Epidural Administration and Cell-Based Therapy

### **Chapter 5**

## Perspectives of Cell-Based Therapy for Degenerative Diseases of the Spine: The Reason for Choosing the Epidural Space

*José Correa, Henry Cortés, Lucia Correa and Rita López*

#### **Abstract**

Intervertebral disc degeneration (IDD) is a chronic disease that causes significant disability and dependence and exerts a high cost on society. Concerning IDD, it is the most common cause of back pain, involving any segment of the spine. It is one of the most frequent reasons for consultation in the general population, second only to headache, affecting 80–85 % of people throughout life. Current therapeutic strategies focused on IDD are primarily conservative, including physical therapy and antiinflammatory medication. Surgical techniques intend to stabilize the spine and/or decompress the spinal or foraminal canal, searching for relieve of symptoms; however, do not address the cause of the degeneration and even accelerate the degeneration of adjacent segments. Understanding of the biology of platelet-rich plasma (PRP) and other growth factors conducted usto use of PRP as a promising biological therapeutic strategy for enhance the regenerative process, searching the healing of the intervertebral disc. With current few in vitro studies, and fewer clinical studies linking the bases of regenerative medicine (RM) in the management of degenerative disc disease, our pioneering research was to state the bases, fundamentals, results, and the new trends around the RM techniques focused on the pathology of the spinal canal, taking the advantages that offer the epidural route.

**Keywords:** epidural space, intervertebral disc degeneration, intervertebral disc regeneration, platelet-rich plasma, tissue engineering

#### **1. Introduction**

Low back pain (LBP) has become a major public health issue for people under 45 years. This global problem has an estimated prevalence of about 7.5% in the global population (WHO, 2017). LBP is a costly and challenging condition to manage. LBP has become one of the main reasons for limiting of physical activities and is spreading in epidemic proportions [1, 2]. With these concerns in mind, it is important to

highlight that lumbar disc degeneration is the most common cause of low back pain. Intervertebral disc disease (IDD) is a progressive, chronic disorder and number one cause of LBP.

Understanding of the IDD pathophysiology and its clinical course will allow us to focus on a rational treatment for the patient, when possible. Current treatments for IDD proposed in most ́consensus protocols ́ do not correspond, unfortunately, to the pathophysiological process involved in the IDD, as these treatments are mainly focused on relieving pain (palliative pain medicine) [3]. Recent studies addressing the treatment of LBP, as opposed to current protocols, focus their management strategy based on the genesis that triggers pain. These pioneering studies [4–6] show that epidural PRP injections can improve significantly in the pain score (VAS-scale) and function (MACNAB-score) in patients with IDD diagnosis.

The aim of this chapter is to overview our pioneering research, the bases, fundamentals, and results. Also, this research includes the near future around the regenerative medicine (RM) techniques associated to the medullary canal. This research document also aims to highlight the new trends what the Regenerative Medicine focuses on the pathology of the spinal canal.

#### **2. Historical overview**

#### **2.1 The evolution from general anesthesia to spinal techniques**

*… at past, surgeries were horrible …*

The beginning of Anesthesia dates to ancient civilization, seeking to alter the consciousness to prevent pain during surgery. Deliriant herbs as the sleeping sponge (Hippocrates), opium, belladonna, scopolamine, cannabis were the herbal remedies as anesthetics (**Figure 1**). At the XVI century appeared ether (Paracelsus) through the distillation of alcohol and sulfuric acid. Already in 1796 Davy discovered nitrous oxide (N2O) opening the doors to the future of anesthesia [7].

The knowledge of the chemical agents that altered the consciousness, and later the control of mechanical ventilation, through pulmonary insufflation, allowed the use of other drugs, no longer focused to pain control, but to facilitate the conditions of surgery. Appeared then the use of muscle relaxants and other drugs that allowed the control of the hemodynamic conditions of the patient. It came up the concept safety during surgery, the beginning of monitoring.

#### **Figure 1.**

*Preventing pain during surgery: From the use of opium poppy and other herbal remedies (early civilization) to the first public demonstration on October 16, 1846, at Massachusetts General Hospital (modern anesthesia). The history of anesthesia.*

*Perspectives of Cell-Based Therapy for Degenerative Diseases of the Spine: The Reason… DOI: http://dx.doi.org/10.5772/intechopen.107074*

**Figure 2.** *Epidural technique: Towards the improvement of needles and the refinement of local anesthetic.*

It was only from the end of the XIX century, with the development of needles and syringes, that allowed the introduction and safe use of regional anesthesia techniques epidural and spinal- with doctors F. Pagés and M. Dogliotti [8]. In the year 1899 and then at the year 1901 appeared the first publications on the use of spinal anesthesia and epidural anesthesia, respectively. Spinal techniques marked then a global milestone concept in the practice of anesthesia, at surgical activities but also in the developing of the Pain Units.

#### **2.2 Overview about spinal anesthesia**

Associated to the improving of the spinal technique (methods of performing, access route, dose, and the quality of the anesthetic substances) over time, the spinal pathway gained a prominent place, not only in the surgical field, but in other medical areas such as traumatology, rheumatology, pediatrics, internal medicine and oncology (**Figure 2**). Also, with the improvements of the spinal techniques, they reached the *gold standard* procedure in the Pain Units, as they allowed a continuous analgesia when necessary.

With the development of spinal techniques, injecting drugs into the epidural space is one of the most used interventions by anesthesiologists: local anesthetics, opioids, steroids, 'muscle relaxant'(baclofen), benzodiazepines (midazolam), clonidine, adenosine, ketamine, ziconotide, etc. Also, a specific mention to "hematic patch" in the management of post-dural puncture headache. In this way, the epidural space can be used, not only to provide anesthesia, but also to provide analgesia and to treating a variety of acute and chronic settings. In this context, the anesthesiologist should have a solid knowledge of the administered drugs within the epidural space.

Here we must add, then, another 'new drugs' to use into the epidural space: the biological therapies, the cell-based therapy.

#### **3. Pathology of the medullary canal**

Diseases engaged to the medullary canal, involved therefore to the epidural space, can be summarized as follows [9]:

1.Infection


It is not the aim of this chapter to deepen the study of the pathology of the medullary canal, but it is important to illustrate the changes that are linked to the degenerative processes of the discovertebral segment (number 4) in order to focus and understand what the vanguardist Regenerative Medicine therapy offers in the processes of the discovertebral impairment. In this regard, our goal is then to highlight the benefits of using the epidural space when we inject growth factors into the spinal segment. (Correa et al).

#### **4. Degenerative disease of the spine**

The spine is an articulated and highly resistant system, extending from the head to the pelvis. It plays a major role in protecting your body and supporting its movements. In between each vertebra of your spine lies an intervertebral disc. These discs allow the spine to generate movement and have flexibility. In addition, these discs serve as shock absorbers, protecting your vertebrae during everyday activities.

Spinal discs consist of a strong fibrous cartilage (the annulus fibrosus) which encloses a gel-like inner layer (the nucleus pulposus). As we age, these discs can weaken and become injured because of our personal habits, activities, diseases, and genetics. Degenerative disc disease is a painful degenerated disc. Degenerative disc disease is then an umbrella term that point out the pain that could extend from the neck to the lower back, associated with disc damage (**Figure 3**).

