School of Medicine

OR. TO. of C.
Torreon Unit

“Anesthesiology”
PERIDURAL ANESTHESIA
José Alejandro Moreno Arellano
Sesatty Daisy Flowers
Concept

■ Epidural anesthesia is an anesthesia

Extra, epi or epidural

sico
local in the extradural space (epidural or
epidural).
■ The approach can be cervical,
thoracic, lumbar
Anesthesia for surgical
purposes and Tx for
different types of acute
and chronic pain
Anatomical bases: space

the

■ Limit
□ His the
□ Inf
me and
□ lat
with
□ Ant
□ P s sheets,
s busy
to p
■ Posterior approach and penetration.
■ Thin in the cervical region,
thicker in the lumbar region.
■ Yellow ligament offers
characteristic resistance
due to its elasticity and
thickness of several mm.
 Contents of the epidural space
■ Very developed at the back.
■ It contains a very fluid fat, in which voluminous veins run that
constitute the intraspinal venous plexuses.
Also crossed by the arteries destined for the medulla and its envelope.
■ The width of the epidural space: ° Distance
that separates the yellow ligament from the dura
mater.
° It varies with the diameter of the marrow.
° Two intumescences (C6 and T12).
Width
Level 1.5 to 2mm
lower cervical Neck flexion, 3 to 4 mm.
Below C7 3 to 5mm
5 to 6mm
Mid thoracic
L2, maximum width
■ Arteries, veins and lymphatics.
The intraspinal venous plexus communicates with the abdominal
and thoracic veins through the conjunction foramina.

■
The pressures are transmitted.
■
■ These anatomical provisions highlight 3 important points for
the safety of epidural anesthesia:
Physiology of epidural anesthesia:
■ Epidural pressures (P -):
Puncture level Posture
and position

□ Ventilation
□ Age

conjunction holes
Q. Thoracic > P. Lumbar > P. Sacral
Occupation of abdominal cavity =
■ Needle reflux:
Epidural compliance* needle

Injection speed: ■ .3-.7ml/sec

Catheter

■ Extension of anesthesia □ P.
residual epidural*
■ Mechanism of action of anesthesia:
F Action locations:
■ N. mixed spinal cords for vertebral (conjunctive
foramina)
dorsal root ganglion
Spinal roots in the dura mater cuff and tract
The marrow.
body day 1» spinal cord

ralz
nerve

neuroforamen
 Blocking of posterior fibers

disrupts somatic sensitivity

visceral (even

■ Blocking of the anterior fibers of

the
root prevents efferent motor
transmission (muscle relaxation) and autonomic
transmission (parasympathetic effects
Passage of local anesthetics from the epidural
space to the subarachnoid: action at the root
and spinal cord level.

■ Relative waterproofness of duram

Arachnoid villi Vessels of the dural cuff

■ [ ] maximum in posterior CSF

Extradura spinal nerves
vertebral body

Conjunction foramina Paravertebral nerve

spinal

space
Pedicle

Spinal cord

prickly «ADAM

□ Age (+
□ - diffusion) Substance

Establishment and extension of

analgesia:
□ Metameric pattern.
□ Latency period 2-6min.
Vertebrae
|(pine ntQl.i
■ Variation in establishment:
° Thoracic, lumbar and

■ Variation of the initial

extension
■ Root caliber.
■ Thickness of the meningeal
envelope.

■ Variation in the

anesthetic:
5 + or - negativity of the
diffusion of

epidural pressure.
Mid thoracic region:
° Extension asc. and off identi °
Anesthesia suspended .

Lumbar region:
° Quick extension to T. information and L.

Sacral (caudal) region: ° Slow

establishment.
Activation of epidural block:
Local anesthetic + 3ml of epinephrine*. +: spinal anesthesia,
+Fc.
Increasing dose:
■ Fractional doses:

■ Before vacuuming:

■ “Catheter migration”

To be sure of being well

positioned, the entire
anesthetic can be infused in a single or non-fractionated dose.
Factors that influence the extension of
anesthesia:
Size*, position* and injection speed

F —Vol.m +Extension of
Volume and [ ]:
blocking (+metamers) +Intensity of
sensory block
F +[ ]
—

Age:
a
+ Age
e-Vol. by metamer.
-Need for vol. for +
extension.
■ Atherosclerosis and DM:
° Greater but slower extension.

