Adjuvant Dosing in Spinal and Epidural Anesthesia

Introduction to Adjuvants

• The American Society of Anesthesiologists recommends clonidine as the most evidence-based non-narcotic adjuvant for neuraxial blocks, with preservative-free formulations at 1-2 micrograms/kg providing prolonged analgesia and enhanced block duration 1

Clonidine (Alpha-2 Agonist)

• Clonidine is used as a first-line additive for subarachnoid blocks requiring prolonged analgesia at a dose of 1-2 micrograms/kg (or 30-75 micrograms in adults) 1
• The American College of Anesthesiologists suggests that preservative-free formulations of clonidine must be used for neuraxial administration 1

Epidural Dosing

• The European Society of Anaesthesiology recommends the use of clonidine as an adjunct with long-acting local anesthetics for pediatric caudal/epidural blocks 2, 3, 4
• The American Society of Regional Anesthesia and Pain Medicine suggests that clonidine can be combined with local anesthetic for postoperative analgesia in continuous epidural infusions 2, 3

Pediatric Regional Anesthesia

• The Society for Pediatric Anesthesia recommends the use of clonidine to improve block quality and duration in pediatric regional anesthesia 5

Fentanyl (Opioid)

• The American College of Anesthesiologists recommends the use of fentanyl at a dose of 12.5-15 micrograms combined with 2.5 mg bupivacaine for labor analgesia 6
• The American Society of Anesthesiologists suggests the use of fentanyl at a concentration of 2-2.5 micrograms/ml with bupivacaine 0.0417-0.1% at 1-3 ml/hr for continuous infusion in pediatrics 6

Morphine (Opioid)

• The American Society of Anesthesiologists recommends the use of morphine as a caudal block adjunct for prolonged postoperative analgesia in pediatrics 5

Critical Considerations

• The American Society of Anesthesiologists emphasizes that preservative-free formulations are mandatory for all neuraxial adjuvants to prevent neurotoxicity 1