Mechanism of action of Epidural Anaesthesia

•When local anaesthetic is injected into epidural space, it

gradually diffuses across the dura into the subarachnoid space
•Also leakage through the intervertebral foramen into
paravertebral spaces.
•It acts primarily on the spinal nerve roots, and to the lesser
degree on spinal cord and paravertebral nerves
•Epidural space is relatively larger than spinal space, more
anaesthetic volume is required.
• Blockage of neural transmission in the posterior nerve
root interrupts somatic and visceral sensation.
• Blockage of anterior nerve root fibers prevents efferent
motor and autonomic outflow.
 
Somatic Blockage

• Sensory block interrupts both somatic and visceral

painful stimuli.
• Smaller and myelinated fibers more easily blocked
than larger and unmyelinated ones.
• Size and character of fiber types, concentration of LA
and the fact that concentration of local anaesthetic
decreases with increasing distances from level of
injection resulting in differential blockade.
• Sympathetic blockade- two segments or more cephalad
than Sensory block (Pain, light touch), which in turn
several segments more cephalad than Motor blockade.
Autonomic bloakade

• Interruption of efferent autonomic transmission

produces sympathetic blockade.
• Sympathetic outflow >> thoracolumbar (T1-L2),
parasympathetic outflow is craniosacral.
• Neuraxial anesthesia does not block the vagus nerve.
• The physiological responses to neuraxial blockade
result from decreased sympathetic tone or unopposed
parasympathetic tone, or both.
Epidural anaesthetic agents
• Uses-as a primary anesthetic, supplementation of
general anesthesia, or analgesia.
• The choice of short- or long-acting, single shot
anesthetic or the insertion of a catheter depends on
duration of procedure.
• Commonly used short- to intermediate-acting agents-
chloroprocaine, lidocaine,and mepivacaine.
• Longer-acting agents include bupivacaine,
levobupivacaine, and ropivacaine.
Dosage of epidural anaesthesia
• Generally accepted guideline for dosing epidural
anaesthesia in adult = 1-2 ml per segment
• Cervical/Thoracic = 0.7 to 1 ml per segment
• Lumbar level = 1.25-2 ml per segment
• Following initial 1-2 ml per segment bolus, repeated
doses are done on a fixed time interval OR
• once regression of sensory block occurs, 1/3 to ½ of
initial activation dose can be safely reinjected.
Concentration and differential block

• Lower concentration of LA >> less penetration to

nerve root>> differentially blocking sensory and pain
fibers over motor fibers
• E.g In Obstetrics: Bupivacaine 0.25% 20cc usually
only provides sensory block and spare motor block >>
patient can push when needed to.
Agents for epidural anesthesia
Bupivacaine
• Bupivacaine is long acting amide
• approximately four times more potent than lignocaine
• is available in concentrations of 0.25% and 0.5% with
or without adrenaline.
• Bupivacaine exhibits a high degree of lipid solubility
and is extensively bound to plasma protein (95%) and
hence longer duration of action
Levobupivacaine
• Levobupivacaine is the pure S-isomer of bupivacaine
and is less cardiotoxic but equipotent in sensory and
motor blockade.
• Levobupivacaine is available as 0.25%, 0.5% and
0.75% solutions.
• Duration- > 4 h may be achieved with a 0.75%
solution.
Lidocaine
• Lidocaine is used in concentrations of 1%–2% with or
without adrenaline 1:200,000.
• Without adrenaline, the duration of action is
approximately 1 h
• With adrenaline, approximately 1.0–2.5 h depending
on surgical site.
Ropivacaine
• Ropivacaine is a long-acting agent,
• less cardiotoxic than bupivacaine , less dense motor
block for a similar degree of sensory blockade.
• less potent than bupivacaine and so, slightly higher
concentrations/doses are usually employed.
• more rapid onset of action than bupivacaine or
levobupivacaine
Epidural adjuvants
• Neuraxial adjuvants are used to prolong analgesia and
decrease the adverse effects associated with high doses
of a single local anaesthetic agent.
• Neuraxial adjuvants include opioids, vasoconstrictors
and alpha-2 adrenoceptor agonists
• Epidural opioids are most commonly used as adjuvants
Epidural opioids
• can be given via an epidural catheter, either as boluses
or as part of a low-concentration local anaesthetic
solution.
• Bolused opioids such as fentanyl can usefully increase
the density of a sensory block
• Epidural opioids will diffuse across the dura and
arachnoid mater into the subarachnoid space to bind
opioid receptors in the dorsal horn of the spinal cord
• Lipophilic opioids such as fentanyl and sufentanil produce
rapid onset of analgesia with short overall duration
compared to hydrophilic opioids such as morphine.
• After epidural delivery, CSF opioid levels peak at 6
minutes for sufentanil, 20 minutes for fentanyl and 1-4
hours for morphine.
• Intrathecal doses are usually approximately 1/10th of the
epidural dose.