EPIDURAL ANESTHESIA

DOCTOR NASRULLAH KHAN MBBS FCPS

INTRODUCTION
Epidural

anesthesia is form of neuroaxial anesthesia in which drugs are injected in the epidural space with help of needle or through catheter placed in the space for this purpose. The injection so placed causes loss of sensation and loss of pain, by blocking the transmission of signals through nerves in or near spinal cord. When injection goes inside Dura (CSF)it is called spinal anesthesia. Epidural analgesia is a term used for pain relief when relatively less concentrated drug in low volume is used in epidural space.

Epidural blockade is becoming one of the most useful and versatile procedures in modern anesthesiology. It is unique in that it can be placed virtually at any level of the spinal canal, allowing more flexibility in its application to clinical practice as compared to spinal blockade. It is believed to reduce autonomic hyperactivity, cardiovascular stress, tissue breakdown, metabolic rate, pulmonary dysfunction, and immune system dysfunction. It decreases mortality and morbidity to 30%

INDICATIONS

As a sole anesthesia for any specific operation, For supplementation of general anesthesia , Combined with spinal anesthesia For management of labor pain For postoperative pain relief. For diagnostic and therapeutic purpose in chronic diseases.

HISTORY OF EPIDURAL
Epidural anesthesia is central block with many applications. In 1901 Epidural space was first described by CORNING. In 1921 FIDEL PAGES used epidural anesthesia in humans. In 1945 TUOHY introduced the needle which is still being used for epidural anesthesia.

EPIDURAL SPACE
The epidural space lies just outside the Dural sac

containing the spinal cord and cerebrospinal fluid (CSF). Superiorly the space extends to the foramen magnum, where Dura is fused to the base of the skull. Caudally it ends at the sacral hiatus. The epidural space can be entered in the cervical, thoracic, lumbar, or sacral regions to provide anesthesia. Beyond the epidural space lie the spinal meninges and CSF. The epidural space has its widest point (5 mm) at L2. In addition to the traversing nerve roots, it contains fat, lymphatics,and an extensive venous plexus. In pediatric patients the caudal epidural approach is

 As the epidural needle enters the midline of the

back over the bony spinous processes, it passes through: Skin Subcutaneous fat Supraspinous ligament Interspinous ligament Ligamentum flavum Epidural space The distance from skin to the space varies depending on the body habitus. The distance is 4 cm in 50% of the population, and 46 cm in 80% of the population. In the thin patient, the distance can be less than 4 cm, and in the obese, greater than 8 cm.

Drugs and equipment used

Local anesthetics alone like bupivacaine,

lignocaine. Narcotics alone like pethidine or fentanyl. Local anesthetics +Narcotics Various other drugs to enhance the effect of analgesia like neostigmine or ketamine. Epidural set

EPIDURAL SET

INDICATIONS
General Indications
Epidural anesthesia can be used as sole

anesthetic for procedures involving the lower limbs, pelvis, perineum and lower abdomen. It is possible to perform upper abdominal and thoracic procedures under epidural anesthesia alone, but the height of block required, with its attendant side effects, make it difficult to avoid significant patient discomfort and risk.

Specific Indications Hip and knee surgery. less blood loss deep venous thrombosis is reduced Vascular reconstruction improves distal blood flow Amputation. lower incidence of phantom limb pain following surgery.
Obstetrics.

lower maternal mortality owing to anesthetic factors than under general anesthetic. Less chance of wound infection.
l

 Epidural analgesia has been shown to minimise the

effects of surgery on cardiopulmonary reserve, i.e. diaphragmatic splinting and the inability to cough adequately, in patients with compromised respiratory function, such as those with chronic obstructive airway disease, morbid obesity and in the elderly. Epidural analgesia allows earlier mobilization, reduces the risk of deep venous thrombosis, and allows better cooperation with chest physiotherapy, preventing chest infections. Epidural analgesia in thoracic trauma with rib or sternum fractures improves respiratory function by allowing the patient to breathe adequately, cough and cooperate with chest physiotherapy.

CONTRAINDICATIONS
Absolute contraindications include patient refusal, severe uncorrected hypovolemia (sympathectomy with hypovolemia may cause profound circulatory collapse), increased intracranial pressure (may predispose patient to brainstem herniation if accidental dural puncture occurs or if a large volume of anesthetic is rapidly injected into the epidural space), and infection at the site of injection. True allergies to local anesthetics of both classes, although exceedingly rare, is also an absolute contraindication.

Relative contraindications are coagulopathy, whether iatrogenic or idiopathic, previously an absolute contraindication, is now considered a relative contraindication. uncooperative patient (therefore exposing neural structures to an unacceptable risk of injury), fixed cardiac output states (inability to increase cardiac output in response to sympathectomy), anatomic abnormalities of the vertebral column (making placement technically impossible), and unstable neurologic disease (may mask exacerbation signs/symptoms).