■
Pregnancy:
° Lower doses (1 to 3).

■ 1-2ml of AL per metamer:

° For a T4 block, from L4-L5

J— Yo
Impact on different systems:
■ Purpose of neuraxial block: sensory block and
possibly reversible motor.

■ Non-selective blocking (
° F. sensory (nociceptive motor.
F. autonomous

*Fiber size i , myelination, [ ] achieved,

duration of contact.
Neurological:
° Non-selective blocking.
° Axonal CMI: caliber and myelination.
° Opioids: selective blockade.

Blockade timeline:
° 1°- B fibers (pre-ganglion sympathetic ):
■ Regional vasodilation.
■ 2°- Fibers C and A δ:
° -Superficial (somatic) and visceral sensitivity.
° -Touch and pressure.
° -Thermal sensitivity.

■ 3°- Fibers A β and A γ :

° -Propioception.

■ 4°- Motor fibers A α:

° Variable gauge (+/- [ ])

■ Extension evaluation:
° Dermatomas (puncture).
Thermal sensitivity.
Bromage classification.
 Classification of nerve fibers:
Table 16-1. Classification of nerve fibers*
sensitive
Fiber type Modality Diameter (mm) Driving (m/sec)
classification

Ah Motorboat 12 to 20 70 to 120
Ah Type Proprioception 12 to 20 70 to 120
the 12 to 30 70 to 120
ad Proprioception
Type Ib
TO . Pressure to touch Proprioception 5 to 12 30 to 70
Type II
Motor (muscular bundle)
3 to 6 15 to
Pain 30
Type Cold temperature 2 to 5
III Touch 12 to
Preganglionic autonomic fibers
b Pain <3 3a 14

c Hot and cold temperature Touch 0.4 to 1.2 0.5 to 2

Type IV .. . . - ---------------------------------------- -—.......
dorsal root Postganglionic sympathetic fibers

c 0.3 to 1.3 0.7 to 2.3

Friendly
* Peripheral nerve fibers and their respective neurons are classified from A to C according to the diameter of the axon, the cover (myelinated or
demyelinated) and the conduction speed. Sensory fibers are also classified from I to IV. Type C fibers (type IV sensory) are demyelinated, while
type A fibers are slightly myelinated.
Cardiovascular:
° Arterial hypotension (sympathetic blockade): ■ Age,
history, associated drugs. ■ Position, volume, venous return.
■ Increase in P. thoracic for
controlled ventilation.
Cervical Nerves

° Blockade below T4: ■ Vasodilatation.

° Blockade greater than T4 ( rare ): ■ Heart condition.

Sacral Nerves

Thoracic Nerves

Lumbar Nerves
■ Cardiac stability Epidural > Spinal.
E: Sympathetic blockade according to metameric
level of anesthesia
A: Sympathetic blockade 2-3 meta above the
metameric level.
E: slower onset (25 mi ■ Greater opportunity for
compensation.
A: rapid establishment (12 min)
Blocking less than T4:
Peripheral vasodilation (+FS)
M. lower and splanchnic (25%)
Moderate hypoTA in subjects sa
Dilates capacitance vessels ve
stasis ve
less VR.
 *Compensation: M. higher (-FS, -CV). +GC
(+Fc).

■
■
Epidural T1-T4 block: e Premedicated,
advanced age or relative hypovolemia □
hemodynamic effects.

- Prevention — -solutions
pre-anesthesia (10-20ml/kg
-vasopressors such as
ephedrine and phenylephrine.
IV). -Trendelenburg position
-atropine
Epidural block of level higher than T4:
e T1-T3 block:
Blockade of cardiac reflexes.
■ Dorsal vzgal nucleu ucleus of solitary

■ Blockade of outflows from the vasomot center of

the heart. medulla

obbongata

■ Vasoconstriction blockade of M. yes

fecending
conneetione

° C5-T1 block:
■ Moderate hypoTA, -Fc and discrete ele

systemic arterial resistance

Factors that modify the
hemodynamic effects of epidural
anesthesia:
■ Systemic effects of local anesthetics and
adrenaline:
□
Few effects.
β □
: tachycardia, -PAM, +GC and peripheral
vasodilation.