In the 1970s, Kirkaldy-Willis first described the "degenerative cascade" of the degenerative disc disease (DDD) (**Figure 4**) [10]. From an initial dysfunction of the disc, the fissure of the annulus fibrosus losing the capacity of containing the nucleus pulposus (first stage), to comprising the mobile segment, disc and facet joint degeneration leads to dynamic spinal instability (second stage), the patient finally develops a multifactorial stenosis, which may or may not be associated to instability (third stage) (**Figure 3**).

**Figure 3.** *DDD: The evolution of the disc damage.*

*Perspectives of Cell-Based Therapy for Degenerative Diseases of the Spine: The Reason… DOI: http://dx.doi.org/10.5772/intechopen.107074*

#### **Figure 4.**

*Kirkaldy-Willis spine: The "degenerative cascade".*

In this regard, the pathogenesis of the intervertebral disc disease process (IDD) involves a complex interplay of inflammatory, immunological, and pressure-related processes [11].

#### **In anatomical terms, intervertebral discs are the largest avascular structure of the body.**

Intervertebral disc, the flat, rubbery piece, that separate the bones of the backbones, have a very poor regenerative capacity [12]. Disc cells depend on the blood supply at the margins of the discs for their nutrients. The nucleus and inner anulus of the disc are supplied by capillaries that arise in the vertebral bodies, penetrate the subchondral bone, and terminate at the bone-disc junction. Despite being highly implicated in disc degeneration, the end plate has hardly been quoted into regenerative strategies [13, 14].

Current therapeutic approaches should therefore be focused on combating the disc's poor nutritional supply, diffused from the blood vessels of the vertebral body through the cartilaginous end plate. However, the current treatments for IDD, proposed in most ́consensus protocols ́ do not correspond to the pathophysiological process involved in the IDD, as these treatments are mainly focused on relieving pain (palliative pain medicine). Surgical techniques (including fusion, laminectomy, and discectomy), aim to stabilize the spine and/or decompress the spinal or the foraminal canal thus alleviating symptoms, but these techniques are not addressed to regarding the cause of the degeneration, and sometimes even accelerate the degeneration of the adjacent segments.

**So, it is only through the understanding of the spine pathophysiology and its clinical course that will allow us to provide a rational treatment for patients.**

At present, treatment options for degenerative disc disease remain suboptimal, and development and outcomes of novel treatment options currently must be considered unpredictable.

#### **5. Understanding platelet-rich plasma (PRP)**

The biology of platelet-rich plasma and its effect in the process of healing is a promising biological therapeutic strategy for enhance the regenerative process and healing of the damaged tissue (**Figure 5**).

The regenerative potential of PRP is based on the release of growth factors that occurs with platelet rupture. The first clinical report of PRP used as tissue regenerative therapy was published in 1998 by an oral surgeon who incorporates PRP into spongy bone grafting to reconstruct large mandibular defects [15]. Since then, PRP has been widely used in oral and maxillofacial surgery to improve osseointegration of dental implants and accelerate the healing process [16, 17]. More recently it has been used to treat injuries to the musculoskeletal system. Thus, at present, the use of PRP as a tissue regeneration therapy is well accepted for its modulating and stimulating properties of cell proliferation of mesenchymal origin (fibroblasts, osteoblasts, endothelial cells, epithelial cells, adipoblasts, myocytes and chondrocytes, mainly).

Platelet Rich Plasma (PRP) is then, the novel therapeutic tool of autologous nature that is strongly emerging in recent years with a successful therapeutic use. Different PRP studies have showed a beneficial effect on the target cells, which allows to propose its use the treatment of several pathological processes: the healing of wounds, the processes of tissue regeneration, or in the treatment of cellular involution that takes place with aging [18]. Clinically, PRP has been shown to decrease pain and increase function in chronic elbow tendinosis patients. PRP has also been used in plantar fasciitis, spinal fusion, and in total knee arthroplasty with varying degrees of success. PRP accelerated wound healing of human skin punch wounds in a recent prospective, controlled study.

**In conclusion, the rationale behind the use of PRP is the deliver a high concentrations of growth factors and cytokines which can improve the healing process.**

**Figure 5.** *Platelet-rich plasma: Growth factors and pro- and anti-inflammatory properties.*

#### **5.1 Tissue and cicatrization engineering around PRP**

#### *5.1.1 Regeneration: the healing process*

Plasma rich in growth factors (PRGF) is a recent cell-based technique being evaluated for promoting tissue healing, as PRGF has shown in vitro and in vivo the potential to stimulate matrix metabolism [19–24]. Upon activation, these platelets release a variety of cell signaling molecules such as platelet-derived growth factor (PDGF), insulin-like growth factor (IGF-1), transforming grow factor (TGF-β1), vascular endothelial growth factor (VEGF), hepatocyte growth factor (HGF) and basic fibroblastic growth factor (FGF). Other mediators, nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), and other neurotropic factors such as fibrin, fibronectin, and vitronectin, are also activated [24–26]. All these plasma biological mediators govern tissue repair although their mechanisms of action in the healing process are still poorly understood.

#### *5.1.2 The anti-inflammatory effect with PRGF*

Evidence suggests that biomolecules conveyed by PRGFs are instrumental agents that modulate early inflammation [27], also involved in the macrophage polarization, angiogenesis, and fibrogenesis, the stem cell-like myelinating SC activation, and finally, they have an active rol in the resolution of inflammation. Considering this benefit (anti-inflammatory effect) on the spinal axis intrathecal administration of transforming growth factor β1 (TGF-β1), a potent anti-inflammatory cytokine, has demonstrated to alleviate nerve injury- induced neuropathic pain in rats, attenuating nerve injury-induced neuropathic pain [28]. TGF-β1 acted as a powerful neuromodulator and rapidly (within minutes) suppressed chronic constriction injury–evoked spinal synaptic plasticity and dorsal root ganglion neuronal hyperexcitability, alleviating early- and late- phase neuropathic pain symptoms, such as allodynia and hyperalgesia, for several weeks in murine models. These previous studies -in murine models-, allowed us to raise the hypothesis that PRP could help us to relieve neuropathic pain that is associated with DDD [29].

#### *5.1.3 The neuroprotective effect of PRGF*

Several growth factors present in plasma including the nerve growth factor (NGF), brain derivate neurotrophic factor (BDNF), PDGF, VEGF, IGF-1, transforming growth factor beta (TGFB) alone or in combination have been shown to exert an antiapoptotic and neuroprotective effect on mesenchymal stem cells (MSCs), neurons, the Schwann cells (SCs), and human neural stem cells [25, 30].

#### **6. Epidural PRP**

The clinical evidence for PRGF treatment of discogenic low back pain in humans was reported in 2011 [31]. Since then, many research papers, in vitro and in vivo studies, have confirmed the efficacy of PRGF in IDD management. However, early in vivo studies used intradiscal injection of PRGF. These early documents concluded that intradiscal injection of autologous PRGF in patients with low back pain is safe and free of adverse events [29–33]. However, the intradiscal injection of PRGF technique is a more laborious proceeding and probably limits the effects. The first document injecting PRP into the

epidural space was our paper [4]. Knowing the biology of platelet-rich plasma and its restorative effect on cartilages (in general) and its repairing effect on the vertebral disc (in particular) allowed us to propose the use of PRP into the epidural space.

#### **6.1 Why PDGF into the epidural space?**

The choice of the epidural space needs a good knowledge of its anatomy and its content, as well as the pharmacodynamics of the medication we are using.

