Epidural: The Indications and Contraindications for Epidural Analgesia

Epidural analgesia is indicated for use for acute postoperative pain management,obstetrics and clinical conditions where it is considered to be of benefit to the patient e.g. acute lower limb ischaemia, rib fractures.

There are some absolute contraindications to the insertion of an epidural catheter which are as follows:

• Coagulopathy 
  • APTT ratio or INR >1.4
  • Platelet count < 100
  • Low molecular weight heparin (e.g. Enoxaparin, Clexane) given within last 12 hours if on prophylactic dosing (20 or 40mg) or within last 24 hours if on therapeutic dosing (>40mg)
  • Clopidogrel given within the last 7 days
• Local sepsis
• Allergy to amide local anaesthetics.

There are some relative contraindications

• If APTT ratio or INR 1.2-1.4.

It is imperative that stringent risk management strategies are in place in order to facilitate the safe use of epidurals in the clinical areas.  These strategies encompass appropriate education and assessment of competence for those caring for patients with epidural analgesia.

Guidelines to drive safe, consistent practice, regular documented specific observational assessment and for clarity and consistency pre-printed prescriptions and care plans.

Please refer to section 5 of the acute pain guidelines (reproduced courtesy of The Pain Management Service, Cardiff and Vale University Health Board) and the ANZCA guidelines (2010).