REGIONAL ANESTHESIA PART 2

EPIDURAL ANESTHESIA

Bassim Mohammed Jabbar 

MSc ansthesia & intensive care unit 
EPIDURAL SPACE
Potential space between the dura mater and ligament flavum Made up of
vasculature, nerves, fat and lymphatic
Extends from foramen magnum to the sacrococcygeal ligament. Is
segmented and not uniform in distribution
The Bounds of the Epidural Space
Anterior- posterior longitudinal ligament, Lateral- pedicles and
intervertebral ligaments, Posterior- ligamentum flavum
Epidural level (cervical ,thoracic, lumber, Caudal)
 Widest at Level L2 (5-6mm)
 Narrowest at Level C5 (1-1.5mm
Distances from Skin to Epidural Space
Average adult: 4-6cm (80%)
Obese adult: up to 8cm
Thin adult: 3cm
Volume : 118ml
 EPIDURAL ANESTHESIA CONTINUE

Indication and Contraindication:

 The same of spinal anaesthesia.

 Additionalindication is the post operative Pain

management using the epidural catheter
technique.
 Complications: the same of spinal anaesthesia,
except the post dural puncture headache.
EPIDURAL ANESTHESIA

Local anaesthetic solutions are

deposited in the peridural space between
the dura mater and the periosteum lining
the vertebral canal. The injected local
anaesthetic solution produces analgesia
by blocking conduction at the intradural
spinal nerve roots.
SPREAD OF LOCAL ANESTHETIC IN THE EPIDURAL SPACE

 Local anesthetic injected into the epidural space moves in a horizontal

and longitudinal manner.
 Theoretically the longitudinal spread could reach the foramen
magnum and sacral foramina if enough volume was injected
Horizontally the local anesthetic spreads through the intervertebral
foramina to the Dural cuff.
 Local anesthetics spread through the Dural cuff via the arachnoid villa
and into the CSF.
 Blockade occurs at the mixed spinal nerves, dorsal root ganglia, and
to a small extent the spinal cord
 TYPES OF EPIDURALS
There are two main types of epidurals

1. Regular Epidural (used by most women)

 Pumped or injected into your lower spine through a catheter
 Combination of opioids and anesthetics (given with the epidural
to decrease the required dose of local anesthetic)
2.

Allows pain relief for 4-8 hours

VOLUME
Can be variable
General rule: 1-2 ml of local anesthetic per dermatome
i.e. epidural placed at L4-L5; you want a T4 block for a C-sec. You have 4 lumbar
dermatomes and 8 thoracic dermatomes. 12 dermatomes X 1-2 ml = 12-24 ml
Dose of local anesthetics administered in thoracic area should be decreased by 30-
50% due to decrease in compliance and volume
Height
.The shorter the patient the less local anesthetic required
A 1 ml per dermatome while someone who is tall may require the full 2 ml per
dermatome
Gravity
Position of patient does affect spread and height of local anesthetic BUT not to the
.point of spinal anesthesia
i.e. lateral decubitus position will “concentrate” more local anesthetic to the
.dependent side will a weaker block will occur in the non-dependent area
A sitting patient will have more local anesthetic delivered to the lower lumbar and
sacral dermatomes
 Sterile
Technique is Essential! Remember
the continuous/direct communication!
EPIDURAL SET
Syrange10ml.1
Tohy needle.2
.Epidural catheter.3
.Filter.4
.connector.5
 EPIDURAL CATHETERS
Ideal Placement (adult) 10-12 cm at the skin

Epidural catheters have markings

that indicate their length.
= there is a mark at the tip of the catheter
= the 1st single mark up the catheter is 5cm
= double mark up the catheter is 10 cm
and so on

A change in depth of the catheter indicates migration

either into or out of the epidural space
INSERTION OF EPIDURAL CATHETER
Positioning of patient
The site is dependent upon the area of
pain
Fixing the catheter
Incision Level
Thoracic T4-T6
Upper abdo T6-T8
Lower abdo T8-T10
Pelvic T8-T10
Lower extremity L1-L4
CATHETER MIGRATION
Catheter migration into a blood vessel in the
epidural space or subarachnoid space
rapid onset LOC
Decrease loss of sensory or motor loss (marcain)
Toxicity
Profound hypotension
Out of the epidural space
ineffective analgesia
no analgesia
.drugs deposited into soft tissue
 EPIDURAL ANESTHESIA
Test Dose: 1.5% Lido with Epi 1:200,000
Tachycardia (increase >30bpm over resting HR).1
High blood pressure.2
Light headedness.3
Metallic taste in mouth.4
Ring in ears.5
Facial numbness.6
Note: if beta blocked will only see increase in BP not HR
Bolus Dose: Preferred Local of Choice
milliliters for labor pain 10
milliliters for C-section 20-30
PAIN ASSESSMENT
：Verbal numeric rating scales
The patient is asked to rate pain on a numeric scale,
usually 0–10, where 0 is no pain and 10 is the worst
pain imaginable
the Wong-Baker FACES Pain Rating Scale
MOTOR AND SENSORY ASSESSMENT
:Sensory assessment
Use ice in the tip of a glove *
Start in upper neck and move down *
thorax bilaterally assessing all
potential dermatomes
Level of block is where intensity of cold *
changes or the cold sensation is absent
MOTOR AND SENSORY ASSESSMENT

