REGIONAL

ANESTHESIA

Speaker : Arie Andrianto

Consulant : Dr. Purwito Nugroho
Sp.An MM

WHAT DEFINITION of
ANESTHESIA?
Anesthesia (from Greek -, an-,
"without"; and , aisthsis,
"sensation").
Anesthesia is the use of medicine to prevent
the feeling of pain or sensation during
surgery or other procedures that might be
painful (such as getting stitches or having a
wart removed).

COMPONENTS OF
ANAESTHESIA
The famous components of general
anaesthesia are

TRIAD
1. UNCOSCOUSNESS.
2. ANALGESIA
3. MUSCLE RELAXATION

THE TYPE OF
ANESTHESIA
ANESTHESIA

General
Anaesthesia

Regional
anaesthesia

Neuraxial
blockade

Spinal
anesthesia

Peripheral
nerve block

Epidural
anesthes
ia

Local
anaesthesia

General Anaesthesia
Insensible does not necessary
imply loss of consciousness.
General anaesthesia
Inhalational
IV ,IM or P/R

LOCAL
ANAESTHETIC
As anesthesia means no
sense, so there are drugs
which can block the nerve
conduction peripherally with no
need of brain depression.
So patient will be conscious

REGIONAL ANESTHESIA
Regional anesthesia is the injection of a
local anesthetic around major nerves or the
spinal cord to block pain from a large region
of the body, such as a limb.
No CNS depression; patient conscious
Regional anesthetic techniques
categorized as follows
1. Epidural and spinal anesthesia
2. Peripheral nerve blockades: cervical,
brachial, axial

NEURAXIAL
BLOCKADE
EPIDURAL
AND
SPINAL ANESTHESIA

NEURAXIAL BLOCKADE
1. Spinal cord: By injection of local
drug in sub-arachnoid space in
CSF, this must be bellow L2
2. Epidural: The drug is injected
outside dura [no puncture] to block
the nerve roots at its exit from
spinal cord.

Anatom
y

Epidural Anesthesia Levels

Adapted with permission from Unintended subdural injection: a complication of epidural anesthesia- a case report, AANA Journal, vol. 74, no. 3, 2006.

Spinal vs. Epidural Anesthesia

Spinal
Easier to perform
Smaller dose of LA required (usually < toxic IV dose)
Rapid blockade (onset in 2-5 minutes)
Very effective blockade
Hyperbaric LA solution - position of patient important

Epidural

Technically more difficult; greater failure rate

Larger volume/doses of LA (usually > toxic IV dose)
Significant blockade requires 10-15 minutes
Effectiveness of blockade can be variable
Use of catheter allows for continuous infusion or
repeat injections
Slower onset of side effects
Position of patient not as important
SG of LA solution not as important

SPINAL VS. EPIDURAL ANESTHESIA

Tempat insersi
Tempai injeksi
Tempat kerja

Anetesi Spinal
Hanya vertebra lumbal
(dibawah L2/3)

Anestesi Epidural
Sakral, lumbal,
thorakdan servical

Ruang subarachnoid
Ruang epidural
(LCS)
Ruang subarachnoid (saraf dan medulla spinalis)

Dosis obat LA

Kecil

Besar

Onset

Cepat

Lebih lambat

Blok motorik

Kuat

Sedang

Henti jantung, PDPH,

spinal tinggi, total
spinal.
tidak

Intoksikasi local
anestetik, hematom
epidural
Ya, dengan kateter

Komplikasi
Analgesi postop

Spinal

Epidural

Epidural Anesthesia

Indications
Full stomach
Anatomic distortions of upper airway
Obstetrical surgery (T4 Level)
Decreased post-operative pain
Continuous infusion

Spinal Anesthesia

Contraindications to
Regional Anesthesia

Absolute Contraindications for

Neuraxial Blockade
Patient refusal
Ischemic Hypertrophic Sub-aortic
Stenosis
Infection at the site of injection
Coagulopathy
Severe hypovolemia
Increased Intracranial pressure
Severe Aortic Stenosis
Severe Mitral Stenosis

Relative Contraindications
Sepsis
Uncooperative patients
Pre-existing neuro deficits/neurological
deficits
Demylenating lesions
Stenotic valuvular heart lesions (mild to
moderate Aortic Stenosis/Ischemic
Hypertrophic Sub-aortic Stenosis)
Severe spinal deformities

Complications of Neuraxial Blockade

Failure of technique
Systemic drug toxicity due to overdose or
intravascular injection
Peripheral neuropathy due to intraneural
injection
Pain or hematoma at injection site

 Epidural anesthesia
Systemic toxicity of LA
(accidental intravenous)
Catheter complications
(shearing, kinking, vascular or
subarachnoid placement)

PREPARATION FOR REGIONAL

ANESTHESIA
Thorough pre-op evaluation and assessment
of patient
Technique explained to patient
IV sedation may be indicated before block

Neuroaxial Technique
Preparation & Monitoring

EKG
NBP
Pulse Oximeter
Patient Positioning

Lateral decubitous
Sitting
Prone (hypobaric
technique)

Spinal
Needles

Epidural
Needles

Spinal
Needles

Epidural
Needles

REGIONAL ANESTHESIA
DRUGS
Lidokain
The recommended maximum safe doses of
lidocaine are as follows:
LIDOCAINE WITHOUT EPINEPHRINE ------ 3 mg/kg
LIDOCAINE WITH EPINEPHRINE ------ 7 mg/kg
Bupivakain
The recommended maximum safe doses of
bupivacaine are as follows:

BUPIVACAINE WITHOUT EPINEPHRINE ------- 2.0

mg/kg
BUPIVACAINE WITH EPINEPHRINE ------- 2.5 mg/kg

Spinal Anesthesia

Epidural Anestesi

Roy A. Greengrass, M.D.

Associate Professor of Anesthesiology
Mayo Clinic, Jacksonville, FL

PERIPHERAL
NERVE
BLOCKADES
Cervical, Brachial, Axial

Indications for
Peripheral Blockade
In addition to some of the peripheral nerve
block indications
Patient mentally prepared to accept
neuraxial blockade
No contraindications
No need for routine labs unless meds or
conditions dictate this

Contraindications to
Peripheral Nerve Block
Pediatric patients, combative patients,
demented patients
Pre-existing peripheral nerve neuropathies
Bleeding disorders
Local anesthetic toxicity risk
Sepsis

Risks for Peripheral Nerve

Block
Toxicity of local anesthetics
Transient or chronic paresthesia
Nerve damage
Intra-arterial injection (seizures/cardiac
arrest)
Block failure (need to supplement or
induce general anesthesia)

Advantages of Peripheral
Nerve Blocks
Improved patient satisfaction
Less immunosuppression
Less nausea and vomiting
Non-general anesthetic option for patient
with malignant hyperthermia
Patient who is hemodynamically unstable
or too ill to tolerate a general anesthetic

Brachial Plexus

Musculocutaneous Nerve
Median Nerve
Ulnar Nerve
Radial Nerve

Axillary Block
Position
Head turned away
from arm being
blocked
Abduct to 90
Forearm is flexed to
90
Palpate brachial artery
for pulse

Other Blocks

Thank you for your

attention