1.) Asymmetric or one-sided block:
Caused by positioning ? Change patient's position (patient must not be in dorsal or supine position), 3 to 5 ml local anaesthetic after test dose (Bupivacaine 0.25 to 0.5%, Lidocaine 1.5 to 2%, 2-Chloroprocaine 2 to 3%)
Catheter moved ? Withdraw the catheter 1 cm, aspiration test, test dose and "top up"-dose of 3 to 5 ml (see IEA)
Incorrect placement of catheter? If asymmetric block continues, reposition epidural catheter (in next segment)
2.) Declining block:
Catheter moved ? With CIEA, first check that catheter is in correct part of the epidural space (aspirations test, test dose), then "top up"-dose of 3 to 5 ml (see IEA)
Interval between injections too long ? With CIEA consider possibility of equipment failure (pump switched of, disconnection and/or empty pouch)
Incorrect placement of catheter? (See above)
3.) Increasing motor block:
Catheter moved ? With CIEA first check that catheter is not in the intrathecal space (aspiration and glucose test), reposition catheter (in next segment)
Dilution mistake? Bupivacaine given in a higher concentration leads to a motor blockade, Bupivacaine 0.125% usually works analgesically
4.) "patchy" Blockade:
Catheter moved ? (See above)
Analgesia "window": After testing to ensure catheter correctly placed, can often be corrected by addition of opiates (Fentanyl 50 µg in NaCl 10 ml); do not combine epidural opioids with 2-Chloroprocaine (antagonism), but apply systemically.
5.) acute surgical intervention:
Forceps:
Intensify the analgesic blockade, so that a good perineal analgesia is achieved: 10 to 15 ml Chloroprocaine 2% or 3%, possibly with an addition of NaHCO3 8.4% 1ml/10 ml, in half-sitting position; if it is not an emergency indication: Lidocaine 1.5% or 2%, Bupivacaine 0.25% or 0.5%
Cesarean Section:
Convert the analgesic block to an anaesthesia with level T4, choose drugs according to time available:
< 10 min: Chloroprocaine 3% with NaHCO3 8.4% 1ml/10 ml
< 20 min: Lidocaine-CO2 2% with Adrenaline 1/200 000 + Fentanyl 50µg in NaCl 10 ml (use Fentanyl only if requirement is for a better quality anaesthesia)
6.) Postoperative pain therapy:
Systemic : Paracetamol, Pyrazolone derivative, Opiate
Epidural : Morphine 2 to 3 mg only, if supervision is guaranteed for a minimum of 12h (SaO2, AF) and if no other opiate or tranquilizer is being given (Attention: depress respiratory drive), O2 nasally
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