Epidural Anesthesia

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

Epidural Anesthesia

Presentation divided into two sections: Anatomy and Physiology Techniques

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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

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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

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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

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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

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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
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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 15-20cc 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

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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

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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-move-bouncemove-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

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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 C-section 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..