Epidural

Anesthesia
Vincent Conte, MD
Associate Clinical Professor
Nurse Anesthesia Program
FIU College of Nursing

Epidural Anesthesia

1)
2)

Presentation divided into two

sections:
Anatomy and Physiology
Techniques

Epidural Anesthesia

A Neuraxial technique that offers a wider

range of applications than a Spinal
Anesthetic
An Epidural block can be performed at the
Lumbar, Thoracic, Cervical and Caudal level
Wide use of applications; Operative
anesthesia, Obstetric Anesthesia &
Analgesia, Postop pain control and Chronic
Pain Management
It can be used as a Single Shot or with a
catheter that allows intermittent boluses or a
Continuous Infusion

Epidural Anesthesia

1)
2)
3)
4)

One advantage of an Epidural is that

the muscle blockade can range from
none to complete
Everything can be regulated and
changed by:
Choice of drug
Concentration of LA
Dosage
Level of Injection

Anatomy

The Epidural space surrounds the Dura

Mater posterior, laterally and
anteriorly
Nerve roots travel in this space as they
exit the spinal cord laterally
They then exit the foramen and travel
peripherally to become peripheral
nerves carrying both afferent and
efferent pathways

Anatomy

1)
2)
3)
4)

Other contents of the Epidural

space include:
Fatty connective tissue
Lymphatics
Venous plexus (Batsons)
Septa and Connective tissue bands

Physiology

Local anesthetics or other solutions

injected into the epidural space
(steroids, narcotics) spread
anatomically
Horizontal spread is to the region of the
dural cuffs with diffusion into the CSF
and leakage through the intervertebral
foramen into paravertebral spaces
Longitudinal spread is preferentially
cephalad in direction

Physiology

1)
2)
3)
4)
5)
6)

Possible sites of anesthetic action

include:
Paravertebral nerve roots
Intradural spinal roots
Dorsal and Ventral spinal roots
Dorsal root ganglia
The Spinal Cord
The Brain itself (by diffusion)

Physiology

Initial blockade is PROBABLY a result of

anesthetic blockade at the spinal roots within
the dural sleeves
The Dural Cuffs or Sleeves have a
proliferation of arachnoid villi and
granulations that effectively reduce the
THICKNESS of the dura mater facilitating
rapid diffusion of the LA from the Epidural
space, through the Dura and into the CSF
surrounding the nerve roots
Then the local anesthetic diffuses into the
nerve root itself, producing anesthesia to that
particular dermatome

Physiology

Because Epidural anesthesia is

DIFFUSION dependent, relatively LARGE
volumes of LA are needed to achieve a
block that spans several dermatomes
The block ONLY goes as high or low as
you regulate it (by volume)
Its not like a Spinal which is
EVERYTHING distal to the level of the
block; it is a DIFFERENTIAL block
dependent on the volume and site of
injection

Advantages

1)
2)
3)
4)

Consequently, Epidural techniques have

the advantage of better control of level
(and also of sympathetic blockade)
Epidural techniques allow for the
placement of a continuous catheter
which is especially useful for:
Cases of unpredictable duration
Prolonged postoperative analgesia
Chronic pain control
Obstetric Analgesia & Anesthesia

Spread of Anesthesia

To be able to choose the most appropriate

anesthetic dose, concentration and volume of
LA, the anesthetist must be familiar with the
variables that affect spread and duration of
Epidural Anesthesia
The variables are more numerous than those
of spinal anesthesia and Baricity plays a VERY
small factor when dealing with Epidurals,
whereas in a Spinal, baricity is a KEY factor in
spread and distribution of the block

Spread of Anesthesia

1)
2)
3)
4)
5)
6)
7)
8)
9)

The factors that affect the level of the Epidural

block are:
Injection Site
Dose
Volume
Concentration
Position
Age
Height and Weight (?)
Pregnancy (?)
Speed of injection (?)

