EPIDURAL (EXTRADURAL) ANESTHESIA (ALSO CALLED AS PERIDURAL BLOCK)

Indications:
● can be utilized for upper abdominal, thoracic and even neck surgeries.
● used for postoperative pain management.
● painless labor (by continuous infusion through a catheter).
● also used in chronic pain management.
Epidural Needles:
● The most commonly used is the ​Tuohy​needle​.
● Other needles which can be used are ​Weiss​(it is winged) and ​Crawford​(straight blunt
bevel with no curve).

Technique:
- Like spinal it can be in sitting and lateral position.
- Usually epidural space is encountered ​at 4-5 cm from skin ​and has ​negative pressure
(loss of resistance in the space).
- Once the needle is confirmed in epidural space, a test dose of 2-3 ml of hyperbaric
lignocaine with adrenaline is given and if in 5 minutes there is no evidence of either
spinal block (inability to move foot) or intravascular injection (tachycardia by adrenaline),
further doses can be given.
- Epidural catheter is passed through the needle.
- 3-4 cm of catheter​should be in epidural space.
- A microfilter is attached to the catheter to prevent contamination.

Site of Action of Drug

1.Anterior and posterior nerve roots (main site
of action).
2.Mixed spinal nerves.

Drugs used for Epidural Anesthesia

1.Local anesthetics​:
Ropivacaine because of its high safety profile is most preferred.
2.Opioids​:
- Morphine​: 4-6 mg (diluted in 10 mL saline), Onset within 30 minutes. Effect lasts for
12-16 hours.
- Fentanyl​: 100 mcg {diluted in IO mL saline), Onset within 10 minutes. Effect lasts 2-3
hours.

💉💉​Fentanyl (2-4 mcg/mL) + bupivacaine (0.125%)​➡ is the most commonly used

combination for postoperative analgesia and painless labor.💉💉

​The ​advantages​of epidural opioids over local anesthetics:

1.​Only sensory block is produced​.
2.​The effect​of a single dose (especially morphine) ​lasts long​(12-16 hrs).
3.​No sympathetic block​.

Disadvantages​:
1. Respiratory depression.
2. Urinary retention.
3. Pruritus.
4. Nausea and vomiting.
5. Sedation.

Factors Affecting the Spread (Level) of Block:

1. Volume of the drug.
2. Age.
3. Patient position.
4. Intra-abdominal tumor or pregnancy.
5. Level of injection.
6. Length of vertebral column.
7. Concentration of local anesthetics.

Advantages of Epidural over Spinal:

1. Less hypotension.
2. No post-spinal headache.
3. Level of block and duration of anesthesia can be changed.
Disadvantages Over Spinal:
1. Inadequate block / block failure rate is high.
2. Higher chances of total spinal.
3. Accidental dural puncture.
4. More chances of epidural hematoma and intravascular injection.
5. Higher chances of infectious complications.(due to catheter ➡ the maximum period for it
is 4 days).
6. Higher incidence of local anesthetic toxicity due to higher volume used.
7. Intraocular hemorrhage. (due to rapid injection of the drug).
8. Higher incidence of back pain.
9. Epidural sets are expensive.
10. Technically epidural is more difficult.

CAUDAL BLOCK (EPIDURAL SACRAL BLOCK):

- It is a type of epidural block commonly utilized in children.
- The drug is injected in sacral hiatus.
- utilized to produce analgesia for perianal surgeries, genital surgeries.
- Any ​infection in the perineal region is contraindicated​for caudal block.

Contraindications for Central Neuraxial Blocks

Absolute contraindication :
● Raised intracranial pressure​.
● Patient refusal.
● Severe hypovolemia and hypotension​.
● Patients on anticoagulants​(Patients on antiplatelets aspirin and NSA/Ds can be safely
given central neuraxial blocks).
● Bleeding disorders and coagulopathies​.
● Infection at a local site.
● Severe fixed cardiac output lesions​(aortic and mitral stenosis, constrictive pericarditis,
coarctation of aorta).

Relative contraindication :
● Mild to moderate fixed cardiac output lesions.
● Mild to moderate hypotension and hypovolemia.
● Uncontrolled hypertension.
● Severe ischemic heart disease especially with recent hx of MI.
● Thrombocytopenia.
● Heart block and patients on B blockers.
 ● Spinal deformity or previous spinal surgery.
● Psychiatric and uncooperative patients.
● History of headache.
● GI perforation.
● Myelopathy or peripheral neuropathy.
● CNS disorders (multiple sclerosis - spinal stenosis).
● Resistant surgeon.
● Chronic backache.
● Septicemia and bacteremia.

LEVEL OF BLOCK REQUIRED FOR COMMON SURGERIES

- it is important to block nerve supply of all the organs involved during surgery, not only
the level of skin incision.
- ​Level of block required for some common surgeries​:

● Cesarean section➡ Up to T4​ .

● Prostate➡ Up to T10​.
● Testicular surgeries ➡Up to T10​.
● Hernia➡ Up to T10.
● Appendix➡ Up to T8.
● Hysterectomies➡ Up to T6.
● Perianal surgeries➡ Sacral segments.