The first published study using the epidural space while injecting PRGF was our paper [4]. Our first line of work was only a clinical trial, assessing the pain relief response and assessing the degree of functional recovery of the patient. Our reason for changing the intradiscal injection technique, preferring the epidural space was that, compared to intradiscal injection, growth factors by epidural route would fulfill an effective outcome by acting not only on the discs, but also over the facet joints and the ligamentum flavum, and, because of its anti-inflammatory activity. That further study had allowed us to confirm that this technique -epidural PRP- help with relieving the neuropathic pain (NP) associated to IDD [29].

#### **6.2 Axial structure: the "poly-articular component"**

We have considered the axial region as a "multi-articular component", where the epidural space would be an ideal place to inject PRP (**Figure 6**). The epidural space will allow us to reach the intervertebral disc, but also the facet joint, and even more, we can get the benefit of PRP in the foraminal region. Thus, the epidural space permits a pharmacological manipulation of various segments of this region, considering its inter-cellular signaling pathway.

#### **6.3 Plasma rich in growth factors: the chemical signaling**

Inter-cellular signaling is the communication between cells. The main difference between the different categories of signaling is the distance that the signal travels

**Figure 6.** *Anatomy of the axial region.*

*Perspectives of Cell-Based Therapy for Degenerative Diseases of the Spine: The Reason… DOI: http://dx.doi.org/10.5772/intechopen.107074*

through the organism to reach the target cell. In chemical signaling, a cell may target itself (autocrine signaling), a cell connected by gap junctions, a nearby cell (paracrine signaling), or a distant cell (endocrine signaling).

Multiple studies have demonstrated a beneficial effect of many of these growth factors, e.g., platelet-derived growth factors (PDGFs), fibroblast growth factors (FGFs), and granulocyte-macrophage colony stimulating factor (GM-CSF) on the healing process, accelerating wound closure with increased reepithelialization, cell infiltration, granulation formation, and angiogenesis. In all stages of the repair, a wide variety of different growth factors and cytokines are involved. The release of these various growth factors, cytokines, and low-molecular-weight compounds from degranulating platelets, are the mediators for the healing process. Fibroblasts, osteoblasts, endothelial cells, leukocytes, monocytes, and macrophages are cells involved in the produce of growth factors.

**Growth factors and cytokines work as paracrine signals, that means they act locally, between cells that are close together** [34]**.**

With these two concepts in mind (the axial structure and the way to act of the PRP) we considered that growth factors by epidural route would fulfill our expecting outcome.

Using PRGF in patients with IDD was considered, few years ago, merely as another "off the shelf" alternative. Recent studies, and our clinical results, now we have a different opinion: PRGFs should be the "flagship" within in the multimodal therapeutic scheme for IDD. Accumulated evidence, in both preclinical and clinical settings, indicates that PRGF and fibrin scaffold have an important therapeutic role in patients with IDD: (1) its potential to enhancing cartilage regeneration, (2) reducing the catabolic factors that lead to cartilage degradation, (3) its neuroinflammatory therapeutic modulation, (4) its neuroprotective effect. With these effects in mind, we achieve the sensory and motor functional recovery. However, only a few cell-based clinical trials targeting IDD repair or regeneration have been published, and most of them use axial PRP through intradiscal injection. Also, none of them have the longterm necessary MRI study in the clinical follow-up. In our understanding, we decide to use the biological therapy by the epidural approaching in the management of IDD. Injecting PRP into the epidural space means cytokines (inflammation control) and high concentrations of growth factors (tissue repair and regeneration). Epidural PRP allows us to suggest this is the first-line technique in the healing process of IDD.

**PRP is a rich source of growth factors that promote tissue regeneration. Also, PRP suppress cytokine release, limiting inflammation, improving thereby, the healing process. So, Epidural PRP allows us to suggest this is the first-line technique in managing IDD.**

#### **6.4 Our designed study with PRP within the epidural space**

The preliminary study, a clinical trial in which PRGF was injected into the epidural space for promoting IDD regeneration, started since 2014, and published in 2016 [4]. That preliminary trial included 70 patients, and they were injected with one epidural PRGF dose. That pilot trial focused on clinical perspectives (pain relief and assessment of patient satisfaction through VAS score and Macnab criteria).

Then, a new and larger study [5] reached 250 patients who received two doses of epidural PRP and who were assessed with magnetic resonance imaging (MRI) one year after PRP treatment to find disc or facet join changes if they occurred. That was probably the most extensive follow-up document that links PRGF used in injection

into the epidural space as a method of intervertebral disc regeneration in cases of disc disease, and the only one with MRI evaluation before PRGF treatment, and then one year posterior to the PRGF therapy.

Even considering that it was a field of research, still in early development, our novel alternative treatment with promising clinical results for intervertebral disc disorders was far distant from the poor results usually achieved with previous consensus protocols, those based on palliative pain medications, but not focused on treating the underlying disease.

#### **6.5 Design of the second study**

Prospective observational, nonrandomized, single-center clinical study carried out between January 2015 and June 2017. We have included 250 patients, who were between 18 years to 70 years of age, with neck or back pain with or without radicular pain, and with a diagnosis of a spinal disc herniation confirmed with MRI imaging. After receiving institutional approval and informed consent signed by all patients, they were approached for enrollment. In the majority of patients, the etiopathogenesis of the axial or radicular pain was due to multifactorial origin: disc disease, facet joint arthrosis, hypertrophy of the ligamentum flavum, and in many cases associated to central canal narrowing or foraminal stenosis.

#### **6.6 Results of the preliminary study**

Epidural PRGF injections for IDD showed clinically significant improvements in pain (VAS-scale) and function (MACNAB-score) (**Table 1**) throughout two years of follow-up.

Mean VAS-scale improved in 85% of patients, from 9 to 3, and the mean MACNAB-score was considered GOOD at six months and EXCELLENT at the end of one year after the epidural PRGF injections. The need for opioid rescue decreased from 96% to none at the end of one year follow-up (**Table 2**). However, 15% of the patients did not improve the pain score; but no patient showed a worsening of the symptoms. Positive changes in MRI images one year following the second epidural dose have been documented in few patients, but this aspect needs further research.

With these results, our pilot study showed a definitive role of PRP injection via the epidural space for chronic prolapsed intervertebral disc patients.

**1. Excellent:** No pain. No restriction of mobility. Return to normal work and level of activity.

**2. Good:** Relief of current symptoms. Occasional back or leg pain of sufficient severity to interfere with the patient's ability to do his normal work or his capacity to enjoy himself in his leisure hours. Able to return to modified work.

**3. Fair:** Improved functional capacity but handicapped by intermittent pain of sufficient severity to curtail or modify work or leisure activities. Still handicapped and/or unemployed.

**4. Poor:** No improvement or insufficient improvement to enable increasing activities. Continued objective symptoms of root involvement. Probable further operative intervention needed, irrespective of length of postoperative follow-up.

*Perspectives of Cell-Based Therapy for Degenerative Diseases of the Spine: The Reason… DOI: http://dx.doi.org/10.5772/intechopen.107074*


**Table 2.**

*Outcome of patients after epidural PRGF injections.*

### **7. Conclusions**


epidural space- will allow an effective activity on the disc, but also over the facet joints, and on the ligamentum flavum. Its antineuroinflammatory activity would relieve the associated neuropathic pain.

7.Finally, in IDD, the regenerative medicine option, such as the use of mesenchymal stem cells or platelet-rich plasma, has shown preclinical and clinical positive results. However, additional more powered high-quality studies are needed to really appreciate the long-term safety and efficacy of this technique approaches in the IDD process.

