Neuroaxial Block

Dr.Erniody,Sp.An.,KIC.,M.Kes.
Revised: 3 September 2016
33 vertebrae total:
7 CERVICAL (labeled C1 - C7)
12 THORACIC (labeled T1 - T12)
5 LUMBAR (labeled L1 - L5)
5 FUSED to form the SACRUM (labeled S1 – S5)
4 COCCYGEAL
Spinal anaesthesia is a technique whereby a local
anaesthetic drug is injected into the cerebrospinal fluid.
- Check for lower limb weakness as an early indicator that the
injection was correct.
- Inability to straight leg raise suggests the block will cover at
least all the lumbar segments.

- Cold can be used but will usually demonstrate blocked

segments higher than those with surgical anaesthesia.
- Pinprick will generally be closer to the level of surgical
anaesthesia.

- To be completely happy that surgery can be performed

painlessly it is wise to ensure that the level of testing to cold or
pinprick is at least 2-3 segments higher than that needed. This
will provide a margin for error and also ensure that the
operative site does not regain sensation too quickly.
Epidural anestesia merupakan salah satu bentuk teknik blok
neuroaksial, dimana penggunaannya lebih luas daripada
anestesia spinal.

Epidural blok dapat dilakukan melalui pendekatan lumbal,

torak, servikal atau sacral (yang lasim disebut blok caudal).

Teknik epidural sangat luas penggunaannya pada anestesia

operatif, analgesia untuk kasus-kasus obstetri, analgesia
post operatif dan untuk penanggulangan nyeri kronis.

It takes approximately 6-8 times the amount of local

anesthetic in the epidural space to produce the same degree
of blockade with a spinal anesthetic.
• Test dose: mendeteksi kemungkinan injeksi ke ruang
subaraknoid atau intravaskuler.
• Test dose klasik dengan menggunakan kombinasi obat
anestesi lokal dan epineprin : 3 ml lidokain 1,5 % dengan
0,005 mg/mL epineprin 1:200.000.
• Apabila 45 mg lidokain disuntikan kedalam ruang
subaraknoid akan timbul anestesi spinal secara cepat.
• 15 ug epineprin bila disuntikan intravaskuler akan
menimbulkan kenaikan nadi 20% atau lebih.

• tes aspirasi sebelum injeksi dapat dilakukan untuk

mencegah injeksi obat anestesi lokal secara intravena.
As a general guideline, 1–2 mL per segment to be blocked
in a lumbar epidural, 0.7 mL per segment for a thoracic
epidural, and 3 mL per segment to be blocked for a sacral/
caudal epidural is used as an initial loading dose.

After the initial dose, one quarter to one third of the amount
can be administered 10–15 min later to intensify the sensory
block. The overall level of the block will not be significantly
increased with this method.

Repeat doses, commonly referred to as “top-ups,” need to

be given before the level of the block has receded by more
than two dermatomes.

One half to two thirds of the original volume of local

anesthetic should be given for each repeat dose.
Dosing Regimen: Lumbar Epidural

• The loading dose for epidural anesthesia is between 10 and 20

mL, given in increments of 5 mL.
• Wait 3–5 min between each increment to check patient response.
• If the block is incomplete, replace the catheter rather than waste
time trying to reposition it or give a larger dose of local anesthetic.
• Give one quarter to one third the initial dose 15 min after initial
bolus to enhance the sensory block.
• Epinephrine and bicarbonate will speed up the onset and
enhance the quality and duration of the block. Fentanyl will
improve the quality of the block.
• A continuous infusion is an alternative to bolus dosing; it has the
advantage of hemodynamic stability and can be continued
postoperatively for analgesia.
A continuous infusion through the lumbar epidural catheter
can be started after the initial bolus to maintain surgical
anesthesia.

The usual infusion rate is between 4 and 15 mL/h.

The wide range is usually dependent on the age, weight,

and extension of the block desired in a particular patient.
Factors that affect the height of epidural
anesthesia are fewer and less predictable
than spinal anesthesia and include the
following:
• Volume of local anesthetic
• Age
• Height
• Gravity
Sympathetic block:
2-6 Sympathetic
dermatomes T5 Sensory
higher than Motor
the sensory
block

Motor block:
2
dermatomes
lower than
sensory
block
• Failure to achieve analgesia or anaesthesia occurs in about
5% of cases, while another 15% experience only partial
analgesia or anaesthesia.
• Blok unilateral dapat terjadi bila obat diberikan lewat
kateter yang keluar dari ruang epidural menarik
kateter 1-2 cm dan disuntikan ulang dimana pasien
diposisikan dengan bagian yang belum terblok berada
disisi bawah.
• Epidural placement is a safe, effective --> providing
surgical anesthesia or postoperative analgesia.
• It has the benefit of being used for segmental
blocks or for more complete motor–sensory blocks
necessary for surgery.
• It reduces the adverse physiologic responses to
surgery --> decrease the incidence of myocardial
infarctions and postoperative pulmonary sequelae,
and can reduce the incidence of hypercoagulable
events.
• The complications associated with intubation and
general anesthesia are avoided.
Clinical Pearl:
• Epidural catheter can be placed:
Heparin subcutaneous: 4h after the last
dose
• LMWH should be held at least:
12 h before placement of catheter
2 hour after removal
• If an epidural vein is punctured:
subcutaneous heparin should be held at
least 2 h
LMWH held at least 24 h
• Epidural placement should be avoided:
Zero for aspirin
3-5 days after warfarin
5-7 days after clopidogrel
14 days after ticlopidine
• GIIa/IIIb inhibitors should be withheld for at
least 4 weeks after epidural placement.
• Epidural placement is relatively safe with
INR < 1.5
The time from epidural catheter removal to
anticoagulant drug administration is at least:
- 24 hrs for warfarin
- 2 hrs for low dose heparin
- 6-8 hrs for LMWH.
Thank Q