□
■ Hypovolemia and epidural anesthesia:
Aggravating: -TA, -GC and -PAM. Caution in edos.
relative or real.
Adrenaline: maintains BP.
■ Epidural and general anesthesia:
and HypoTA with stable Fc and GC.
e Prevention: avoid bradycardia with atropine
(90-100 bpm)

■ Decreased venous return:

-RV due to vasodilation.
Aggravating factors: artificial ventilation or
SxVCS: ■ Full-term pregnancy (DD), forced
Qx positions -2
■ Intestinal obstruction, ascites, tumors
■ Epidural anesthesia and reduction of preQx
bleeding:
° HypoTA
° Venous vasoplegia
° Sympathetic blockade (prevents //

° Compensated vasoconstriction
° Spontaneous ventilation preserved.
Respiratory:
° Slightly reduce ventilation:
■ M motor block. accessories * c.)
■ Rare phrenic block, rare dyspnea and
apnea*.
■ Greater effects with general anesthesia.
■ Thoracic epidural.

Transient RAO, without the need for SV.

%nümmei
Digestive:
+Peristalsis (+SNAP).
Reappearance of intestinal transit f
posQx.

Thermoregulation :
□ Chills:
Cutaneous vasodilation.
Stimulation (-) of thermorece per
Heat desensitization.
+ with Bupivacaine.
■ Endocrinometabolic:
° Adrenal cortico activation.
° Modifies intermediate metabolism
Hyperglycemia, insulin sensitivity,
lipid and protein catabolism.
“Help” with trans and post-Qx stress
 □ T5 blockade _ inhibits ADH and ACTH

■
■ Essential endocrine or metabolic effects:

° Reduction or complete blockage of catecholamine secretion

in response to Qx stress.

° Increased secretion of cortisol, with residual effects.

° Does not modify insulin secretion.

Decreases renin secretion.

It does not influence the secretion

and peripheral use of H.
 thyroid.

Protection against the posQx catabolic response.

■ Others:
° It does not reduce immunocompetence as much
as general anesthesia.
° Less risk of transQx hemorrhage.
° Reduces the incidence of post-Qx
thromboembolic complications.

Thr NEW ENGLAND

JOUR NA L of MEDICI N E
 Epidural anesthetics:
■ Objective: primary or complementary
anesthetic.

■ Dose: depends on the duration of Qx:

■ Single or fractionated dose (catheter).

■ Action time: short, intermediate, long.

■ “Two-segment regression time.”
e Safe to infuse 30-50% initial dose.
Approximate duration of
fractional doses:
 Table 16-7. Time to two-segment
Anesthetic Time variation (min)
*
Cycloprocaine
50 to 70
Prilocaine 90 to 130
--- — -- . ... -ra----- . . , . • - •= > .... ..................................................................................................................

Lidocaine
90 to 150
Mepivacaine 120 to 160
...... Yo
Bupivacaine 200 to 260
 Adjustments in the pH of
the EO:
■ pH 3.5-5.5: chemical stability and
bacteriostasis.
° Commercial: ionic form.

■ Lock Start:

° It depends on the penetration of the non-ionic

 form of AL into nerve membranes.

■ Alkalization = + Non-ionic, quick start. ° HCO3

(1mEq/10ml): lido, mepiva and
chloroprocaine.
 Drugs for epidural
anesthesia:
Table 16-6. Drugs for epidural anesthesia

Agent Concentration Start sensory block engine lock

2% Mild to moderate
Chloroprocaine Faster Faster Deep Pain Reliever
3% Deep

Lidocaine Intermediate Minimum

< 1% 1.57o 27o Deep Deep Pain
Intermediate Mild to moderate
Reliever
Intermediate Deep
Mepivacaine 17th Intermediate ■■
Dense Pain Reliever Deep Minimum
27th Intermediate
Prilocaine 27th ■•• Deep Minimum
Fast
37th Deep Deep
Fast
Bupivacaine < 0.257o 0.375 to 0.57o Slow Analgesic Minimum
0.757o Slow Deep Mild to moderate
Slow Deep Moderate to dense