#### **Author details**

José Correa1 \*, Henry Cortés2 , Lucia Correa<sup>3</sup> and Rita López1

1 Hospital Santiago Apóstol, Miranda de Ebro, Spain

2 Pain Management-Palliative Care, Medical Cannabis Global Health Initiative Specialist, Spain

3 IQS, Universitat Ramon Llull, Barcelona, Spain

\*Address all correspondence to: josep24909@hotmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Perspectives of Cell-Based Therapy for Degenerative Diseases of the Spine: The Reason… DOI: http://dx.doi.org/10.5772/intechopen.107074*

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[35] J. Correa, P Abella. Unidades del dolor del siglo XXI. ¿Protocolos de consenso o medicina basada en la evidencia? (21st Century Pain Units: Consensus Protocols or Evidence-Based Medicine?) Revista Persona y bioética de la Universidad de la Sabana, Bogotá. ISSN-e 0123-3122, 22, 1, 2018. 29-38

Section 4

## Epidural Administration and the ICU

#### **Chapter 6**

## Epidural Analgesia for Pain Management in the Intensive Care Unit

*Kingsley U. Tobi*

#### **Abstract**

The pain of patients admitted into the ICU remains poorly reported and managed. It has been reported that about half of patients admitted to both medical and surgical ICU experienced significant pain during their stay in the unit. Most of these patients tend to develop psycho-traumatic experiences both while in the unit and after discharge. This chapter thus highlights the drawback of poor pain management of critically ill patients and the role of epidural analgesia in contributing to better pain control in the ICU.

**Keywords:** epidural analgesia, pain, critically ill, ICU, pain management

#### **1. Introduction**

Pain, as defined by the International Association for the study of pain, is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage [1]. It is common among patients in the intensive care unit (ICU). Previously, a prospective study reported that about half of patients admitted to both medical and surgical ICU experienced significant pain during their stay in the unit [2]. Although most ICU patients cannot self-report pain, its presence often leads to deleterious consequences during and after discharge from the unit. Adequate pain control in the ICU is essential and adds to optimal patient care with improved outcomes.

The pain of patients admitted into the ICU remains poorly reported and managed. Most of these patients as a result tend to develop psycho-traumatic experiences both while in the unit and after discharge. This chapter thus highlights the drawback of poor pain management of critically ill patients and the role of epidural analgesia in contributing to better pain control in the ICU.

#### **2. Aetiology of pain in ICU**

The aetiology of pain among ICU patients ranges from injuries sustained prior to admission, postoperative pain, pain due to patient's pathology and pain during

routine nursing procedures such as turning, wound dressing and suctioning. A significant increase in pain intensity during patient turning in the ICU compared to when they were lying down at rest has also been documented [3].

#### **3. Impact of pain on ICU patients**

Poor or inadequate pain relief in the intensive care unit has a multi-systemic impact on the critically ill patient. Suboptimal pain management in the ICU can lead to anxiety, delirium and sleep deprivation. Anxiety leads to agitation, patientventilator asynchrony and difficulty in weaning from the ventilator [4]. Inadequate pain relief can lead to improper sleep, and lack of adequate sleep can increase pain response in ICU patients.

Furthermore, inadequate analgesia in the ICU is associated with increased oxygen consumption and sympathetic responses with increased poor outcomes. In mechanically ventilated patients, pain may lead to retained pulmonary secretions, resulting in secondary bacteria colonisation and the development of ventilator-associated pneumonia (VAP) [5]. Ventilator-associated pneumonia complicates ICU management, with an increased risk of morbidity and mortality.

In addition, poor pain control in the ICU can often lead to post-traumatic stress disorder (PTSD). Granja and colleagues found that about two out of ten ICU patients experience severe pain six months after being discharged from the unit [4]. This can lead to chronic pain with its attendant psychosocial and economic burden on the patients, family members and the health care system.

The stress response following, for example, surgical intervention causes an increase in stress hormones in the circulation. This can result in arteriolar vasoconstriction, impair tissue perfusion, and reduce tissue-oxygen partial pressure [6]. The consequences include poor wound healing and surgical wound infection [7], resulting in poor patient outcomes in the ICU.

#### **4. Pain assessment in the ICU**

Most patients admitted to the ICU cannot correctly communicate the intensity of their pain. This may be due to a reduced level of consciousness and the different interventions provided, such as airway and ventilatory support [8]. Since the inability to report pain does not exclude its presence [9], the need to properly assess pain intensity among ICU patients cannot be overemphasised.

Due to patients' inability to communicate their pain, behavioural and physical responses have been used to assess pain in the ICU. The two commonly employed behavioural pain assessment tools used in sedated and ventilated patients are the Behavioural Pain Scale (BPS) and Critical-Care Pain Observation Tool (CPOT) [10]. The BPS is a clinical observational score depending upon the patient's facial expressions, upper limb posturing, and tolerance of the controlled mechanical ventilation. The score ranges from 3 to 12, and a score of >6 requires pain management [10].

See **Table 1** below:


**Table 1.**

*Behavioural pain scale (BPS).*

The Critical-care Pain Observation Tool is a pain assessment tool with four clinical components, facial expressions, body movements and muscle tension and compliance with invasive mechanical ventilation. The score ranges from 2 to 8, and a score of more than 2 requires pain management intervention. See **Table 2**:


#### **Table 2.**

*Critical-care pain observation tool (CPOT).*

In our setting, the Behavioural Pain Scale (BPS) is easier to use and, when combined with other clinical observations, helps to determine the adequacy of analgesia in our patients.

#### **5. Pain management in the ICU**

One of the methods of achieving pain control in the ICU is via epidural analgesia. Epidural analgesia/anaesthesia is a form of neuraxial block where local anaesthetic agents and other adjuvants, such as opioids, are deposited into the epidural space. This may be done as a single-shot technique or with a catheter or continuous infusion. It offers a wide range of applications and may be performed at the cervical, thoracic, lumbar and sacral levels.

In a survey conducted in England, 89% of ICUs use epidurals for pain relief [11]. There are, however, some concerns about "the safety of placing epidural catheters in sedated patients, and confirmation of a good catheter position can be difficult in the critically ill patient if sensory level testing is not reliable" [12]. Apart from the safety concerns raised with epidural analgesia in the ICU, placing an epidural catheter in critically ill patients is sometimes difficult. This may be due to difficulty with properly positioning patients for the procedure, presence of contraindications such as sepsis and coagulopathy, common in ICU patients and the haemodynamic complications following the procedure. With the availability of trained personnel and improved monitoring, epidural analgesia can be safely done for appropriate patients in the ICU.

#### **6. Anatomy of the epidural space**

The epidural space is a potential space between the dural sheath and the spinal canal. It is continuous within the vertebral column and extends from the foramen magnum to the sacrococcygeal membrane of the sacral canal [13]. The foramen magnum occupies the superior boundary, and the sacral hiatus occupies the inferior boundary. The posterior longitudinal ligament and ligamentum flavum form the anterior and posterior boundaries, respectively. The vertebral laminae, pedicles and intervertebral foramen form the lateral boundary.

Some of the contents of the epidural space include semi-liquid fats (extra-dural fats), lymphatics, arteries and large thin-walled veins. The capacity of the epidural space is far greater than the capacity of the subarachnoid space. It requires 1.5–2.0 mls of LA to block a spinal segment via the epidural route against 0.3 mls via the subarachnoid space.

