The epidural agent is chosen based on the desired clinical effect, whether it is to be used as a primary anesthetic, for supplementation of general anesthesia, or for analgesia. The anticipated duration of the procedure may call for a short or long acting single shot anesthetic or the insertion of catheter. Commonly used short to intermediate acting agents for surgical anesthesia include lidocaine, chloroprocaine, and mepicacaine. Long-acting agents include bupivacine, levobupivacaine, and ropivacaine. Levobupicacaine, the S-enantiomer of bupivacaine, is less toxic than bupivicaine but is no longer available in the United States. Only preservative-free local anesthetic solutions or those specifically labeled for epidural or caudal are employed.

Following the initial 1-2 mL per segment bolus (in fractional doses), repeat doses delivered through an epidural catheter are either done on a fixed time interval, based on the practitioners experience with the agent, or when the block demonstrates some degree of regression. Once some regression in sensory level has occurred, one-third to one-half the initial activation dose can generally safely be reinjected.

It should be noted that chloroprocaine, an ester with rapid onset, short duration, and extremely low toxicity, may interfere with the analgesic effects of epidural opioids. Previous chloroprocaine formulations with preservatives, specifically bisufite and ethylenediaminetetraacetic acid (EDTA), proved to be problematic when inadvertently injected in a large volume intrathecally. Bisulfite preparations of chloroprocaine were believed to cause neurotoxicity, whereas EDTA formulations were associated with severe back pain (presumably due to local hypocalcemia). Current preparations of chloroprocaine are preservative free and without these complications. Some experts believe the local anesthetics when injected in very large doses intrathecally may have been at least partially responsible for neurotoxicity.

Bupivacaine, an amide local anesthetic with a slow onset and long duration of action, has a high potential for systemic toxicity. Surgical anesthesia is obtained with a 0.5% or .75% formulation. The 0.75% concentration is not recommended for obstetric anesthesia. Its use in the past for cesarean section was associated with several reports of cardiac arrest resulting from inadvertent intravenous injection. The difficulty in resuscitation and the resultant high mortality rate results from the high protien binding and lipid solubility of bupivacaine which causes the agent to accumulate in the cardiac conduction system leading to refractory reentrant arrhythmias.

 

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