Injection Site
INJECTION SITE:
Unlike Spinal anesthesia, Epidural anesthesia
produces a segmental block that spreads
both caudally and cranially
Based on that fact, then the INJECTION SITE
is arguably THE most important
determinant of the spread of an epidural
block
The injection site should be in the MIDDLE of
the range of dermatomes that needs to be
anesthetized and closest to the main nerve
roots involved

Injection Site

Caudal epidural blocks are largely

restricted to sacral and LOW lumbar
dermatomes
Thoracic levels can be reached by the
caudal approach only if large volumes
(30cc) are given, and then the block
is patchy at best because of the
distance that the anesthetic has to
travel

Injection Site

Lumbar local anesthetic injections of

10cc tend to spread caudad to
include all the sacral dermatomes
Lumbar injections of 20cc volumes
produce much better quality sacral
blocks and can also extend cranially
to include the midthoracic levels

Injection Site

Thoracic injections tend to produce a

symmetric segmental band of anesthesia with
minimal lumbar spread
When using a thoracic approach, it is prudent
to decrease your volume by about 30-50% to
prevent cranially spread
It is generally not feasible to produce surgical
anesthesia in the low lumbar or sacral nerve
distributions when using thoracic injection
sites
Thoracic injection sites are ideally suited for
procedures of the chest and upper abdomen
or for relief of post-op thoracotomy pain with a
catheter being placed for continuous infusions

Dose, Volume &

Concentration

Within the range typically used for

surgical anesthesia, drug
CONCENTRATION is relatively
unimportant in determining block
spread
DOSE & VOLUME, however, are
important variables in determining
both spread and quality of the
Epidural block obtained

Dose, Volume &

Concentration

If drug CONCENTRATION is held

constant, increasing the volume of LA
(and thereby increasing the DOSE)
results in significantly greater average
spread
DOSE = Volume x Concentration (i.e.
15cc x 2.5mg/cc = 37.5mg; 20cc x
2.5mg/cc = 50mg)
The CONCENTRATION of the LA
generally affects the DENSITY of the
block, NOT the spread

Dose, Volume &

Concentration

So a small volume of a more

concentrated LA will produce a very
limited BUT very strong block
But take the same DOSE and double
the volume, the spread will increase
BUT the strength of the block may
not be as intense

Dose, Volume &

Concentration

NOTE: The increase in block level IS NOT in

direct proportion to the volume increase.
Doubling the volume WILL NOT double the
block spread. It is a NON-linear relationship
and doubling the volume will only increase the
level about 1/3-1/2 the original number of
segments
The same relationship exists with DOSE;
doubling the dose will usually only increase
the level of block the same 1/3-1/2 of the
original number of segments blocked

Dose, Volume &

Concentration
Recommended amounts of LA differ as
to which level is being injected:
Cervical/Thoracic doses are 0.7 to 1cc per
segment with an initial volume of 10cc
Lumbar level doses are 1.25 1.5cc per
segment with an initial volume of 1520cc
This is due to the narrowing of the
spinal canal as it progresses cranially

Concentration and
Differential Block

Using a lower concentration

anesthetic can sometimes give you a
differential block
The lower concentration means the
dose is lower and there is less LA to
penetrate the nerve roots so the
block acts more peripherally on the
nerves, differentially blocking sensory
and pain fibers over larger muscle
fibers in the center of the nerves

Concentration and
Differential Block
An example of this is used in Obstetrics:
Bupivicaine 0.25%, 20cc, usually ONLY provides
a sensory block but leaves the motor fibers
intact so the patient can push when needed to
If Bupivicaine 0.5% is given with the same
volume, then a sensory as well as motor block
is obtained, paralyzing the muscles at the
levels of the block so NO pushing is going to be
possible
There is quite a bit of individual sensitivity and
some people may end up with a purely sensory
block while others may end up with significant
muscle weakness or paralysis; (ooooppps!!)