The veins within the epidural space constitute a close network which runs vertically. They form four (4) main trunks, namely: two (2) on either side of the posterior longitudinal ligament and two (2) posteriorly in front of the vertebral arches. The epidural veins anastomose freely with extra-dural veins, the azygous veins and the intracranial veins. The veins are called valveless venous plexus of Bateson.

The epidural space has a negative pressure transmitted intra-pleural pressure via the thoracic paravertebral space. This negative pressure may also be due to the relative overgrowth of the vertebral canal compared with the dural sac. Artefactual or transient negative pressure results from the needle's anterior dimpling of the dural. It can also arise from the anterior indentation of the ligamentum flavum by the epidural needle. In addition, back flexion causes stretching of the dural sac and pushes CSF out. *Epidural Analgesia for Pain Management in the Intensive Care Unit DOI: http://dx.doi.org/10.5772/intechopen.109255*

#### **7. Indications for epidural Analgesia in the ICU**

Indications for epidural Analgesia in the ICU include [12]:


#### **8. Contraindications for epidural Analgesia**

These could be absolute or relative. Absolute contraindications include:


Relative contraindications include:


#### **9. Technique for epidural Analgesia**

Three methods can be used to administer epidural analgesia in the ICU: singleinjection and intermittent boluses, continuous infusion via an indwelling catheter or patient-controlled epidural analgesia (PCEA). Continuous infusion via an indwelling catheter is often preferred in the ICU because it offers a constant plasma level of administered analgesics, thus providing better and more efficacious pain relief [13].

The following are steps to performing an epidural in the ICU.

*Patient selections:* Most surgical patients admitted to the intensive care units postoperatively in which epidural anaesthesia was provided would have an epidural catheter in situ. Others who do not already have one are selected based on a careful assessment of patient status, risks, benefits, indications and contraindications of epidural analgesia.

*Patient consent:* After careful patient selection, informed consent should be obtained from the patient if awake or from the relative before proceeding with the technique. Informed consent should involve a careful explanation of the procedure and the risks and benefits of the procedure. Consent may be in the form of written or verbal.

*Positioning:* epidural analgesia can be done with the patient sitting or lateral decubitus. However, in the ICU, the commoner position for an epidural is the lateral decubitus position due to the peculiarities of ICU patients. With the patient in the appropriate position, an epidural needle, typically a Tuohy needle, is inserted into the appropriate intervertebral space to the epidural space aseptically. Correct placement is confirmed with a loss of resistance or hanging drop technique.

*Placement of catheter:* Following confirmation of the correct needle placement in the epidural space, an epidural catheter may be threaded into the epidural space through the Touhy or spinal needle for a continuous top-up. The epidural catheter is advanced 2–3 cm into the epidural space [14], after which the needle is carefully removed. A slide-lock adapter may be attached to the end of the catheter to allow the attachment of an injection port or infusion tubing. A filter can also be attached to the infusion tubing to ensure sterility. The placement of an epidural catheter is determined by the dermatome innervating the area of pain to be treated. On the other, an epidural catheter can be placed directly at the site of injury or at the site of surgical incision.

*Prevention of intrathecal or vascular injection:* Two techniques are used to prevent the intrathecal and/or vascular placement of an epidural catheter, namely, aspiration and the use of a test dose. For the aspiration method, a syringe filled with two millilitres of preservative-free sterile normal saline is attached to the end of the catheter and gently aspirated for 30 seconds. A bloody tap implies that the catheter is in an epidural vein. In addition, an increase in heart rate or blood pressure following a test dose of a local anaesthetic with 1:200,000 adrenaline indicates that the tip of the catheter may be in an epidural vein. More than one millilitre of clear fluid which is positive for cerebrospinal fluid shows that the catheter is in the subarachnoid space. Following a satisfactory placement, a transparent sterile dressing is applied over the catheter site, while the other length is secured with a plaster [15].

#### **10. Drugs which are injected into the epidural space**

Local anaesthetic agents are the most commonly used medications for epidural analgesia in the ICU. The commonest LA for epidural analgesia is plain bupivacaine, an amide which is approximately 95% protein bound and is metabolised primarily in the liver via conjugation with glucuronic acid [16]. It comes in three different concentrations: 0.25%, 0.5%, and 0.75%. Bupivacaine for use in the ICU for analgesia is the plain formulation (plain Marcaine), and it is usually administered via an epidural catheter either as intermittent boluses or as a continuous infusion. A dose of 10–15 mg may be administered bolus after a test dose as described above. The drug may be repeated PRN at 3–5 mg.

While administering epidural bupivacaine, monitoring for the motor block using the Modified Bromage scale [17] and watching out for local anaesthetic toxicity is necessary.

The scale is as follows:

*Epidural Analgesia for Pain Management in the Intensive Care Unit DOI: http://dx.doi.org/10.5772/intechopen.109255*


No block or partial block is desirable for ICU patients on epidural bupivacaine for pain relief.

Signs of local anaesthetic toxicity (LAST) may not be easily detectable in the sedated patient in the ICU, and thus, a high index of suspicion is required. Despite this, "the incidence of LAST in sedated patients is not higher than in others" [18].

Signs of LAST include:


Early recognition and prompt intervention are advocated in order to prevent unfavourable outcomes.

Opioids are the main medications used for Analgesia in ICU patients due to their potency and a concomitant mild sedative and anxiolytic effects. It can be administered by multiple routes. The commonly used opioids include fentanyl, remifentanil, and morphine. Morphine is usually administered as a 2–5 mg bolus or at 1–20 mg/h via continuous infusion. Epidural administration of 5 mg of morphine sulphate can provide adequate postoperative [19] analgesia for up to 24 hours. Lower doses are however, recommended in patients with hepatic or renal insufficiency which is common among ICU patients.

One of the most common side effects of epidural morphine is respiratory depression, with an overall risk of less than 1%. This is nonetheless, similar to that of opioids administered via the parenteral route [20, 21]. Others are miosis, constipation, urinary retention, pruritus, hypotension, nausea and vomiting. The sedative effect of morphine is beneficial in patients in whom sedation is indicated, such as mechanically ventilated patients and those in whom invasive procedures need to be performed.

Other analgesic adjuvants may be administered via the epidural route to improve pain relief in critically ill patients in the ICU. These include α2-agonists, such as clonidine and dexmedetomidine. In addition to providing analgesia, dexmedetomidine infusion has been shown to reduce the prevalence and duration of confusion and delirium [22]. The side-effect profile of both α2-agonists includes bradycardia, cardiac asystole and hypotension. Although rare, it can cause rebound hypertension and can cause withdrawal syndrome [22].

### **11. Conclusion**

Pain relief is an integral part of the management of critically ill patients in the intensive care unit. Epidural analgesia is a helpful component of a multimodal analgesia approach to patients in the ICU. Careful patient selection, availability of trained personnel and increased patient monitoring will ensure the safe delivery of epidural analgesia in the ICU.