Ropivacaine < 0.27o Analgesic Minimum

0.3 to 0.57o Slow Slow Slow Deep Mild to moderate
0.6 to 1.07o Deep Moderate to dense
 LOCAL ANESTHETICS
Anesthetic Type 1 Relative TO Latency (min.) Duration Conc2 Maritime dose3 S/v
lipophilia T 1/2 C/V
(h) (h)

Bupivacaine TO 30 8,1 5' 6-8 2,7 0,25 0,5 300 200

Chlorprocaine AND 0,6 9, 1 9 0,5- 1 or, 1 1-3 800 600

Etidocaine TO 140 7,7 4 4-9 2,5 0,5- 1,5 300 300

Lidocaine TO 3,5 7,8 3! 1-2 lS 0,5-2 500 300

Mepivacaine TO 2 7,7 4 2-3 2 0,5-2 500 300

Prilocaine TO 2 7,8 2 1-3 lS 0,5-3 600 400

Procaine AND 0,6 8,8 10’ 0,7-1 0,1 1-2 750 500

Tetracnine AND 80 8,4 15’ 3-5 h

0,35-1 300 200

Specks.- (1) E= Ester; A= Amida. (2) Concentration on the mind used. (3)
Expressed in milligrams (mg), S/V= Without vasoconstrictor C/V= With
vasoconstrictor.
 Epidural anesthesia technique:
Equipment:
° Standard sterilized tray
for epidural anesthesia:
1 or 2 Tuohy needles, 17-18G.
1 syringe of 5ml and 2 of 10
1 25G needle, infiltration
■
1 needle of 21-22G, internal
■
infiltration
■
Compresses, gauze and
■ clamps Local anesthetic and

antiseptic solution
■ epidural catheter

■
■ Epidural needles:
° Touhy needle:
■ Distal upward curvature
■ Proximal fins.
■ Firm and marked body (c
■ Anti-clogging chuck.

Tuohy -Whitacre

Quincke Gertie Marx

Sprotte

Polymedic
Practical performance of epidural puncture:
° Patient position:
■ Clinical status of the same.
■ Anesthesiologist routine.
■ Sitting (Lumbar).
■ Lateral decubitus (fetal).

° Identification of the puncture site.

■ L2-L2 and L3-L4.

° Eccentric antisepsis x3 with isodine.

° Infiltration:
■ Avon or intradermal button.
■ Lidocaine .5-1%. (1-2ml)
■ Lig. supra and interspinous and yellow.
 anatomical structures
crossed during the
. Lumbar level:
F Vertebral or spinal midline.
e Paravertebral (oblique)* °
Interspinous space ( medial ).

° Skin.
° TCSC.
° Lig. supraspinatus.
° Lig. interspinous.
° Lig. yellow.
 Identification of the epidural space:
■ Two techniques:

■ 1 P. negative (+inspiration
° “The pending drop or Gutiérrez
floats.”

■ 2-Transitory resistance of the

Lig. yellow:
 1-Loss of resistance:
Syringe with 5-10 ml (liquid chuck:
serum or anesthetic
Epidural needle (Whitacre) Rhythmic
compressions on the embolus.
Firm bimanual.
Give up resistance _ Id. n Do not turn
the needle, only if it is difficult to insert
Insert catheter in case of
be n

■ Fix catheter.
Air resistance:
Resistance with solution:
2-Gutiérrez Technique:
+P. neg. mid thoracic.* Same
steps as the previous one. Fined
needle (Touhy).
Place a drop of solution or even
he
to
of the needle.
th
pavilion
■ Inspiratory advance.
■

■ Additional introduction of drops to

confirm.
Epidural anesthesia by single
injection and continuous
epidural anesthesia

epidural.
Catheters

Polyvinyl chloride , polyethylene

Teflon and rarely nylon
The ideal catheter:
Inert material, do not go too rigid or resistant to
certain t
Radiopaque *
Sufficient length.

Diameter that allows a

A
needle to pass through a N
needle. Inner gauge that c
1
IC 7
allows liquid without resistance.
gi
 The ideal catheter:
■ Walls: sufficient thickness to avoid
obstruction or kink.
■ Regular, blunt tip.
■ A lateral hole in the proximity of the
disc end: obstruction of the disc
hole by neighboring tissues. Layers.
■ Centimeter graduations.
 rstraight of the
needle il of the catheter.
tad when passing the
bezel.

