Troubleshooting inadequate epidural analgesia

This algorithm shows a reasonable approach to modifying epidural drugs and pump settings for most patients with inadequate analgesia. Specifics should be modified for patient factors and the clinical situation. For further information, refer to UpToDate content on continuous epidural analgesia techniques.

LA: local anesthesia; PIEB: programmed intermittent epidural bolus; PCEA: patient-controlled epidural analgesia.

* Using a hydrophilic opioid (eg, hydromorphone) may provide improved analgesia if the catheter or block is incongruent with the surgical site.

¶ Use of PIEB is not well studied for thoracic epidurals, and may be associated with increased hypotension, particularly for high thoracic epidurals.

Δ If the catheter was initially placed more than 3 cm into the epidural space, consider withdrawing the catheter by 1 to 2 cm. The catheter should be sited 3 to 5 cm in the epidural space.

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Troubleshooting inadequate epidural analgesia