ANESTESI

REGIONAL

M. Dwi Satriyanto
 Anestesi

Umum Regional
I.V Topikal
I.M Infiltrasi
Inhalasi Field Block
P.O Blok Saraf Tepi
P.Rectal Spinal
Epidural
Intra Vena

KOMBINASI
 SPINAL CORD
 31 spinal cord segments
 8 cervical segments
 12 thoracic segments
 5 lumbar segments
 5 sacral segments
 1 coccygeal segment
 Two enlargements
 Cervical enlargement (C4-T1)
 Lumbosacral enlargement (L2-S3)
ANESTESI UMUM :
 Impuls masih sampai ke C.N.S.
 Cortisol 
 Cathecolamin 
 Tachycardi
 Gula darah 

ANESTESI REGIONAL :
 Impuls kurang / tidak sampai ke C.N.S.
 Blokade segmen TH5 – L1 berarti splanchnic
sympathic system terblok
 Cortisol N / 
 Cathecolamine N / 
KEUNTUNGAN :
 Sederhana, murah
 Non eksplosif
 Tidak polusi
 Alat sederhana
 Perawatan pasca bedah mudah
 Sadar  resiko aspirasi (-)
 Perdarahan 
 Respon otonom-endokrin 
KERUGIAN :
 Pasien ingin tidak sadar
 Tidak praktis bila perlu beberapa kali
suntikan
 Takut operasi belum selesai  efek
obat habis
 Efek samping  serius, sulit diatasi
Obat Lokal Anestesi
1. Ester Compound
 Cocaine
 Procaine / Novocaine
 Tetracaine / Pontocaine
2. Amide Compound
 Xylocaine / Lidocaine
 Prilocaine / Citanest
 Bupivacaine / Marcaine
 Etidocaine / Duranest
 Agent Concent: Onset & Max:Single Potency
Clinical use Duration dose

Cocaine 4-10% Topikal Slow 30’ 150 Mg -

Procaine Infiltrasi 1% Slow 500 Mg – EPI Low

Epidural 2% 30’-45’ 600 Mg + EPI
Plexus blok 2% 10–12 Mg/Kg
Spinal 10%

Chloro Infiltrasi 1% Rapid 600 Mg – EPI Interme

procaine Epideral 2% 45’-60’ 650 Mg + EPI diate
Plexus block 2% 10-15 Mg/Kg

Tetracaine Topikal 0,5-1% Slow 100 Mg High

Infiltr 0,1-0,2% 180’-300’ 2 Mg/Kg
Epidrl 0,4-0,5%
Spinal 1%
 Agent Concent: Clinical Onset & Max:Single Potency
use Duration dose

Xylocaine Infiltr 0,5-1% Rapid 300 Mg – EPI Interme

Epidural 1-2% 60’-120’ 500 Mg + EPI diate
N.block 1-1,5% 7-8 Mg/Kg
Topical 4%
Spinal 5%
Prilocaine sda Slow 175 Mg – EPI Interme
60’-120’ 250 Mg + EPI diate
3-4 Mg/Kg
Bupivacaine Infilt 0,25-0,5% Slow 175 Mg – EPI High
N.blok 0,5-0,75% >180’- 250 Mg + EPI
Spinal 0,5% >300’ 3 – 4 Mg/Kg
Etidocaine Infiltrasi 0,5% Rapid 300 Mg – EPI High
N.blok 0,5-1% >180’ - 400 Mg + EPI
Epidrl 1-1,5% >300’ 4-5 Mg/Kg
 Metabolism Allergy Sterilis :
(Heat)
ESTER.C Hydrolisa (+) (-)
(Ps.Choline) PABA
Plasma

AMIDE.C Degradasi (-) (+)

Liver
General sensory
Anesthesia cortex
• All sensation loss cerebral
• Unconscious

Subarachnoid
Lokal/Regional
Anesthesia
• Partial sensation loss
• Conscious
Nerve Ending
Epidural Medula Spinalis
Gambaran anestesi pada obat anestesi lokal
ditentukan oleh :
 Lipid solubility  potensi intrinsik
 Makin larut, makin poten
 Procaine L.S. = 1
 Bupivacaine L.S. = 30
 Etidocaine L.S. = 140
 90 % Axollemma = lipid

 Protein binding
 Protein binding  lama kerja
 Procaine P.B. = 5
 Bupivacaine P.B. = 95
 Protein membran = 10%
 p Ka
P Ka = pH dimana bentuk ion dan non ion seimbang
Untuk mula kerja bila pKa mendekati pH jaringan
onset of action lebih cepat
 p Ka lidocaine = 7,7
 Bupivacaine = 8,3

