Soli Deo Glor

EPIDURAL ANESTHESIA:
FACTORS AFFECTING HEIGHT
AND LOCAL ANESTHETIC
USED

Lecture 11

Developing Countries Regional Anesthesia Lecture Series

Disclaimer

Doses are only general recommendations.

There are several factors that may result in
either an inadequate or high epidural block.
Every effort was made to ensure that
material and information contained in this
presentation are correct and up-to-date. The
author can not accept liability/responsibility
from errors that may occur from the use of
this information. It is up to each clinician to
ensure that they provide safe anesthetic
care to their patients.

Introduction to Epidural
Anesthesia

Epidural anesthesia produces a reversible

loss of sensation and motor function much
like a spinal with the exception that local
anesthetic is placed within the epidural
space.
Larger doses of local anesthetic are
required to produce anesthesia when
compared to a spinal anesthetic.
Doses must be monitored to avoid toxicity.

Introduction to Epidural
Anesthesia

An epidural catheter allows the

versatility to extend the duration of
anesthesia beyond the original dose by
the administration of additional local
anesthetic.
Epidural catheters may be left in place
for postoperative analgesia.

Epidural Anesthesia
Indications

Cesarean section
Procedures of the uterus, perineum*
Hernia repairs
Genitourinary procedures
Lower extremity orthopedic procedures
Excellent choice for elderly or those who
may not tolerate a general anesthetic

Epidural Anesthesia

Should NOT be used in patients who are

hypovolemic or severely dehydrated.
Patients should be pre-hydrated with .5
1 liter of crystalloid solutions (i.e. ringers
lactate) immediately prior to the block.

Epidural Anesthesia

Higher failure rate for procedures of the

perineum.
Lower lumbar and sacral nerve roots are
large and there is an increased amount
of epidural fat which may affect local
anesthetic penetration and blockade.
This is known as sacral sparing.

Epidural Anesthesia
Advantages

Easy to perform (though it takes a bit

more practice than spinal anesthesia)
Reliable form of anesthesia
Provides excellent operating conditions
The ability to administer additional local
anesthetics increasing duration
The ability to use the epidural catheter
for postoperative analgesia

Epidural Anesthesia
Advantages

Return of gastrointestinal function

generally occurs faster than with general
anesthesia
Patent airway
Fewer pulmonary complications compared
to general anesthesia
Decreased incidence of deep vein
thrombosis and pulmonary emboli
formation compared to general anesthesia

Epidural Anesthesia
Disadvantages

Risk of block failure. The rate of failure is

slightly higher than with a spinal
anesthetic. Always be prepared to induce
general anesthesia if block failure occurs.
Onset is slower than with spinal
anesthesia. May not be a good technique
if the surgeon is impatient or there is
little time to properly perform the
procedure.

Epidural Anesthesia
Disadvantages

Normal alteration in the patients blood pressure

and potentially heart rate (generally slower onset
with less alteration in blood pressure and heart
rate than with a spinal anesthetic). It is essential
to place the epidural block in the operating
room/preoperative area with monitoring of an ECG,
blood pressure, and pulse oximetry. Resuscitation
medications/equipment should be available.
Risk of complications as outlined in Introduction to
Neuraxial Blockade chapter. There is an increase
in the complication rate compared to spinal
anesthesia.

Epidural Anesthesia
Disadvantages

Continuous epidural catheters should not

be used on the ward if the patients vital
signs are NOT closely monitored.
Risk for infection, resulting in serious
complications.

Absolute Contraindications
Epidural

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

Controversial

Prior back surgery

Inability to communicate with the patient
Complicated surgeries that may involved
prolonged periods of time to perform,
major blood loss, maneuvers that may
complicate respiration

Mechanism/Site of Action

Administered at a physiologic distance

when compared to spinal anesthesia.
The intended targets are the spinal
nerves and associated nerve roots.
Several barriers to the spread of local
anesthetic to the intended site of action
results in the requirement of larger
volumes of local anesthetic when
compared to spinal anesthesia.

Barriers

Dura mater between the epidural space

and spinal nerve and nerve roots act as
a modest barrier.
The majority of the solutions is absorbed
systemically through the venous rich
epidural space.
Epidural fatty tissue acts as a reservoir.
The remainder reaches the spinal nerve
and nerve roots.