### **Author details**

Kingsley U. Tobi Faculty of Health Sciences and Veterinary Medicine, Department of Surgical Sciences, Division of Anaesthesiology, University of Namibia, Windhoek, Namibia

\*Address all correspondence to: tobikingsley265@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

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[2] de Jong A, Molinari N, De Lattre S. Decreasing severe pain and serious adverse events while moving intensive care unit patients: A prospective interventional study (the NURSE-DO project). Critical Care. 2013;**17**:R74

[3] Vazquez M, Pardavila MI, Lucia M, Aguado Y, Margall MA, Asiain MC. Pain assessment in turning procedures for patients with invasive mechanical ventilation. Nursing in Critical Care. 2011;**16**:178-185

[4] Granja C, Gomes E, Amaro A, et al. JMIP study group: Understanding post-traumatic stress disorder-related symptoms after critical care: The early illness amnesia hypothesis. Critical Care Medicine. 2008;**36**:2801-2809

[5] Marino PL. Analgesia and sedation. In: Marino PL, Sutin KM, editors. The ICU Book. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007. pp. 885-907

[6] Akça O, Melischek M, Scheck T, et al. Postoperative pain and subcutaneous oxygen tension. Lancet. 1999;**354**:41-42

[7] Hedderich R, Ness TJ. Analgesia for trauma and burns. Critical Care Clinics. 1999;**15**:167-184

[8] Kirksey KM, McGlory G, Sefcik EF. Pain assessment and management in critically ill older adults. Critical Care Nursing Quarterly. 2015;**38**:237-244

[9] McGuire DB, Kaiser KS, Haisfield-Wolfe ME, Iyamu F. Pain assessment in non-communicative adult palliative care patients. The Nursing Clinics of North America. 2016;**51**:397-431

[10] Rijkenberg S, Stilma W, Endeman H, Bosman RJ, Oudemansvan Straaten HM. Pain measurement in mechanically ventilated critically ill patients: Behavioral pain scale versus critical-care pain observation tool. Journal of Critical Care. 2015;**30**:167-172

[11] Low JH. Survey of epidural analgesia management in general intensive care units in England. Acta Anaesthesiologica Scandinavica. 2002;**46**:799-805

[12] Schulz-Stübner S, Boezaart A, Hata S. Regional Analgesia in the critically ill. Critical Care Medicine. 2005;**33**:1400-1407

[13] Epidural management, Epidural Analgesia, Epidural Anesthesia, Thoracic. Available from: https:// www.cancertherapyadvisor.com/ home/decision-support-in-medicine/ critical-care-medicine/epiduralmanagement-epidural-analgesiaepidural-anesthesia-thoracic-epidurallumbar-epidural-regional-anesthesia/

[14] Holladay J, Sage K. Epidural catheter. [Updated 2022 Jun 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; Jan 2022

[15] Gerheuser F, Roth A. Epidural anesthesia. Der Anaesthesist. 2007;**56**(5):499-523

[16] Bupivacaine HCL Injection and Bupivacaine and Epinephrine Injection. Available from: https://www. accessdata.fda.gov/drugsatfda\_docs/ label/2010/071165s020lbl.pdf

[17] Breen TW et al. Epidural anesthesia for labor in an ambulatory patient. Anesthesia and Analgesia. 1993;**77**:919-924

[18] Kessler P, Steinfeldt T, Gogarten W, Schwemmer U, Büttner J, Graf BM. Peripheral regional anesthesia in patients under general anesthesia: risk assessment with respect to parasthesia, injection pain and nerve damage. Der Anaesthesist. 2013;**62**(6):483-488

[19] Epidural Morphine Article— StatPearls. Available from: https:// www.statpearls.com/articlelibrary/ viewarticle/21231/

[20] Mugabure BB. A clinical approach to neuraxial morphine for the treatment of postoperative pain. Pain Research and Treatment. 2012;**2012**:612145

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Section 5

## Epidural Service and Low Resource Setting

### **Chapter 7**

## Perspective Chapter: Epidural Anaesthesia Service Delivery in Anaesthesia Workforce Constrained Regions

*Chimaobi Tim Nnaji*

#### **Abstract**

Epidural anaesthesia is often under-utilized in our environment. This could be linked to scarcity of specialist anaesthesia providers in anaesthesia workforce constrained regions. To have an effective and safe surgical and obstetric intervention, there is need to have specialist anaesthesia providers that proffer effective leadership in anaesthesia services and delivery of emergency and essential patient care, to help combat the extremely high avoidable anaesthesia-related morbidities and mortalities. Epidural anaesthesia can offer both intraoperative and postoperative analgesia, with the potential to reduce morbidity and mortality. It's use in labour analgesia has been found to be very effective, with good obstetric outcome. Nevertheless, epidural anaesthesia requires the availability of human, technical and economic resources. But, despite the fact that healthcare is given a strategic priority in the life of people, delivery of safe surgical and non-surgical services is linked to anaesthesia workforce capacity and its impact in the society.

**Keywords:** epidural anaesthesia, analgesia, specialist anaesthetist, anaesthesia workforce, safety

#### **1. Introduction**

Epidural anaesthesia and analgesia services is a technique for perioperative and procedural pain management with multiple applications that may be used as a primary surgical anaesthetic, resource for postoperative pain management, chronic pain relief or labour and obstetric delivery analgesia [1]. It is safe and relatively easy to perform by trained personnel. Nevertheless, it requires adequate training and high level of skill acquisition. Epidural anaesthesia and analgesia services takes into consideration the anatomy of the patient's spine, procedural indications and contraindications, in the view of the interprofessional teams' role in providing and improving care for patients who undergo surgery or require pain management. Irrespective of the benefit of potentially providing excellent analgesia, its use reduces the exposure of patient to other anaesthetics and analgesics, decreasing side effects [2]. Nevertheless, the importance of collaboration and communication amongst the health care team involved in the care of patients who receive epidural anaesthesia or analgesia service is important in improving outcomes. Epidural anaesthesia or analgesia can be administered as a single shot, intermittent/programmed bolus or a continuous infusion for long-term pain relief. Many beneficial aspects of epidural analgesia or anaesthesia have been reported, including better suppression of surgical and labour stress, positive effect on postoperative nitrogen balance, more stable cardiovascular haemodynamic, reduced blood loss, better peripheral vascular circulation, better labour analgesia and postoperative pain control [2].

Epidural anaesthesia and analgesia services is one of the unique facets of anaesthesia service delivery, which forms an important part of medical services in any country and undeniably strengthens the healthcare systems. Nevertheless, irrespective of the strategic priority given to healthcare in the life of the global population, the delivery of safe surgical and non-surgical services is linked to anaesthesia workforce capacity and its impact in the society. The epidural analgesia and anaesthesia services in any region of the world are particularly susceptible to the level of socio-economic development of such region, and like any other anaesthesia service delivery, the practice faces numerous challenges exclusively related to high number of pathologies, shortage of materials and drugs, infrastructure and human resources [3]. In many developing countries, especially sub-Saharan Africa, there is a critical shortage of healthcare workers and very limited resources. The health systems are stretched by diseases such as HIV/AIDS, tuberculosis, diarrhoea diseases and malaria and the loss of trained staff to the developed world and insecurities. Furthermore, economic effects of longterm conflict continue to rampage most of the developing countries.

Epidural anaesthesia and analgesia service are particularly vulnerable to development pressures and the quality of epidural anaesthesia and analgesia services is highly correlated with perioperative mortality and morbidity of the patients [4]. Hence, the presence of adequate infrastructure, skilled anaesthesia providers and the use of effective sanitation are paramount to improving the epidural anaesthesia and analgesia service, which will have a pro-founding positive effect on acute and chronic pain management services, obstetric services and perioperative outcome.