 Intrinsic vasodilator activity

 Potensi dan lama kerja
 Derajat absorbsi vaskuler, tergantung blood flow
 bila vasodilatasi  obat cepat habis
 Semua obat anestesi lokal  vasodilatasi kecuali
cocaine.
 Lidocaine > Mepivacaine
Maka ada 3 golongan obat anestesi lokal

1. Potensi rendah & lama kerja pendek

 Procaine
 chloroprocaine

2. Potensi sedang & lama kerja sedang

 Lidocaine
 Mepivacaine
 Prilocaine

3. Potensi kuat & lama kerja panjang

 Bupivacaine
 Tetracaine
 Etidocaine
 Spinal Anestesi
L.A  Subarachnoid space
 Blokade anterior
 Blokade posterior

Serabut saraf dari kecil  besar

 Otonom
 Sakit
 Temperatur
 motorik
 Blokade otonom 2 – 3 segmen lebih tinggi
dari level analgesi kulit

 Blokademotoris 2 – 3 segmen lebih

rendah dari level analgesi kulit
indikasi
 Operasi abdomen terutama bawah
 Operasi hernia inguinalis
 Operasi ekstrimitas bawah
 Operasi kandung kencing dan prostat
 Operasi kebidanan
Keuntungan
 Penderita tetap sadar
 Relaxasi cukup baik
 Komplikasi paru post op hampir (-)
 Perdarahan selama op berkurang
Kerugian
 Hypotensi
 Tensi turun sekali
 Durante & post op muntah / mual-mual
 Sakit kepala post op
 Kadang ada gangguan nafas
Penatalaksanaan
 Cairan 0,5 – 1 L
 Post suntikan :
 Test analgesi anestesi
 Monitor nafas
 Susah nafas  O2 masker
 Paralise intercostal & diafragma  bantuan nafas
 Tensi < 100 mmHg  hypotensi
• < 100 mmHg  cairan 2 – 3 fles

• O2 mask

• Ephedrine : 10 – 15 Mg I.V. / 25-50 Mg I.M.

(Vasopressor)
 Pasien resiko tinggi, coroner / cerebral ischaemi
 Ephedrine drip dini
Terapi
 Tidur terlentang 24 jam
 Banyak minum / infus
 Gurita
 Analgetik
 Epidural Blood Patch
 Epidural Analgesia
 Di daerah lumbal, thoracal, caudal
 Indikasi dan kontraindikasi = spinal anestesi

 Keuntungan spinal dibandingkan epidural :

 Obat anestesi lokal lebih sedikit
 Onset lebih singkat
 Level anestesi lebih pasti
 Teknik lebih mudah
 Keuntungan epidural dibandingkan
spinal :
 Bisa segmental
 Tidak terjadi headache post op
 Hypotensi lambat terjadi
 Efek motoris lebih kurang
 Dapat 1–2 hari dengan kateter  post op
pain
 Kerugian epidural dibandingkan spinal :
 Teknik lebih sulit
 Jumlah obat anestesi lokal lebih besar
 Reaksi sistemis 
 Total spinal anestesi
 Obat 5–10x lebih banyak untuk level
analgesi yang sama
 Keuntunganepidural dibandingkan
anestesi umum :
 Sedikit pengaruh pada respirasi
 Diperoleh analgesi, relaksasi otot dan usus
 Dapat diberikan pada pasien dengan
kontra indikasi muscle relaxant
Anatomi
 Duramater berakhir di S2
 Diameter ± 0,5 cm, paling besar di L2
 Jarak rata-rata dari kulit 4-5 cm
 Ruang epidural berisi jaringan ikat, lemak,
vena, arteri, pembuluh lymfe dan saraf
 Vena distensi pada : batuk, hamil, mengedan
 Foramen intervertebralis lebih permeabel
pada usia muda
 Metode menentukan ruang epidural
 Metode Loss of Resistance
 Metode Hanging Drop

 Bila pakai udara jangan lebih dari 3 ml

komplikasi
 Tertusuk duramater
 Post spinal headache
 Total spinal anestesi

 Reaksi sistemis : akibat obat anestesi lokal

dan epinephrin
 Caudal Analgesi
 Indikasi : operasi perineal

 Kontra indikasi : = epidural

 Cara :
1. Cari cornu sacralis kanan-kiri
2. Diantaranya adalah membran sacro
coccygeal  hiatus sacralis
 Kerugian :
 Sulit mencapai level analgesi yang tinggi
 Bisa terjadi relaksasi sistemik
 Kegagalan 5-10%