Motor
assessment

Bromage
Score
ASSESSMENT OF THE SEDATION LEVEL

Alert None 0

Easily aroused Mild 1

Difficult to arouse or Moderate 2

RR <10

Unresponsive or RR Severe 3
<8
CAUSES OF BREAK THROUGH PAIN
Epidural catheter kinked or dislodged.1
Epidural catheter disconnected at filter.2
Epidural block is unilateral on the wrong side.3
Insufficient epidural infusion rate to cover.4
desired dermatomes
The epidural catheter tip is situated too high or.5
too low in the epidural space
CONSIDERATIONS IN CHOOSING
.L.A DRUG
Understanding of local anesthetic potency &*
duration
Surgical requirements and duration of surgery*
Postoperative analgesic requirements*
Use only preservative free solutions*
Read the labels, ensure that it is preservative free*
or prepared for epidural/caudal
anesthesia/analgesia
MEDICATION COMMONLY USED
OPIOIDS-Fentanyl +Morphine
affect the pain transmission at the opioid(
)receptors
:L.A
inhibits the pain impulse transmission in the nerves with (
)which it comes in contact

Short Acting L.A: 2-chloroprocaine

Intermediate ActingL.A: lidocaine and mepivacaine
Long ActingL,A: bupivacaine, etidocaine, ropivacaine,
levobupivacaine
SHORT ACTING

Intermediate Acting
LONG ACTING
Bupivacaine

Levobupivacaine
OPIOIDS

Mechanism of action-distribution

Vascular uptake by blood vessels in the epidural space *

.Diffusion through dura into CSF to spinal cord to the site of action*

.Uptake by the fat in the epidural space*

OPIOIDS
Morphine (Duramorph/Astramorph)
Hydrophilic(water soluble)
Slow to diffuse across the dura on to the spinal cord
Can cause late respiratory depression
Monitor respiratory status for 12 hrs after the last dose of
duramorph
+Duration 6 hrs
Broad spread
OPIOIDS

Fentanyl (preservative free)

Lipophilic(fat soluble)
Crossess the dura rapidly
Rapid onset of action(segmental)
Decreased risk of late respiratory depression
Onset 5-20 mins
Duration 2-4hrs
Excellent for breakthrough pain
ADVERSE EFFECTS -OPIOIDS
Sedation and resp.depression.1
N/V-Opioids stimulate the chemoreceptor.2
trigger zone
Pruritus- diphenhydramine or narcan (low dose).3
Urinary retention- low dose narcan and /or.4
catheterization
Slowing of GI motility.5
Hypotension.6
LOCAL ANESTHETICS
AMIDES MAX / DOSE
BUPIVACAINE 2 MG/KG
LIDOCAINE 7 MG/KG
ROPIVACAINE 4 MG/KG
MEPIVACAINE 7 MG/KG
PRILOCAINE 6MG/KG
METHODS OF ADMINISTRATION
BOLUS (FENTANYL, DURAMORPH)

CONTINUOUS
INFUSION(MARCAINE+FENTANYL)

All drugs administered epidural should be

.preservative free
All epidural opioids should be diluted with
normal saline prior to intermittent bolus
.administration
 REGIONAL ANESTHESIA IN THE ANTICOAGULATED PATIENT

Heparin: Reverse with FFP or Protamine

IV discontinue 4 hours prior to block
SQ can block one hour prior to dose
Do not D/C cath until 4 hours after heparin D/C’d & obtain normal lab
values

Plavix: No Reversal
Stop 5-10 days prior to surgery
NSAIDS: No Reversal
May be safe for regional block
Ideal to stop 5 days prior to surgery
Aspirin: No Reversal
Stop 7-10 days prior to surgery
 Adjuvant agent in neuraxial blockade anesthesia
Drug use to increase the effecacy or potancy or decrease the side effect of
medication when given concurrently
Epidural dose drugs
Epidural dose Druge
mg 2-5 morphine
mg 2-5 morphine
mg 2-3 diamorphine
mg 2-3 diamorphine
mg 25-50 pethidine
mg 25-50 pethidine
10-50µg sufentanal
10-50µg sufentanal
50-100µg fentanyl
50-100µg fentanyl
0.5-1.0mg/kg ketamine
0.5-1.0mg/kg ketamine
0-20μg/kg/hr medazolam
10-20μg/kg/hr medazolam
1ml of 8.4% NaHCO3 per 10ml of Sodium bicarbonate
1ml of 8.4% NaHCO3 per 10ml of lidocaine Sodium bicarbonate
lidocaine
μμg/ml
g/ml 55 adrenaline
adrenaline
postoperative pain:
postoperative pain: 50-100
50-100μμgg neostigmine
neostigmine
labour analgesia:
labour analgesia: 300-500
300-500μμgg
ANESTHESIA
Spinal anaesthesia
Level: below L1/L2, where the spinal
cord ends
Injection: subarachnoid space i.e
punture of the dura mater Ligamentum flavum and dura mater)
Identification of the subarachnoid
space: When CSF appears
Dosis: 2.5- 3.5 ml bupivacaine 0.5%
heavy
Onset of action: rapid (2-5 min)
Density of block: more dense
Hypotension: rapid
Headache: is a probably complication
Extradural Anaesthesia
Level: at any level of the vertebral
.column
Injection: epidural space (between
i.e without punture of the dura mater
Identification of the Peridural space:
Using the Loss of Resistance
.technique
Doses: 15- 20 ml bupivacaine 0.5%
Onset of action: slow (15-20 min)
Density of block: less dense
Hypotension: slow
.Headache: is not a probable
THANK YOU
Always make your patient comfortable