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Regional Anesthesia

Grace E.P.M. Sianturi

Key Concepts
Spinal, epidural, and caudal block are also
known as neuraxial anesthesia
The principal site of action for neuraxial
blockade is the nerve root.
Interruption of efferent autonomic
transmission at the spinal nerve roots can
produce sympathetic and some
parasympathetic blockade.

Neuraxial blocks typically produce

variable decreases in blood pressure
that may be accompanied by a
decrease in heart rate and cardiac
Deleterious CV effect should
anticipated and steps undertaken to
minimize the degree of hypotension.

Excessive or symptomatic
bradycardia should be treated with
atropine, and hypotension should be
treated with vasopressors

Indications of Neuraxial
May used alone or in connjuction with
GA for most procedures below the neck
Cardiac surgeryThoracic epidural
wer extremity surgeries
Upper abdominal
(cholecystectomy)spinal or epidural

Neonatal surgeryspinal anesthesia

Important mentally preparedchoice
appropriate type surgery,no
Procedures involved major blood
loss,manuvers compromise respiratory
or prolonged surgerygeneral
endotracheal with or without neuraxial

Contraindication to neuroaxial
Infection at the site of injection
Patient refusal
Coagulopathy or diathesis bleeding
Severe hypovolemia
Increased intracranial pressure
Severe aortic stenosis
Severe mitral stenosis

Uncooperative patient
Preexisting neurological defisits
Stenotic valvular heart lesions
Severe spinal deformity

Complications Of neuraxial
Adverse or exaggerated physiological
Urinary retention
High Block: Spinal anesthesia ascending
into the cervical levels causes severe
hypotension, bradycardia, and respiratory
Total Spinal anesthesia
Cardiac arrest
Anterior spinal artery syndrome
Horners syndrome

Complication related to needle/catheter

Dural Puncture/leak
Postdural puncture headache
Neural injury
Nerve root damage
Spinal cord damage
Cauda equina syndrome
Intraspinal/epidural hematoma
No effect/inadequate anesthesia
Subdural block
Inadvertent Subarachnoid block
Inadvertent intravascular injection

Catheter shearing/retention
Epidural abcess
Drug toxicity
Systemic local anesthetic toxicity
Transient neurological sysptoms
Cauda equina syndrome

Spinal Anesthesia
Spinal anesthesia blocks nerve roots as
they course through the subarachnoid
Spinal arachnoid space extends from
foramen magnum to the S2 in adults and
S3 in children
Factors affecting the level of spinal
anesthesia:baricity of anesthetic solution,
position,drug dosage,site injection

Injection of local anesthetic below L1

in adults and L3 in children helps
avoid direct trauma to the spinal
Spinal anesthesia is also referred to
a subarachnoid block or intrathecal.

For spinal anesthesia, the needle is

advanced further through the
epidural space and penetrates the
dura-subarachnoid membranes as
signaled by free flowing
cerebrospinal fluid.

Epidural Anesthesia
For epidural anesthesia, a sudden loss of
resistance is encountered as the needle
penetrates the ligamentum flavum and enters the
epidural space. For spinal anesthesia, the needle
is advanced further through the epidural space
and penetrates the dura-subarachnoid
membranes as signaled by free flowing
cerebrospinal fluid.
Epidural anesthesia is a neuraxial technique
offering a range of aplications wider than the
typical all-or-nothing spinal anesthetic. An
epidural block can be performed at the lumbar,
thoracic, or cervical level

Epidural techniques are widely used

for operative anesthesia, obstetric
analgesia, postoporative pain control,
and the cronic pain management
Epidural anesthesia is slower in onset
(10-20 min) and may not be as dense
as spinal anesthesia

The quantity (volume and

concentration) of local anesthetic
needed for epidural anesthesia is
very large compared with spinal
anesthesia. Significant toxicity can
occur if this amount is injected
intrathecally or intravasculary.

Caudal Anesthesia
Caudal epidural anesthesia is one of the
most commonly used regional techniques
in pediatric patientscommonly after
induction of general anesthesia.
It may also be used in anorectal surgery
in adults.
No longer commonly used for obstetric
analgesiauseful for second stage of

The caudal space is the sacral

position of the epidural space.

Peripheral Nerve Blocks

The greatest immediate risk of nerve
blocks is systemic toxicity from
inadvertent intravascular injection.
Good surgical anesthesia is obtained
only when local anesthesia is
injected in close proximity to the
nerve or nerves that are to be

Perineural injection may produce a brief

accentuation of paresthesia, searing pain
that serves as a warning to immediately
terminate the injection and reposition the
Surgical anesthesia of the upper extremity
and shoulder can be obtained following
neural blocade of brachial plexus or its
terminal branches at several types

Interscaleneshoulder,arm and
Axillaryelbow to hand
per arm
Bier blockshort surgical procedures
Femoral nerve blockthigh,kneeskin
graft,knee arthroscopy,patellar surgery

Blocade sciatic nervehip,knee,distal

lower extremity
Popliteal nerve blockfoot and ankle

Indications Peripheral Nerve

Determined by patient comorbidities
and by obtaining informed consent
Primary and sole
anestheticfacilitate painless
surgerymonitored,airway secure
Less immunosupresive than GA

Contraindications Peripheral
Nerve Blocks

Uncooperative patient
Bleeding diathesis
Local anesthetic toxicity: if too much
Peripheral neuropathy: contralateral
phrenic nerve palsyipsilateral
interscalene block,contraindicated