epidural infusion dose according to millers
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epidural analgesia AND infusion
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Miller's Anesthesia epidural infusion dosing local anesthetic opioid
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Miller’s Anesthesia, 10e does not give one universal epidural-infusion rate. Dose must be tailored to indication, catheter level, age, surgical site, block, hemodynamics, and concurrent opioids.
Labor epidural infusion
Miller recommends dilute local anesthetic with a lipophilic opioid:
| Component | Miller 10e recommended concentration |
|---|---|
| Bupivacaine | 0.0625% to 0.1% |
| Ropivacaine | 0.0625% to 0.17% |
| Additive fentanyl | 1 to 3 micrograms/mL |
| Alternative additive sufentanil | 0.1 to 0.5 micrograms/mL |
These low concentrations aim to maintain sensory analgesia while reducing motor block and hypotension. Higher bupivacaine concentrations, particularly 0.25% or above, are not preferred for a continuous labor infusion because motor block increases. Miller’s Anesthesia, 10e, pp. 8855-8856.
Postoperative thoracic/lumbar epidural infusion
Miller favors a dilute bupivacaine or ropivacaine plus opioid regimen rather than local anesthetic alone or opioid alone. It does not identify a single optimal concentration or rate, stating that the ideal dose with lowest pain and adverse-effect burden remains unknown and must be titrated clinically. Miller’s Anesthesia, 10e, pp. 11727-11728.
Key points:
- Bupivacaine or ropivacaine is selected for preferential sensory over motor block.
- Fentanyl or sufentanil permits relatively rapid titration.
- Hydrophilic opioids, such as morphine or hydromorphone, may also be used but require vigilance for delayed respiratory depression.
- Local anesthetic-opioid combinations provide better postoperative and dynamic analgesia than either component alone. Miller’s Anesthesia, 10e, pp. 11724, 11727-11728.
Pediatric epidural infusion cited by Miller
- Bupivacaine 0.0625% or 0.125% + fentanyl 2 to 10 micrograms/mL
Background infusion: up to 0.2 mL/kg/h
Maximum bupivacaine: 0.4 mg/kg/h - Ropivacaine 0.2%: 0.2 mL/kg/h in one cited continuous-infusion regimen.
Miller’s Anesthesia, 10e, pediatric lumbar epidural section.
Use only preservative-free neuraxial medications, with monitored setting, frequent sensory and motor assessment, blood-pressure monitoring, and respiratory monitoring, especially when epidural opioids are used. Hydrophilic opioids can cause delayed respiratory depression. Miller’s Anesthesia, 10e, pp. 11720-11722.
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