#### **2. Shortage of physician anaesthesia specialist**

Effective and safe pain care, surgical and obstetric intervention requires the presence of specialist anaesthesia providers that proffer quality leadership in epidural anaesthesia and analgesia services during elective, emergency and essential patient care, to help combat the extremely high avoidable anaesthesia-related morbidities and mortalities. This remains elusive in developing countries because of shortage of anaesthesia specialist among other healthcare workers [5, 6]. The number of surgical conditions contributing to the global burden of disease and the potential impact of such on basic surgical services continue to rise. It is estimated that 11% of the world's disability-adjusted life years are from conditions that are very likely to require surgery. Increasing evidence is beginning to emerge that maternal and infant survival is proportionately correlated to the number of health workers including physician anaesthetist providing obstetric care [5, 6]. Physician anaesthetists are scarce in many resource limited countries and they are not available at most referral health facilities and non-existent in remote and rural areas [3].

#### *Perspective Chapter: Epidural Anaesthesia Service Delivery in Anaesthesia Workforce… DOI: http://dx.doi.org/10.5772/intechopen.108560*

The number of Physician anaesthetists serving the looming population in the developing and resource limited countries has continued to decline irrespective of the soaring population, due to lack of political will, poor wages, conflicts and insecurities and migration to developed countries with better wage packages and incentives [3]. Mavalankar and coworkers [7], reported that in Afghanistan with population of 32 million persons, there are only 9 physician anaesthetists and only 8 in Bhutan with population less than 700,000. Another study observed that only 13 physician anaesthetist are available in Uganda to serve a surging population of 27 million persons [3]. Different studies conducted in Zimbabwe [8] and Nigeria [9, 10] identified that there are no specialist anaesthetists in public or provincial hospitals that serve as the referral centres in Zimbabwe and Nigeria respectively. World Health Organization (WHO) has encouraged member states to ensure that anaesthesia is properly prioritized within the health system and that support, follow-up, reporting, and bench-marking take place [11].

A report from the World Federation of Societies of Anaesthesiologist (WFSA) shows that there was a total of 436,596 physician anaesthesia provider in the 153 countries serving a population of more than 7 billion persons. This represents a workforce density of 6.09 per 100,000 population. The study also showed that 355,381 (81.4%) were specialist anaesthetists, 71,990 trainee specialist anaesthetists (16.5%), and 9225 (2.1%) non-specialist physician providers [12]. However, this figure is mainly dominated by developed country statistics. Most countries in Africa like Nigeria, Angola, Burkina Faso, Ethiopia, Zimbabwe and Niger has a workforce of <1 per 100,000 physician anaesthesia providers [12]. Indicating that resource limited and developing countries are still unable to meet the WFSA recommendation of at least 5 physician anaesthesia providers per 100,000 population, in other to ensure an effective leadership in anaesthesia services and delivery of emergency and essential patient care.

The scarcity of specialist anaesthesia physician can have a negative impact on the implementation of epidural anaesthesia and analgesia service in terms of the safety of perioperative, obstetric and pain patients, as well as the quality of healthcare services that will be delivered to the patients. The specialist anaesthesia physician in resource limited countries are over-worked irrespective of their limited number. For example, in Nigeria the physician anaesthetists in the public hospitals are involved in perioperative patient care, patient's resuscitation, critical care medicine, transportation of critically ill patients, acute and chronic pain management, sedation services, as well as healthcare system management, advocacy, simulation and medical education and research [13]. Furthermore, the private hospitals also depend on the services of this constrained specialist anaesthetists to sustain safe and quality healthcare services in their institutions. Thus, making them prone to burnouts and unable to sustain epidural anaesthesia and analgesia services.

#### **3. Obstetrics epidural analgesia service challenges**

Epidural analgesia is widely regarded as the gold standard for pain relief during labour. It involves the titration of low-dose and low-concentration local anaesthetics, to produce safe and reliable analgesia during labour and delivery. A properly monitored labour epidural service has a low incidence of side effects or serious complications to the parturient or foetus [14, 15]. However, in order for this service to be safe and efficacious, epidural labour analgesia need to be accessible 24 hours, every day. But the evaluation of this service in resource limited countries of the world shows

that it is reluctantly or grossly low, or even not available in most health institutions that serves as referral healthcare facilities [16–18]. Furthermore, literature search on the utilization rate of epidural analgesia in labour in resource limited countries shows dearth of data in this region of the world, and it is associated with limited anaesthesia workforce, time constraint, limited anaesthesia materials and equipment, lack of advocacy and awareness of such service (see **Table 1**).

When Jacobs-Martin et al. [16] evaluated the utilization of epidural analgesia services in labour in South Africa women, they observed that the rate was abysmally low, with the incidence of 2.2%, compared with the rate of 23.4% and 90% in developed countries like United Kingdom and United State of America, respectively [24, 25]. They accrued the low rate of epidural analgesia in labour to limited number of available skilled anaesthesia personnel, time constraint, knowledgeable support staff, materials and equipment. Another study conducted by Okojie et al. [16] and Imaregiaye et al. [18] in Nigeria showed that the awareness of this service is grossly low, although with high level of acceptability among the educated and those with previous birth experience. Nevertheless, access to this service was very low, because of unavailability of 24 hours service as a result of low staff strength. In this region of the world, the ratio of physician anaesthesia provider is 0.58 per 100,000 population, instead of the recommended 5 per 100,000 population by WFSA [12]. This could be a determining factor to the lack of advocacy and effective epidural analgesia services in labour, as the limited available specialist anaesthetists are overwhelmed with perioperative and critical care services even at the referral health institutions.

Epidural analgesia is a technical procedure, performed under aseptic technique, where medications like local anaesthetics with or without an additive is injected into the epidural space with the intention of providing analgesia to a specific region of sensory dermatomes [26]. This is followed by subsequent intermittent or programmed top ups, until the mother delivers her baby in a pain free and safe scenario. The availability epidural analgesia service helps to conveys a level of safety to woman in labour and the foetus. Epidural analgesia service has traditionally been viewed as expensive, resource-intensive, time consuming and requiring highly specialized training for the doctors and support staff in resource limited clime. Thus, making it underutilized in this environment.

To deliver an effective and safe epidural analgesia service in labour, personnel, as well as some minimum equipment, materials and medications are required. This includes the availability of physician anaesthetist, obstetrician, trained nursing staff skilled with handling of epidural services and other support staff. There is also need for the availability of supplemental oxygen source, suction machine, related equipment, self-inflating bag and mask device that is able to provide positive pressure ventilation, airway materials like oropharyngeal airway, nasopharyngeal airway, endotracheal tubes for resuscitation, patient monitors with the capability for noninvasive blood pressure, electrocardiographic, pulse oximetry and capnographic monitoring. Furthermore, there is need to have intravenous catheters, crystalloids, infusion sets, syringes, needles, emergency drugs like vasopressors (ephedrine, phenylephrine, epinephrine), atropine, and intralipids, and defibrillators or crash cart [27].

The minimum equipment and medications required for obstetric epidural analgesia services are often not available in most health institutions in developing countries, making it difficult for the limited number of anaesthesia physicians to function and provide effective safe labour epidural analgesia services. The environment is associated with poor operation theatre infrastructure and unavailability of equipment,


*Perspective Chapter: Epidural Anaesthesia Service Delivery in Anaesthesia Workforce… DOI: http://dx.doi.org/10.5772/intechopen.108560*


#### **Table 1.**

*Global epidural anaesthesia and analgesia indices and characteristics.*

lifesaving drugs and anaesthetic agents [3, 28]. Furthermore, the physicians face problems of unreliable electricity, unavailability of compressed oxygen and other gases, sophisticated machines and modern drugs [3, 28]. Safe provision of labour epidural analgesia service necessitates the ability to manage any potential complications or emergencies that may arise. There should be resuscitative equipment and drugs in the event of bradycardia, hypotension, high or total spinal anaesthesia, local anaesthetic toxicity or cardiopulmonary arrest, but these are either not available or in limited supplies.