Position

Some people feel that the Lateral

position is the preferred position to
optimize spread
Others feel that the sitting position is
preferred due to anatomical
advantages
Studies have shown small to NO
differences in spread of block when
comparing the two positions; its your
preference which one to use

Age

Most (but NOT all) studies that have

examined the effect of age on Epidural
blocks have demonstrated a greater
spread in older patients
This is thought to be related to a less
compliant epidural space and Dura
Mater
Even so, the clinical effect is usually AT
MOST an increase of no more than
three or four dermatomes

Height and Weight

The correlation between patient

Height or Weight and spread of
epidural block is very weak at best
and seems to have no clinical
significance
The only instance where it may have
an effect is in EXTREMELY TALL people
(greater than 66) or in EXTREMELY
SHORT (less than 410) or in
MORBIDLY obese patients

Pregnancy

Studies examining the effect of

pregnancy on spread of Epidural blocks
are conflicting
Some have shown a greater spread at
TERM and early in pregnancy
Other studies have shown no significant
differences in level of spread between
pregnant and non-pregnant patients
?????????????

Speed of Injection

Some feel that a rapid injection will

increase the level of spread or decrease the
time it takes for the block to set
This has NEVER been shown to make any
difference in either
Drugs should, in fact, be injected SLOWLY
to avoid rapid increases in CSF pressure,
headache and increased intracranial
pressures
Also, incremental bolus vs. slow, steady
injection has shown NO difference in level
of spread in multiple studies

Speed of Injection

All solutions should be injected in

increments of 3-5cc every 3 minutes
and titrated to the desired anesthetic
level
If a catheter has been placed and you
are injecting through the catheter,
then the catheter needs to be
aspirated prior to every injection to
show no CSF is present

Speed of Injection

This gradual administration of medication

slows the rate of onset of the anesthetic
level and controls the development of the
sympathetic blockade
This is an advantage that you have with an
Epidural that you DO NOT have with a Spinal
The Spinal is ALL or none, whereas the
Epidural can be brought up gradually,
slowing whatever hypotensive response you
may have to a more manageable level (and
saving you an extra pair of pants!!)

Onset of Blockade

The onset of an epidural block can usually be

detected within 5 minutes in the
dermatomes immediately surrounding the
injection site
The time to PEAK effect differs somewhat
among different LAs
Shorter acting drugs usually reach their
maximum spread in 15-20 minutes
Longer acting LAs usually reach their
maximum spread in 20-25 minutes
Increasing the DOSE of LA SPEEDS the onset
of both motor and sensory block

Duration of Block

1)
2)
3)
4)

The DURATION of the Epidural block

depends on:
The LA itself
Dose given
Patient age
Use of Adrenergic Agonists

Local Anesthetics &

Duration

Your choice of LA is the most

important factor in determining
DURATION of the block
Chlorprocaine is shortest, Lidocaine
& Mepivicaine are intermediate and
Bupivicaine and Ropivicaine produce
the longest lasting Epidural blocks

LAs & Duration

Back to the differential block topic:
ETIDOCAINE is a long acting agent that
has a profound muscle relaxation
effect but a weak sensory effect, so
you would end up with a paralyzed
patient in severe pain; it has been
almost completely eliminated from
use as a result of this differential
blockade

LAs and Duration

On the flip side, BUPIVICAINE is the

opposite of Etidocaine
In lower doses (concentrations)
BUPIVICAINE seems to have a preferential
sensory block with minimal motor effect
That is why it is an ideal drug for
Obstetric ANALGESIA during labor,
eliminating pain while preserving muscle
function

Dose and Age

DOSE: Increasing the DOSE of a LA

results in increased duration AND
density of the block
AGE: There are conflicting studies,
but the majority seem to show a
longer duration of action in the
elderly population. The exact reason
is unknown and more studies need to
be performed

Adrenergic Agents and

Duration

Epinephrine in a concentration of 5
micrograms/cc (1:200,000) is the most
common adrenergic agent added to epidural
LAs
It has been shown to prolong the blocks of
Lidocaine and Mepivicaine by as much as 80%
Epinephrine has been shown NOT to
significantly prolong the duration of
anesthesia when added to concentrated
solutions of Bupivicaine and Ropivicaine used
for surgical anesthesia

