New Drugs for Epidural Analgesia

Abstract

In recent years there has been a wide use of the epidural technique not only during surgery to provide anesthesia and analgesia, but also for obstetric and trauma as well as acute, chronic and cancer pain states. Nowadays there is an increase in the number of the epidural drugs. Local anesthetics and opioids are still the pharmacological agents more widely used epidurally, nevertheless other drugs from different pharmacological classes are administered as adjuvant to local anesthetics and opioids or are in various early stages of investigation. Regarding to local anesthetics, the most recent literature focuses on the new enantiomers, ropivacaine and levobupivacaine, the efficacy of which is similar to that of bupivacaine with a reduced risk of cardiotoxicity. About opioids, the other class of drugs mainly used, the debate, in the last years, concerned the physicochemical properties of morphine and of the more recent lipophilic agents, fentanyl and sufentanil, in order to explain the main differences in efficacy and safety. Other categories of agents have been investigated for epidural administration, such as alpha(2)-adrenergic agonists clonidine and dexmedetomidine. They are being used increasingly as adjuvants to local anesthetics and opioids. Ketamine and neostigmine, the more recent studied drugs for epidural use, are still under investigation and are not part of routine clinical practice.

Wherefore ketamine?

“…The obvious cases and outcomes of toxicity studies have often been attributed to ketamine's preservative, chlorobutanol [36]. A strong case can be made for the intrinsic toxicity of ketamine, however [32].…”

Dexmedetomidine an adjuvant to levobupivacaine in supraclavicular brachial plexus block: A randomized double blind prospective study

“…Clinical studies have shown opoid sparing effects of dexmedetomidine when used intravenously along with decrease in inhalational anesthetic requirement (4). It has also been reported to improve quality of intrathecal and epidural anesthesia (5, 6). However, very few clinical trials have studied the effect of dexmedetomidine in supraclavicular brachial plexus block.…”

Caudal epidural block in children and infants: retrospective analysis of 2088 cases

“…In caudal block, the most used local anesthetic agent is bupivacaine, because it is readily available, has a long duration of action and its side effects are very well known 1215. A single-shot caudal injection of bupivacaine as sole local anesthetic provides effective postoperative analgesia 1213.…”