Anesthetic shot

interior of the space can produce nerve root

paresthesia.

atheter.
root mo.

or aberrant path should not be

more than three or four centimeters of catheter or.
bevel up.
lateral deviation and the risk of exit through the holes of
Clinical monitoring of epidural
anesthesia
■ Same imperatives as general anesthesia.
■ Resuscitation material, intubation
Before
■ Safe venous ■ analgesia technique
catheterization.
■ Previous vascular filling

with 500 to 1000 ml of

crystalloid solution.
After
■ Surveillance

mainly cardiovascular
status and ventilation.
Clinical surveillance

■ Sinus tachycardia and slight arterial hypertension.

° Inadvertent intravascular injection of anesthetic solution with
adrenaline.
■ Bradycardia and significant hypotension.
° Very extensive epidural block.
■ Arterial hypotension greater than 30 mm Hg with a
cardiovascular history: accelerate vascular filling and
vasopressors (ephedrine or aramine). The maximum
extension of the

Epidural block is accompanied by a slight

reduction in BP of 10 to 20 mm Hg.
GENERAL COMPLICATIONS

arterial hypotension
° The cause: Intensity and extent of sympathetic
blockade.
° Favors it: Hypovolemia, history
cardiovascular, certain positions,
VCI compression and impairments
■ Limit its frequency and intensity: vascular filling and
prevent positions that prevent RV.
Bradycardia: atropine improves hemodynamic
conditions.
No response to vascular filling. Justifies resorting to
vasoactive drugs
chills, chills
■ Immediately after injection of the anesthetic solution.
■ They disappear when it reaches its maximum extension.
■ Disturbance of thermal sensitivity favored by
peripheral vasodilation.
systemic toxicity due to overdose
■ Inadvertent intravascular injection.
■ Excessive total dose or reduced plasma clearance.
■ 10-12 ml of 0.5% bupivacaine or 2% lidocaine.
e Seizures or major cardiovascular accidents
(cardiovascular collapse, intracardiac conduction
disorder, arrest in asystole).
Particularly serious in childbirth.
■ Accidental overdose:
° CNS symptoms precede

fasciculation
Symptoms is
visuals muscular
Seizures
tonic-
Disorders clones
psychics widespread
s.
■ Serious overdose accidents are prevented by
slowly and fractionally injecting the anesthetic
solution.
ethhemoglobinemia
■ Classic complication of the use of large doses of
prilocaine .
■ Orthotoluidine: promotes the oxidation of Hb into
methemoglobin.
■ Less than 600 mg = acceptable levels.
exaggerated view of the higher level
■ Causes: reduced elasticity of the epidural space with injection of too
high a dose or accidental subarachnoid injection. Rarely a subdural
injection.
• Relative overdose in the elderly, diabetic or arteriosclerotic s.
Injection
• Similar to total spinal anesthesia.
subarachoid
• Difference: Injection
time of establishment
accidental epidural block
and extension of the blockade.
subdur extended
• It has no serious • al
consequences, Potentia
apart from l space
headaches.
• Total spinal
anesthesia:
hypobaric
character.
• Cardiovascular
collapse,
tachycardia,
alveolar
hypoventilation
and loss of
consciousness.
• Control of
ventilation,
vascular filling
and
vasopressors.
respiratory complications
■ Dyspnoea:
° Blockade of the proprioceptive fibers of the
mechanoreceptors of the intercostal muscles.
■ Alveolar hypoventilation leading to apnea:
E Intravascular injection.
Headache
■ Aseptic meningeal reaction.
° Accidental injection of a product
irritant such as antiseptic solutions.
■ Dura mater puncture.
INDICATIONS
CO NTRAIND ICATI ON ES

■ Absolute:
° Patient rejection.
° Hemostasis disorders.
° Uncorrected hypovolemia.
° Local or general infection.
■ Relative:
° Central or peripheral neurological pathology.
° AV or intraventricular conduction disorders.
Bibliography:
■ “Clinical Anesthesiology”
° Morgan Jr., G. Edward, et al.

■ “Theoretical-Practical Anesthesiology Text”

° Aldrete, J. Anthony

■ “Clinical Anesthesiology”
Cabo de Villa, Evangelina Dávila.