Modul Regional

Anestesi (Caudal)
Semester 3
 ANATOMI

Ruang epidural adalah ruang yang mengelilingi meningens

spinal mulai dari foramen magnum sampai hiatus sakralis.

Di ruang epidural terdapat akar saraf, jaringan lemak,

limfatik, arteri dan vena. Sedangkan kaudal epidural
adalah bagian bawah dari sistem epidural dan dapat
diidentifikasi melalui hiatus sakralis.

Daerah sakralis merupakan bentuk segitiga dengan

puncaknya berada dibagian basal.

Processus spinosus yang berbentuk tuberkel pada empat

segmen pertama dan tuberkel pada segmen kelima akan
membentuk hiatus sakralis (Hadzic, 2017)
Obat Anestesi Lokal
- Obat anestesi lokal menyebabkan hilangnya sensasi pada
area tertentu.
- Anestesi lokal merupakan basa lemah terdiri dari bagian
lipofilik dan hidrofilik yang dipisahkan oleh sebuah rantai
penghubung hidrokarbon

Morgan, 2013
Local Anesthesia in Pediatric
• epidural fat is more fluid and less densely packed
• local fixation is reduced and spread is increased in infants as
compared with adults
shorter onset time of action
more extended spread of local anesthetics
shorter duration of action because of reduced secondary release
from local binding sites

(Miller, 2010)
Golongan Anestesi Lokal
• a. Amino Ester dimetabolisme di plasma oleh pseudocholinesterase.
Contohnya, chloroprocaine, cocaine, procaine, tetracaine
• b. Amino Amida, dimetabolisir oleh enzim mikrosomal (p-450) dalam
hati. Contohnya, bupivacaine, etidocaine, lidocaine, mepivacaine,
prilocaine, ropivacaine

Stoelting,2015
FARMAKODINAMIK
Mekanisme Kerja obat anestesi lokal

Stoelting,2015
• 1. Menurunkan potensial aksi, sehingga tidak mencapai ambang
potensial/treshold.
• 2. Berinteraksi langsung dengan reseptor spesifik pada channel Na
yaitu dengan menghambat influks Na.

Stoelting,2015
Physicochemical Properties

• 1. Lipid Solubility. Higher lipophilicity increase potency by increasing the rate of

diffusion through axonal membranes.
• 2. Protein Binding. More protein binding prolongs the duration of effect.
• 3. pKa. Agents with lower pKa value will have faster onset because a greater
fraction of these weak base will exist in the uncharged form at pH 7,4 and thus
will more readily diffuse across nerve membranes.

Stoelting,2015
• LOW POTENCY : procaine
• INTERMEDIATE POTENCY : mepivacaine, prilocaine, chloroprocaine,
lidocaine
• HIGH POTENCY : bupivacaine, tetracaine, etidocaine

Stoelting,2015
Pharmacology of LA in pediatric
• 1. Protein Binding of local anesthehtic is decreased in neonates because of
decreased level of serum albumin. Free drug concentration may be
increased.
• 2. Plasma cholinesterase activity may be decreased in infants less than 6
month old, which theoretically diminished clearance of amino esters.
• 3. Hepatic microsomal enzym system are immature in the neonate, and this
will decrease the clearance of amino amide.
• 4. The increased volume of distribution in the infant and child acts to
decrease free local anesthetic concentration in the blood. The risk of
accumulation of free drug after repeated doses of local anesthetic is
increased.
Morgan, 2013
Terjadinya Blok Kaudal :
Ada tiga tempat bekerjanya
1) Pada serabut saraf ruang epidural terutama
akar spiral dorsal dan ventral.
2) Pada akar serabut saraf yang keluar melalui
foramina intervertebralis.
3) Difusi obat anesthesia local melalui dura ke
dalam subarachnoid.
Morgan, 2013
Absorbsi
Tergantung :
1. Tempat injeksi
2. Penggunaan adj. epinephrin
3. Karakteristik farmakologi obat

KATI, 2017
Distribusi
• Perfusi jaringan, organ dengan perfusi tinggi; Uptake Cepat
• Koefisien partisi jaringan/darah, Ikatan protein yang kuat 
lama di darah, dan jaringan dengan lipid solubility tinggi
mempercepat uptake jaringan.
• Massa jaringan, otot akan memberikan cadangan besar
untuk anestesi lokal

KATI, 2017
Eliminasi
• Anestesi lokal amida dimetabolisme di hati, kurang dari 5% nya diekskresi di ginjal
tanpa perubahan.
• Hidrolisis ester berlangsung sangat cepat dan metabolit yang larut dalam air akan
diekskresikan melalui urine

KATI, 2017
• Bupivacaine in concentrations of 0.125–0.25%
• ropivacaine and levobupivacaine offer the advantages of decreased
cardiac toxicity and reduced motor block
• Ropivacaine and levobupivacaine have equivalent efficacy at either
0.2% or 0.25%
• Duration of analgesia from a single-shot caudal injection ranges from
4–12 hours

