Epidural analgesics - How can safety and efficacy be improved?

Numerous studies have shown that epidural anaesthesia/analgesia is a powerful analgesic technique, but one which has a low therapeutic index. Although traditionally based on the use of local anaesthetics, epidural analgesia is now being performed using combinations of local anaesthetics and opioids with the aim of improving the quality of analgesia and reducing adverse effects. In recent years, there have been major advances in the evaluation of minimum effective doses and concentrations for local anaesthetics and opioids; this has obvious implications when considering safety in anaesthetic techniques, especially in the relief of labour pain or postoperative incisional pain. Moreover, by implementing monitoring rules and analgesic protocols, the development of acute pain services has facilitated the use of epidural anaesthesia/analgesia and improved the therapeutic index of this technique.