 Komplikasi : = epidural
 DRUGS DURATION MAX : DOSE
Cocaine 4% 30’ 200 Mg
Xylocaine 2-4% 15’ 200 Mg
Tetracaine 0,5% 45’ 50 Mg
Signs and Symptoms of Local/Regional
Anesthesia Toxicity

 CNS
 CV
Signs/symptoms of central nervous system
(CNS) toxicity-- CNS toxicity will be enhanced
by acidosis and hypoxia, both of which can
occur very rapidly if convulsions appear (when
breathing may stop and the excessive
muscular activity consumes oxygen stores)
S/S CNS Toxicity
 Unconsciousness
 Generalized convulsions
 Coma
 Apnea
 Numbness of the mouth and tongue, metal
taste in the mouth
S/S CNS Toxicity
 Light-headedness
 Tinnitus
 Visual disturbance
 Muscle twitching
 Irrational behavior and speech
Cardiovascular toxicity
 slowing of the conduction in the
myocardium
 myocardial depression
 peripheral vasodilatation
 usually seen after 2 to 4 times the
convulsant dose has been injected
Prevention and
Treatment of
Local/Regional
Anesthesia Toxicity
prevention
 Always use the recommended dose
 Aspirate through the needle or catheter
before injecting the local anesthetic.
Intravascular injection can have catastrophic
results.
 If a large quantity of a drug is required, use a
drug of low toxicity and divide the dose into
small increments, increasing the total
injection time
 always inject slowly (<10 ml/min) and
communicate with the pt
treatment
 All necessary equipment to perform
resuscitation, induction, and intubation
should be on hand before injection of
local/regional anesthetics
 Manage airway and give oxygen
 Stop convulsions if they continue for
more than 15 to 20 seconds
 Thiopental100 mg to 150 mg IV
 or Diazepam 5 mg to 20 mg IV
Regional Anesthesia
 Spinal Anesthesia, L3-L4 interspace. Free flow
of CSF confirms subarachnoid placement where
local is injected.
 Anesthesia occurs in minutes, lasting up to 2 hrs
depending on agent and dose.
 Level of sympathetic block higher than sensory
block, this in turn above level of motor block.
 Sympathetic block results in hypotension.
 High spinal results in respiratory depression.
 Motor recovers before sensory.
Spinal
Regional Anesthesia
 In Epidural anesthesia, a catheter is
placed in epidural space allowing for
continuous infusion to relieve
postoperative pain.
 Final level of sensory blockade depends
on volume injected not dose.
 Onset slower than spinal.
Epidural
Signs and Symptoms of
Local/Regional Anesthesia Toxicity

 CNS
 CV
Signs/symptoms of central nervous
system (CNS) toxicity-- CNS toxicity
will be enhanced by acidosis and
hypoxia, both of which can occur
very rapidly if convulsions appear
(when breathing may stop and the
excessive muscular activity
consumes oxygen stores)
S/S CNS Toxicity
 Unconsciousness
 Generalized convulsions
 Coma
 Apnea
 Numbness of the mouth and tongue, metal
taste in the mouth
S/S CNS Toxicity
 Light-headedness
 Tinnitus
 Visual disturbance
 Muscle twitching
 Irrational behavior and speech
Cardiovascular toxicity
 slowing of the conduction in the
myocardium
 myocardial depression
 peripheral vasodilatation
 usually seen after 2 to 4 times the
convulsant dose has been injected
Prevention and
Treatment of
Local/Regional
Anesthesia Toxicity
prevention
 Always use the recommended dose
 Aspirate through the needle or catheter
before injecting the local anesthetic.
Intravascular injection can have catastrophic
results.
 If a large quantity of a drug is required, use a
drug of low toxicity and divide the dose into
small increments, increasing the total
injection time
 always inject slowly (<10 ml/min) and
communicate with the pt
treatment
 All necessary equipment to perform
resuscitation, induction, and intubation
should be on hand before injection of
local/regional anesthetics
 Manage airway and give oxygen
 Stop convulsions if they continue for
more than 15 to 20 seconds
 Thiopental100 mg to 150 mg IV
 or Diazepam 5 mg to 20 mg IV
Terimakasih
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