
avoided.
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Numerous studies have demonstrated the benefits of epidural blockade.
Epidural anesthesia or analgesia can reduce the adverse physiologic
responses to surgery such as autonomic hyperactivity, cardiovascular stress,
tissue breakdown, increased metabolic rate, pulmonary dysfunction, and
immune system dysfunction. Thoracic epidural analgesia has been shown to
decrease the incidence of myocardial infarction1
postoperative pulmonary complications2,3 and to promote
the return of gastrointestinal motility without compromising fresh suture
lines in the GI tract.4–6 Epidural anesthesia and
analgesia reduces the incidence of hypercoagulability.7,8
Well-conducted randomized trials have demonstrated the perioperative use of
epidural anesthesia and analgesia may reduce overall mortality and morbidity by
approximately 30% compared with general anesthesia using systemic
opiods.9
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This chapter aims to provide the information necessary to provide safe and
effective epidural blockade. The reader is encouraged to review specific
chapters in this text for a more detailed discussion on specialized topics
such as local anesthetics, combined spinal-epidural anesthesia, obstetric
anesthesia, and serious complications such as epidural hematomas.
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Two French physicians, Jean-Anthanase Sicard, a radiologist, and
Ferdinand Cathelin have been credited with the intentional administration of
caudal epidural anesthesia over a century ago in 1901. They found that
injecting a dilute solution of cocaine through the sacral hiatus can provide an
effective treatment for severe sciatic pain and suggested the technique for
surgical procedures.10 Nineteen years later, a Spanish
military surgeon by the name of Fidel Pages Mirave, is credited with
describing the lumbar approach to “peridural” anesthesia. Unfortunately he
was killed in an accident at the early age of 37, and his work lay dormant
for several years.11 Then in 1931, an Italian surgeon,
Archile Dogliotti, performed abdominal surgery using single-shot lumbar
epidural anesthesia, popularizing the method for producing “segmental
peridural anesthesia.” He noted that a sufficient length of spinal nerves
needed to be blocked with an anesthetic solution of sufficient quantity to
provide adequate anesthesia. He correctly identified the epidural space by
describing the sudden loss of resistance noted after the needle had crossed
the ligamentum flavum.12
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