The sympathetic blockade associated with local anesthetics can result in vasodilation and
subsequent hypotension. The location of the epidural catheter placement affects the efficacy
of epidural analgesia and influences patient outcomes. Epidural catheters should be inserted
in a location congruent to the incisional dermatome. Discrepancy between epidural catheter
insertion level and incision site may lead to an increased rate of side effects secondary to an
increased infusion rate and increased volumes of local anesthetics used. Inadequate pain
relief can lead to early termination of epidural analgesia and masking the potential
beneficial effects of epidural analgesia31
Side effects of epidural opiates include pruritus, nausea and vomiting, urinary retention,
and respiratory depression. Continuous supplementary oxygen should be used.
The choice of analgesic agents administered in the epidural space play a significant role in
the achievement of optimal analgesia. The most common agents used are opioids and local
anesthetics. Other agents include clonidine, neostigmine, adenosine, ketamine.
Removal of epidural catheters may need to be timed to match a therapeutic trough after
prophylactic heparin or low molecular weight heparin is given.