Controversial

The more controversial contraindications to epidural anesthesia include inability to communicate with the patient (placing an epidural in an anesthetized patient) tattoos (potential risk of pigment-containing tissue coring into the epidural space); complicated surgeries with major blood loss, and in surgical maneuvers in which respiration may be compromised or the airway will be difficult to manage.

Anti coagulants and epidural

Epidural blocks can be placed 4 h after the last dose of

subcutaneous heparin, 12 h after the last dose of LMWH. NSAIDs (including aspirin) are no more contraindications to epidural placement.
Epidural placement is relatively safe with

internationalized ratio (INR) < 1.5.

If an epidural vein is punctured, subcutaneous heparin

administration should be held at least 2 h, and LMWH held at least 24 h.

Glycoprotien IIa/IIIb inhibitors should be withheld for at

least 4 weeks after epidural placement.

Epidural placement should be avoided for 7 days after

clopidogrel and 14 days after ticlopidine.(antiplatelets

Advantages/disadvantages as compared to GA
Avoidance of airway manipulation; useful for

asthmatics, known difficult airways, and patients with a full stomach Decreased stress response; less hypertension and tachycardia and cortisol release Less thrombogenesis and subsequent thromboembolism; a proven benefit in orthopedic hip surgery Improved bowel motility with less distention; sympathetic blockade provides relatively more parasympathetic tone The patient can be awake during the procedure; desirable for cesarean deliveries and certain arthroscopic procedures Less postoperative nausea and sedation Better postoperative pain control, especially for

 Less pulmonary dysfunction, caused by both better

pain control and absence of airway manipulation Faster turnover at the end of the case because there is no emergence time Disadvantages Initiation is slower at the beginning of the case. It is less reliable, with higher failure rate. There are occasional contraindications, including coagulopathy, hemodynamic instability, spinal instrumentation, or patient refusal.

Advantages/disadvantages as compared to spinal

Epidural anesthesia can produce a segmental block

focused only on the area of surgery or pain (e.g., during labor or for thoracic procedures). The gradual onset of sympathetic block allows time to manage associated hypotension. Duration of anesthesia can be prolonged by redosing through an indwelling epidural catheter. There is more flexibility in the density of block; if less motor block is desired (for labor analgesia or postoperative pain management), a lower concentration of local anesthetic can be used. Theoretically with no hole in the dura there can be no spinal headache; however, an inadvertent dural puncture occurs 0.5% to 4% of the time with the large-bore epidural needle, and about 50% of such patients require treatment for headache

 Because newer technology in spinal needles has

decreased the incidence of headache requiring treatment to less than 1%, this advantage is probably no longer true.

Disadvantages
The induction of epidural anesthesia is slower because of

more complex placement, the necessity of incremental dosing of the local anesthetic, and the slower onset of anesthesia in the epidural space. Because a larger volume of local anesthetic is used, there is risk of local anesthetic toxicity if a vein is entered with the needle or catheter. Epidural anesthesia is less reliable; it is not as dense, the block can be patchy or one-sided, and there is no definite

FACTORS AFFECTING LEVEL OF EPIDURAL

Site of injection

Dosage
Posture Vasoconstrictors Age, height & weigh Alkalinisation of local anaesthetics

COMPLICATIONS
Hypotension caused by sympathetic blockade,

which may be prevented by fluid preload and patient positioning. Subarachnoid injection of a large volume of local anesthetic (total spinal). This can be prevented by aspirating the catheter for CSF and giving a small initial dose of local anesthetic to look for rapid onset of sensory block if the drug enters the CSF. (Remember: the onset of an epidural anesthetic is slow.) If a total spinal occurs, treat hypotension with pressors and support ventilation with positive pressure by mask or intubation.

 Postdural puncture headache caused by accidental

dural puncture with the large-bore epidural needle. Although not completely preventable, this can be treated in various ways,depending on the preference of the patient and anesthesiologist. Common therapies include analgesics, caffeine, or an epidural blood patch. Factors determining choice of treatment include severity of the headache and how aggressively the patient wishes to be treated. To provide a blood patch, up to 20 ml of the patients blood is placed in the epidural space to seal the dural hole and elevate low CSF pressure. Epidural hematomas, which are extremely rare and usually occur spontaneously in clinical settings outside of the operating room rather than following neuraxial procedures. When they are associated with regional anesthesia, there is almost always a preexisting coagulopathy. Epidural hematomas present as back pain and leg weakness and must be diagnosed by computed tomography (CT) or magnetic resonance imaging. If the

 Intravascular injection of local anesthetic, which can

be prevented by aspirating the catheter for blood, injecting a marker such as epinephrine that will cause tachycardia if injected into a vessel, and using incremental dosing (no more than 5 ml at a time). If an intravascular injection occurs . Stop convulsions with an induction agent or rapid-acting anticonvulsant. Intubate the trachea, if necessary, for ventilation and airway protection. Treat cardiovascular collapse with pressors, inotropes, and advanced cardiac life support protocols. Recent work in animals and case reports in humans have supported use of intralipid infusion to treat local anesthetic toxicity from bupivacaine. The lipid may act as a sink to remove circulating bupivacaine from the circulation.