The most common side effects of epidural blocks are bradycardia and
hypotension related to sympathetic block. Hemodynamic changes can be more pronounced with
intermittent bolus dosing, in patients with hypovolemia, or those with
reduced venous return secondary to high positive end-expiratory pressure
(PEEP) ventilation. Based on data from lumbar punctures and meningitis from
the beginning of the twentieth century,53 current sepsis
and bacteremia are considered contraindications for intrathecal opioid
applications and, by analogy, for placement of epidural catheters. However,
many ICU patients, especially after trauma and major surgery, present with a
clinical picture of SIRS. Fever and increased white blood cell counts alone,
that is, in the absence of positive blood cultures, do not provide a
reliable diagnosis of bacteremia. The combination of the serum markers
C-reactive protein (CRP), procalcitonin, and interleukin-6, on the other hand,
have been shown to indicate bacterial sepsis with a high degree of
sensitivity and specificity54–57 and can guide the
decision to place an epidural catheter. Regarding the patient's coagulation
status, the current recommendations of the American Society of Regional
Anesthesia (ASRA)58,59 should be followed. Adequate safety
intervals during the administration of anticoagulative drugs are equally
important for the placement and removal of epidural
catheters.60,61 Although there is no compelling evidence
of increased risks of epidural bleeding with developing coagulopathy or
therapeutic anticoagulation while an epidural catheter is in place, the
benefits of epidural analgesia should be weighed against this potential,
highly detrimental complication.