Adrenergic Agents and

Duration

However, when added to more dilute

concentrations of Bupivicaine, as used for
OB Analgesia, it has been shown to increase
the duration AND quality of the block
The mechanism proposed, although never
proven, is that through vasoconstriction, it
slows the systemic absorption and
elimination of the LA
Why it does not work with higher
concentrations of Bupivicaine and
Ropivicaine is not clearly understood

A & P Conclusion

The extent and duration of both

Spinal AND Epidural blocks are
influenced by a number of variables,
some of which are under the control
of the anesthetist
Understanding the impact of these
variables will allow the anesthetist to
select the most appropriate drug and
dose for any given clinical situation

A & P Conclusion

HOWEVER, even the most

experienced anesthetist will STILL
have blocks that are not adequate or
may fail completely
The frequency of failed blocks can be
kept to a minimum if the clinician
aims for a block that is a little higher
and a little longer than would ideally
be used for the given procedure

A & P Conclusion

REMEMBER, it is often easier to deal

with a block that is too high or too
long than to attempt to cover up for
a block that is too low or not dense
enough
Its always better to have a little
more than a little less, especially
with Regional Anesthesia

Break Time!!

Technique

Patient preparation and positioning

are similar to a Spinal Anesthetic
Either the sitting or lateral decubitus
positions can be used
Emergency equipment and monitors
should be immediately available and
you need to be prepared to use it if
any thing goes wrong

Technique

The most commonly performed Epidural

is a Lumbar Epidural, followed by a
Caudal, then Thoracic and finally
Cervical
Today most high thoracic and cervical
epidurals are performed under
flouroscopic guidance by pain specialists
as it takes a greater level of skill to
successfully perform those procedures

Technique

As you can see in the following diagram,

the angles of approach for the various
levels are markedly different
The Lumbar region is at or greater than
90 degrees to the skin
The Thoracic is at a much more acute
angle due to the anatomical
arrangement of the Thoracic Spinous
Processes
Finally the Cervical is at an angle in
between the previous two

Technique

1)
2)

3)

4)

The Lumbar region is by far the easiest due

to:
The angle of the Spinous processes
The larger spaces BETWEEN adjacent spinous
processes
Easily identifiable location by using easy to
find landmarks (Iliac crests)
Width of epidural space is greatest at this
level as well so if you are a little off the mark,
you still stand a good chance of finding it

Technique

With a Spinal Anesthetic, the practitioner

seeks CSF by piercing the Dura
In an Epidural, the practitioner seeks to
place the tip of the needle into the fatfilled space DEEP to the Ligamentum
Flavum and SHALLOW to the Dura
This is done by using a completely
different needle and injection technique
than with a Spinal anesthetic

Technique

The Epidural is most often performed with

a 16, 17 or 18 gauge needle with a
BLUNTED tip designed to facilitate passage
of a catheter into the epidural space at the
beginning or end of the procedure
The blunted tip is also designed specially
to AVOID puncture of the dura and if it
comes in contact with the Dura, the lack of
a sharp point will hopefully just inwardly
push the dura without puncturing it

Technique

The procedure is begun by identifying your

anatomical landmarks and locating your
planned interspace of insertion
Then the patient is positioned similar to
that of a Spinal Anesthetic
A sterile prep is performed with the
planned insertion point at the center of
both the prepped area and in the middle of
the special hole in the drape that is
provided in the kit

Technique

Local anesthetic (usually Lido 1% plain) is

injected at the planned insertion site and a
skin wheal is raised with an injection of 1-2
cc of local with the 25g skin needle (see kit)
Then some people change local needles and
place the 22g needle on the local syringe,
and in the center of the skin wheal, go
deeper along the planned injection tract,
injecting slowly as they penetrate deeper
into the subcutaneous tissue

