2010 Regional Epidural Anesthesia

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4 advantages
Epidural Anesthesia

Back 1

Greater clinical flexibility

Decrease adverse physiologic responses

Thoracic epidural advantages:

Decreased morbidity and mortality by approximately 30% compared to GA with systemic opioids

Front 2

Absolute Contraindications
just review

Back 2

Pt refusal
Preexisting CNS disease
Unstable CNS disease
Skin infection
Septicemia or bactermia
Hypovolemia
Coagulopathy
Documented true allergy to local anesthetics
Severe aortic stenosis
Severe mitral stenosis

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Epidural Anesthesia
Ultimate target of the local anesthetic is

Back 3

the spinal nerves and their associated nerve roots

Front 4

Epidural Veins
Account for large

Back 4

uptake of LA

Front 5

Epidural Veins
site Most prominent

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lateral to the spinous process

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Obese have greater volume of

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epidural fat

(Decreased volume of fat in elderly)

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Increased fat below level L5
may result in

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Difficulty delivering LA to sacral nerve roots

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required to achieve an epidural block

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Large doses

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3 things that greatly reduce the mass of drug to reach the spinal nerves

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Physical distance,
tissue barriers
and absorption of LA

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Position
with epidural 2X

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No significant difference in the cephalad spread between lateral or sitting positions

May be an increase in patchy block or missed segments on the nondependent side when in the lateral position

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Anatomic changes with advanced aging

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Areolar tissue more dense and firm sealing the foramina allowing less leak of LA

dura more perm to LA

decreased absorption

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Pregnancy and Obesity
with epidural

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Engorgement of intervertebral plexus
Decreased dose by approximately 1/3

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Increased volume requirements with

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higher blocks
the higher you go up the spinal cord, the more m.l. you need

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LEVEL
Volume:

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1.0 - 2 cc / dermatome
more in lumbar / less in thoracic

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Test dose:

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1.5% lidocaine with 1:200,000 epinephrine

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Tuohy needle is

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(17 gauge)

Front 17

Major advantage of epidural vs. spinal

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Can be REDOSED

Front 18

Slower onset
Longer duration
2x

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Bupivacaine
0.5. 0.75%
Ropivacaine
0.5, 0.75. 1.0%

Front 19

Selection of Local Anesthetics
Intermediate
2x

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Lidocaine
1.5, 2.0%
Mepivacaine
1.5, 2.0%

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Selection of Local Anesthetics
Fast onset
Short duration

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2-Chloroprocaine
3%

Front 21

Bupivacaine .5
max
Ropivacaine .5

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2mg/kg

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Chloroprocaine

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800-1000mg

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2- Chloroprocaine
Excellent choice for

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for emergency c/s due to low toxicity and quick onset of action

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2- Chloroprocaine
Large volumes have caused

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back spasms (repeated doses)

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accidental intrathecal injection
2- Chloroprocaine

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Adhesive arachnoiditis: persistent neurologic deficits

Front 26

Lidocaine
required for sensory block

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At least 1%

Front 27

Lidocaine
% increases the motor block

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Increasing to 1.5%-2%

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Mepivacaine
Resembles

has 4x properties

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lidocaine

Intrinsic vasoconstrictive properties
May be slightly more toxic than lidocaine
Not recommended in obstetric use
High degree of placental transfer

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Bupivacaine
0.125%

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is appropriate for laboring analgesia, but insufficient for surgical anesthesia

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Bupivacaine
0.75%

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not recommended in obstetrics

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Bupivacaine
max dose

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2-3mg/kg

Front 32

Bupivacaine
type of plock

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Motor block less dense
Lower concentrations give a less dense motor block than other LA
Profound sensory blockade
Modulation of kappa receptors

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Bupivacaine
Modulations

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kappa receptors

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Bupivacaine
toxicity

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High potential for toxicity
High potency and high protein binding
Difficult resuscitation if inadvertently given IV
Cardiotoxic

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Ropivacaine
form

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Levorotary form only

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Ropivacaine compared to
bupivacaine

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Less motor block and shorter duration of action than

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Most clinically relevant factors in determining the level and duration of blockade

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Most clinically relevant factors in determining the level and duration of blockade

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Increase in dosage (ml) of drug will produce

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more intense analgesia and prolonged duration

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Increase concentration (mg) will produce

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a faster onset and more intense motor block

Front 40

Local Anesthetic Dosing per level

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Usually about 2ml per level

Epidural is at L3. Want T4 level
Need ~ 24 ml

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Anesthesia vs. Analgesia

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Analgesia = sensory block
Anesthesia = motor block

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Epidural Opioid Dosing

4x

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Morphine 2-5 mg
Fentanyl 25-100 mcg
Sufentanil 20-50 mcg
Dilaudid 0.75-1.5 mg

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Once loss of resistance is achieved
drops of saline should

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be SLOW and feel cold to touch

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Unfortunately, may see CSF as well if dural puncture and it will be

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Will be faster flowing and warm to touch
Remove needle immediately*

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Loss of resistance in most people is

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4-6 cm

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Questionable LOR, may be ?

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lateral- refill syringe w/ 1-2 ml of saline, recheck loss

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with Dural puncture:
need to

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Need to attempt epidural at a higher level

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Recommended distance is to leave in the epidural space is

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3-5cm

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Epidural Technique
Test Dose

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3 ml of 1.5% lidocaine

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Positive Test Dose
Intravascular

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heart rate will increase by 20% in 30-60 seconds.

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Positive Test Dose
Subarachnoid

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Signs of spinal anesthesia will occur w/in 3 minutes.
Toes will feel warm, tingling; will get some kind of level of anesthesia.

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Epidural Dosing
Injection

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Place pt in desired position
Local anesthetics settle based on gravity
If you are anesthetizing for RIGHT knee surgery, lay patient on right side

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Epidural Dosing
after injection
Take BP

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at least every 2 minutes for the next 10-15 minutes.

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Redose without loss of block

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1/2 - 2/3 original dose

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Redose with loss of level

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Redose with original volume

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Unilateral Block
Treatment:

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pull catheter back 1-2 cm and redose

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Headache
Wet tap= dural puncture
Initially treat

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hydration and NSAIDS


May need blood patch

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Blood Patch
2 person job:

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Another very aseptically draws 15 ml of blood from pt.
Blood is injected into epidural space until pt complains of excessive pressure.

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Combined Spinal Epidural- “CSE”

Indications:
2

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Usually for labor and delivery
Advanced dilation in multips
Repeat c-sections

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Combined Spinal Epidural- “CSE”
Advantage:

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Can use as epidural after spinal benefit!

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Combined Spinal Epidural-”CSE”

epidural procedure:

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Once loss of resistance is achieved insert long 25G Whitacre spinal needle until “pop” is felt.
Withdraw stylet, check for CSF.
Inject 1 ml of 0.25% marcaine +/- fentanyl 15 mcg; or just the fentanyl.
Remove spinal needle and thread catheter. Secure.

Lie pt supine and perform test dose.