*Perspective Chapter: Epidural Anaesthesia Service Delivery in Anaesthesia Workforce… DOI: http://dx.doi.org/10.5772/intechopen.108560*

The development of an epidural analgesia service should encompass patients' safety as part of its working protocols. Although the barriers to safe and effective administration of labour analgesia service like inadequate practitioner training, staff reserves, and unavailability of the proper technologies and medicines continue to rampage low resource countries, the desire for such services appears to exist, with evidence that when it is offered, some women chose to accept the service [16, 24].

#### **4. Epidural anaesthesia service for surgeries and safety challenges**

Epidural anaesthesia involves the injection of high volume and dose of local anaesthetic agent into the epidural space to achieve a reversible loss of sensation adequate to allow surgical procedures. It is usually administered for surgeries in the lower abdomen, perineum and lower extremities. Studies have shown that thoracic epidural anaesthesia can be used to perform major upper abdominal and thoracic surgeries, including cardiac and major thoracic vascular surgeries [29, 30]. Although epidural anaesthesia onset of action is slow, and sometimes associated with patchy sensory blocks, when properly performed, it can offer good anaesthesia and outlast the duration of prolonged surgeries. Nevertheless, the epidural anaesthetic effect on reducing intraoperative and postoperative morbidity and mortality varies with the type of surgery performed. Epidural anaesthesia can be performed as a sole anaesthetic or in combination with spinal or general anaesthesia. Its duration of anaesthesia is prolonged with the use of epidural catheters that allows for top ups or continuous injections of local anaesthetic and mixture with additive or local anaesthetic alone, to improve the overall surgical outcome. When used for abdominal aortic surgery, it can shorten the intubation time and intensive care stay [15, 31].

Epidural anaesthesia service requires the availability of human, technical and economic resources. In the present clime of patient safety, people in developing countries continue to suffer due to lack of trained physician anaesthetists, as well as lack of adequate health system infrastructure and equipment, prioritization of anaesthesia and surgical care as part of national health plans. The crisis in human resources for anaesthesia care in many developing countries is contributed by the low standing of the profession, especially in sub-Saharan Africa, and the resulting problems with recruitment and retention of practitioners at all levels. Hence, making it difficult for majority of the population in resource limited areas to access safe anaesthesia services both in cities and in the rural and underprivileged areas of the region. Safe surgical and non-surgical services is a reflection of adequate anaesthesia workforce capacity. Hence, improvements in the safety and quality of anaesthesia is urgently needed, but the challenge is the deficiency in the number of trained physician anaesthetist [32, 33].

Epidural anaesthesia is often under-utilized in our environment. This could be linked to scarcity of specialist anaesthesia providers in anaesthesia workforce constrained regions. To provide guidance and assistance in maintaining and improving the quality and safety of epidural anaesthesia service, specialist physician anaesthesia providers are required. The shortage of specialist anaesthesia physician creates a major hindrance and vacuum for epidural anaesthesia services in the resource limited areas of the world. In some countries, the gap is filled by non-physician anaesthetists, who provides any form of anaesthesia for surgical procedures. Most times they work alone without any support from specialist physician anaesthetists, and they handle cases beyond their training, with the number of morbidity and mortality relating to inappropriate care rising [34, 35]. Pignaton and colleagues reported that the quality of anaesthesia services delivered is highly correlated

with perioperative morbidity and mortality [34]. A study showed that the overall risk of maternal death when non-physician anaesthetists provided care was 9.8 per 1000 compared to 5.2 per 1000 in physician anaesthesia provider care [35].

A meta-analytical study on anaesthesia related maternal mortality in low-income and middle-income countries, shows that in women undergoing an obstetric procedure, the risk of death attributed to anaesthesia was 1·2 per 1000 women, with the highest rates of 1·5 per 1000 in sub-Saharan Africa women. Anaesthesia was reported as the main cause of death in 2.8% of all direct and indirect maternal deaths, with the highest rates in Middle East and North Africa (6.2%), and the lowest in east Asia and Pacific (1.5%). When neuraxial anaesthesia like epidural anaesthesia were compared with the administration of general anaesthesia, the odds of maternal death tripled, with mortality rates of 5.9 per 1000 in general anaesthesia and 1.2 per 1000 for neuraxial anaesthesia. General anaesthesia also doubled the odds of perinatal death compared with neuraxial block [35]. Availability of specialist anaesthesia physician in the resource limited regions will be effective in ensuring leadership in epidural anaesthesia services, delivery of obstetric emergencies and essential patient care. Epidural anaesthesia service use in obstetrics has been found to be very effective, with good obstetric outcome. Epidural anaesthesia service can provide safe and efficient anaesthesia for unplanned or emergent Caesarean delivery by increasing the dose and concentration of the local anaesthetics and/or the adjuvant used for labour analgesia [15, 27].

To ensure safety of lives and improve perioperative care, modern anaesthesia practice has become increasingly dependent on complex equipment and expensive drugs, but this is only obtainable in high income countries. The resource limited regions and countries depend on basic equipment and essential drugs, however, in most places even the basic anaesthesia equipment and essential drugs are not available. Hence, limiting the practice of epidural anaesthesia.

#### **5. Conclusion**

Epidural anaesthesia and analgesia service is required for safe surgical and non-surgical ministration. It provides both intraoperative and postoperative analgesia and reduces perioperative morbidity and mortality. A properly monitored labour epidural service has a low incidence of side effects or serious complications to the parturient or foetus. But this service is often under-utilized in the workforce constrained developing and resource limited countries due to scarcity of specialist anaesthesia providers, as well as unavailability of infrastructural, technical and economic resources. Hence, to achieve an effective and sustainable epidural anaesthesia and analgesia service, there is need to increase and ensure the presence of adequate infrastructure, materials and resources and skilled anaesthesia providers. Resolution of the human resource crisis for anaesthesia care in many developing and limited resource countries will require the commitment of the government and high level of political will, to facilitate the recruitment and retention of specialist physician anaesthesia practitioners and their support staff at all levels of the healthcare system.

#### **Acknowledgements**

I will like to express my deepest appreciation to God for his wisdom and to all the authors, whose work formed the foundation for this medical writing.

No funding was received for this work.

*Perspective Chapter: Epidural Anaesthesia Service Delivery in Anaesthesia Workforce… DOI: http://dx.doi.org/10.5772/intechopen.108560*

#### **Conflict of interest**

The authors declare no conflict of interest.

### **Author details**

Chimaobi Tim Nnaji Department of Anaesthesia, Federal Medical Centre, Owerri, Imo State, Nigeria

\*Address all correspondence to: chymaoby@yahoo.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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### *Edited by Sotonye Fyneface-Ogan*

Epidural administration is used by physicians and nurse anesthetists to administer local anesthetic agents, analgesics, and diagnostic medicines such as radiocontrast agents, glucocorticoids and other medicines. The epidural administration of medication has made some aspects of clinical practice much more accessible. This book focuses on various aspects of epidural administration, from methods to clinical uses, and its diverse applications. The book will be a valuable asset for anaesthesiologists, paediatricians, radiologists, internists, and intensivists in active clinical practice, including medical students and practitioners undergoing residency training.

Published in London, UK © 2023 IntechOpen © mymind / Unsplash

Epidural Administration - New Perspectives and Uses

Epidural Administration

New Perspectives and Uses

*Edited by Sotonye Fyneface-Ogan*