Needle Stabilization

Firmly place the BACK of your non-dominant

hand against the patients skin and below the
epidural needle
Then grasp the needle and eventually the
hub once the epidural space is found
between your thumb and index finger of your
non-dominant hand as it stays in contact with
the patients back (the Bromage Grip)
This stabilizes the needle and prevents any
unwanted movement either in or out which is
especially critical once you find the Epidural
space

Technique

The Epidural needle is place bevel up and

introduced into the skin
It is passed slowly through the
Supraspinous ligament and seated in the
Interspinous Ligament before the stylet is
removed
You can tell that the needle is seated in the
Interspinous ligament by letting go of the
needle; it should still be supported in the
same position, not drop down

Technique

After the stylet is removed, the needle is

slowly advanced using the Loss of
Resistance technique
The LOR syringe is typically made of glass
and is filled with either 3-4cc of air, normal
saline, or a mixture of saline and air
As the syringe/needle combo is advanced,
pressure is applied to the plunger of the
syringe by Bouncing or intermittently
applying pressure to the plunger
The pattern is move-bounce-movebounce-move-bounce until LOR is obtained

Technique

The syringe/needle combo should only be

moved 0.5-1cm at a time and then tested for
resistance or LOR
The syringe/needle combo is advanced by
applying pressure to the NEEDLE and not the
syringe
As the needle passes through the Ligamentum
Flavum, resistance increases and you may feel
a distinct pop as you pass through it
Once you pass through the LF, you will
experience an immediate LOR and then the tip
of the needle will be in the Epidural Space

Technique

In younger patients like you may

encounter in Obstetrics, there may
not be a distinct pop of the LF, just
a sudden loss of resistance
Once the Epidural space is reached,
pass your stylet through the needle to
make sure there are no tissue plugs
possibly blocking the flow of CSF with
an inadvertent Dural puncture

Technique

Once it is determined that your needle

tip is in the Epidural space, begin first
by injecting a TEST dose of 3cc of LA
containing Epi (Lido 1.5% w/Epi)
If you are intravascular, you will see an
increase in heart rate within 30 seconds
It is also important to question the
patient after the injection of your test
dose

Technique

The questions asked should be aimed

at determining if you may have
inadvertently obtained a dural
puncture or are possible injecting
directly into the vascular system
Besides the tachycardia, with an
Intravascular injection, the patient
may experience a ringing or
buzzing in the ears, a metallic taste
in the mouth or circumoral numbness

Technique

If you happen to have gotten a dural

puncture by accident, the test dose
should produce numbness and/or
weakness or a pins and needles
sensation in the lower extremities
This can take up to three minutes to
occur, so you need to wait at least
three minutes before continuing your
injection of LA

Technique

At this point, techniques and opinions

differ as to whether to pass a catheter
and inject your total dose via the
catheter or inject your total dose through
the needle and then insert the catheter
The catheter first crowd feels that it is
better because you can slowly raise your
level of anesthesia having better control
and less incidence of sympathetic block

Technique

The problem with the cath first is

that it is possible for the catheter
NOT to go correctly into the epidural
space. It may come out a nerve root
or kink or coil up and then you will be
performing a useless epidural which
will end up not working or be patchy
or one sided

Technique

The needle crowd believe that the

injection of the LA opens up and
distends the epidural space and
makes it easier to pass the catheter
into the correct location
Also, if the catheter fails, you will have
a complete block for a period of time
and that may be all the time you need
to complete the surgery or procedure

Technique

Regardless of which technique is used,

as you pass the catheter, the patient
should be warned that at that moment
they may feel an electric shock or a
feeling like they hit their funny bone
This is caused by the cath tip brushing
up against a nerve root or two as it is
passed into the epidural space

Technique

As you pass the catheter, you may

initially feel resistance at the tip of the
needle
A slightly stronger push may be
needed and then you will feel the
resistance drop and the catheter will
thread smoothly
It should be inserted between 3-5cm
and no more (3-5 little black lines)

CAUTION

NEVER pull the catheter back through

the needle once it has been inserted

It is possible to catch the catheter on the
needle tip and shear or cut the tip off
Then it becomes a permanent new
addition to the epidural space and will be
there for the rest of the patients life!!!!