(Miller, 2010)
TEST DOSE
• Criteria for a positive test dose in an anesthetized child:
heart rate increase >10 bpm
systolic blood pressure increase >15 mm Hg
change in T-wave amplitude >25% in lead II.
• The recommended test dose in children is 0.5 mcg/kg epinephrine
(0.1 mL/kg of local anesthetic containing 1:200,000 epinephrine) up
to the 15 mcg adult test dose
(Longnecker, 2009)
Acute Pain Management  
Management of pelvic and lower extremity pain
secondary to trauma (without evidence of pelvic
fracture)
Postoperative pain management Cancer Pain Management  
Temporizing measure for pain secondary to acute Chemotherapy-related peripheral neuropathy
lumbar vertebral compression fractures
Bony metastases to the pelvis
Injection therapy for pain secondary to pelvic,
Chronic Pain Management   perineal, genital, or rectal malignancy
Injection of local anesthetics or medications for lumbar Prognostic indicator prior to performing
radiculopathy secondary to herniated disks and spinal neurodestructive sacral nerve ablation(s)
stenosis
Injection of hyperbaric phenol solutions for
Approach to the epidural space in failed back surgery
management of sacral pain
syndrome
Diabetic polyneuropathy
Postherpetic neuralgia
Complex regional pain syndromes
Orchalgia; pelvic pain syndromes
AS (Hadzic, 2017)
Percutaneous epidural neuroplasty
https://www.nysora.com/techniques/neuraxial-and-perineuraxial-techniques/caudal-anesthesia/
Hadzic (2017)
 Misplacement Jarum

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Dosis Volume Anestesi Lokal

Formula Takasaki dan Kolega

● Volume (mL) = 0.05 mL/kg/dermatome to be blocked

Pada anak 1 kg yang dibutuhkan blok sampai level dermatom T10,

Dibutuhkan volume sebanyak = (0.05 mL/kg/dermatome)
= 0.05 x (10 kg) x (12 dermatomes) = 6 mL.

R
 Dosis obat pada continuous kaudal blok untuk
menentukan panjang blok analgesia berdasarkan umur
& berat badan seperti tabel di bawah ini:

T
 Menurut Busoni dosis yang dibutuhkan berhubungan dengan umur & berat badan

T
 Menurut Armitage, kalkulasi volume obat:
- 0,5 ml/kg BB untuk level lumbosacral
- 1 ml/kg BB untuk Thoraco lumbal
- 1,25 ml/kg BB untuk Mid Thoracic.

Dosis toksik tidak melebihi:

-  Bupivacain 3 mg/kg BB
-  Lidocaine 6-7 mg/kg BB
maks 20 cc

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 Untuk Memperpanjang Efek Analgesik

Konsentrasi Dosis Obat Tambahan

Single dose 0.175- 0.5% 0.75-1.25 ml/kg Epinephrine 2.5-5mcg/ml

(max 3mg/kg) Clonidine 1-2mcg/kg
Morphin 30-70mcg/kg
Ketamine 0.5mg/kg

0.4ml/kg/hr or 0.2- Fentanyl 2-5mcg/ml

Continuous 0.1% - 0.2% 0.4 mg/kg/hr

Smith’s Anesthesia for Infant and Children 7th ed. Philadelphia. Moby
Elsevier 2006
O
Adjuvant Pada Caudal
Anestesi
Obat apa saja yang bisa jadi adjuvant untuk
caudal anestesia?
1.Opioid : Fentanyl dan Morphine
2.Clonidine
3.Ketamine
4.Dexmedetomidine
5.Dexamethason
 • Acts on substantia gelatinosa on the
dorsal horn of spinal cord by blocking
fibers carrying nociceptive impulses
both pre- and postsynaptically.
Opioid • Caution : undesirable side effects as
respiratory depression, itching and
vomiting
• Caudal epidural opioids in children
should be restricted to special clinical
situations outside the outpatient
setting.
Effect : enhance the effect of local anesthetics and
prolong analgesia
 • Dosis Fentanyl :

for single-injection caudal 1–2 mcg/mL fentanyl to 0.1%

anesthesia : fentanyl 2 bupivacaine for continuous
mcg/kg epidural infusions

Fentanyl & Morphine • Dosis Morphine :

30 - 90 mcg/kg

Epidural morphine carries a potential risk for respiratory

depression; therefore, continuous pulse oximetry is
recommended with lower doses of caudal morphine and
is mandatory with medium doses. When higher doses of
caudal morphine are used, postoperative admission to
intensive care must be planned.
 • Clonidine is an 1- gonist and acts by
stimulating the descending
noradrenergic medullospinal
Clonidine pathways, which inhibits the release
of nociceptive neurotransmitters in
Effect : prolong analgesia the dorsal horn of the spinal cord.
• Caution : dose dependent
hypotension, sedation, bradicardy
• Dosis clonidine :
for single-injection caudal : clonidine 1–5 mcg/kg

for continuous epidural infusions : clonidine 0.1 mcg/kg/h

 Caution : psychomimetic effects,
controversial series of animal studies
suggesting that ketamine can produce
apoptotic neurodegeneration in the
Ketamine developing brain, preservative-free
formulas are unavailable
• Dosis ketamine :
0.25–0.5 mg/kg, effective without
noticeable behavioral side effects

Ketamine 1 mg/kg can be used as caudal

analgesic solely without the addition of LA

Effect : S-ketamine to a single-injection

caudal block prolongs the analgesic
 Effect : extended duration of pain relief (caudal
Dexmetomidine anaesthesia will last longer with
dexmedetomidine than with morphine)

• Caution : Haemodynamic effects,

notably bradycardia, were
Dexmedetomidine uncommon and mostly related to
the higher (2 mg/kg ) dose
concentration
• Dosis dexmedetomidine : 1-
2mcg/kg
 • 120 patients (3–10 years old)
• lower abdominal surgeries
• 0.5 ml bupivacaine 0.25% in a
dose of 0.5 ml/kg caudally +
Dexamethasone dexamethason

Effect : prolongs the analgesic

• The mechanism of analgesic effect may

be due to the local anesthetic action of
corticosteroids, and also it inhibits the
transcription factor nuclear factor-kB
(NF-kB) which expressed in the nervous
system and causes pain
• Dosis dexamethasone : 0.1 mg/kg
TERIMA KASIH