Caudal Anesthesia

An Epidural technique used for

anorectal surgery in adults
Also one of the most commonly done
regional techniques in pediatric
patients
Technique is the same for both patient
populations
Difference lies of course with size of
equipment and dosage of anesthesia

Caudal Anesthesia

Caudal anesthesia involves needle or

catheter penetration of the
Sacrococcygeal Ligament covering the
Sacral Hiatus
The Hiatus is created by the unfused S4
and S5 lamina
The Hiatus can be felt as a groove or
notch above the coccyx and between two
bony prominences, the Sacral Cornua

Caudal Anesthesia

The Posterior Superior Iliac Spines and the

Sacral Hiatus form a triangle (see photo)
The patient is placed either prone or in
lateral decubitus
A Sterile prep is done similar to an epidural
and the landmarks are again palpated
A needle or catheter is inserted at a 45
degree angle to the skin until a pop is felt
Then the angle of the needle is dropped
down and advanced, aspirating for blood or
CSF every 1-2cm

Caudal Anesthesia

Some clinicians recommend test

dosing as with other techniques,
while most simply rely on
incremental dosing with frequent
aspirations
Repeated injections can be given or a
catheter can be placed for boluses or
a continuous infusion

Caudal Anesthesia

For adults undergoing anorectal procedures,

caudal anesthesia can provide dense sacral
sensory blockade with limited cephalad
spread
A dose of 15-20cc of 1.5-2.0% Lidocaine
with or w/o epi is usually effective
This technique should be avoided in
patients with Pilonidal cysts because the
needle may pass through the cyst track and
introduce bacteria into the epidural space
and lead to infection and abscess formation

Conversion for C-Section

A clinical situation that you will be faced

with is one in which the patient has an
Epidural in place for labor and is receiving
Bupivicaine 0.125 -0.0625% infusion or
periodic Bupivicaine 0.25% boluses and
now has to be converted to a more intense
level of anesthesia for a C-section
The normal Epidural dose of Lidocaine 2%
w/epi for a C-section is 15-18cc WITHOUT
an epidural in place

Conversion for C-section

How much do you give if a Labor

epidural is in place to avoid a high block
with respiratory compromise?????
Opinions vary as much as there are
anesthetists!!!
Some say that with a GOOD labor
Epidural in place, no more that 12cc
should be given; others say no more
than 10cc and some go as high as 15cc

Conversion for C-section

1)
2)

3)

This is a situation in which many

factors come in to play:
The quality of the existing block
Infusion or bolus and how long since
the last bolus?
Has the infusion been turned off for
any length of time prior to the Csection for the patient to push?

Conversion for C-section

Unfortunately, depending on the

answer to those questions, your dose
may vary from a low of 10cc to a
max normal dose of 15-18cc
Only clinical experience can be called
upon in this situation so until you feel
comfortable with your decision,
always consult with your attending or
another CRNA with greater clinical
experience than you

Conclusion

Spinal and Epidural anesthesia each have

advantages and disadvantages that may
make one or the other technique better
suited to a particular patient or procedure
Studies comparing both techniques have
consistently found that Spinal anesthesia
takes less time to perform, produces more
rapid onset of both sensory and motor
block and is associated with less pain
during surgery

Conclusion

Despite these important advantages,

Epidural anesthesia offers
advantages, too
Chief among them are the lower risk
of PDPH, less hypotension, the ability
to prolong or extend the block using
an indwelling catheter, and options to
use the same catheter for
postoperative analgesia

Conclusion

Despite the advantages and disadvantages

of BOTH techniques and even done with very
experienced hands, BOTH blocks can have
systemic, toxic reactions and complications
Be vigilant, be cautious, and be prepared to
handle all the emergencies and
complications that can occur with BOTH
Again, always be prepared to convert to GA
at a moments notice and keep thinking
What if..