Spread of Local Anesthetic in the

Epidural Space

Local anesthetic injected into the

epidural space moves in a horizontal and
longitudinal manner.
Theoretically the longitudinal spread
could reach the foramen magnum and
sacral foramina if enough volume was
injected.

Spread of Local AnestheticsLongitudinal

Spread of Local AnestheticsHorizontal

Horizontally the local anesthetic spreads

through the intervertebral foramina to
the dural cuff.
Local anesthetics spread through the
dural cuff via the arachnoid villa and into
the CSF.
Blockade occurs at the mixed spinal
nerves, dorsal root ganglia, and to a
small extent the spinal cord.

Spread of Local AnestheticsHorizontal

Spread of Local Anesthetics- Local

anesthetics gain access to CSF via
arachnoid granules

Distribution, Uptake &

Elimination

Takes 6-8 times the dose of a spinal

anesthetic to create a comparable block.

This is due to:

Larger mixed nerves are found in the

epidural space when compared to the
subarachnoid space.
Local anesthetics must penetrate arachnoid
and dura mater.
Local anesthetics are lipid soluble and will
be absorbed by tissue and epidural fat.
Epidural veins absorb a significant amount
of local anesthetic with blood
concentrations peaking in 10-30 minutes
after a bolus.

Distribution, Uptake &

Elimination

Local anesthetics absorbed in the

epidural veins will be diluted in the
blood.
The pulmonary systems acts as a
temporary buffer and protects other
organs from the toxic effects of local
anesthetics.
Distribution occurs to the vessel rich
organs, muscle, and fat.

Distribution, Uptake &

Elimination

Long acting amides will bind to alpha-1

globulins which have a high affinity to
local anesthetics but become rapidly
saturated.
Amides are metabolized in the liver and
excreted by the kidneys.
Esters are metabolized by
pseudocholinesterase so rapidly that
there are rarely significant plasma levels.

Factors Affecting Height of

Epidural Blockade

Volume of local anesthetic

Age
Height of the patient
Gravity

Volume

Can be variable
General rule: 1-2 ml of local anesthetic
per dermatome
i.e. epidural placed at L4-L5; you want a
T4 block for a C-sec. You have 4 lumbar
dermatomes and 8 thoracic
dermatomes. 12 dermatomes X 1-2 ml
= 12-24 ml
Big range! Stresses importance of
incremental dosing!

Volume

If you require only segmental anesthesia

than the dose would be less.
Volume of local anesthetic plays a
critical role in block height.
Dose of local anesthetics administered in
thoracic area should be decreased by
30-50% due to decrease in compliance
and volume.

Age

As age increases the amount of local

anesthetic to achieve the same level of
anesthesia decreases. A 20 year old vs
80 year old
This is due to changes in size and
compliance of the epidural space

Height

The shorter the patient the less local

anesthetic required.
A patient that is only 53 may require 1
ml per dermatome while someone who is
63 may require the full 2 ml per
dermatome

Gravity

Position of patient does affect spread and

height of local anesthetic BUT not to the
point of spinal anesthesia.
i.e. lateral decubitus position will
concentrate more local anesthetic to the
dependent side will a weaker block will
occur in the non-dependent area.
A sitting patient will have more local
anesthetic delivered to the lower lumbar
and sacral dermatomes

Gravity

L5-S2 sometimes will have patchy

anesthesia due to sparing. By having
the patient sitting or in a semifowlers
position one can concentrate local
anesthetic to this area.
Trendelenberg or reverse trendelenberg
may help spread local anesthetic
cephalad or alternatively limit the
spread.

Local Anesthetics used for

Epidural Anesthesia

Considerations in choosing

Understanding of local anesthetic

potency & duration
Surgical requirements and duration of
surgery
Postoperative analgesic requirements

Local Anesthetics for Epidural

Anesthesia

Use only preservative free solutions

Read the labels, ensure that it is
preservative free or prepared for
epidural/caudal anesthesia/analgesia

Categories according to
duration of action

Short Acting: 2-chloroprocaine

Intermediate Acting: lidocaine and
mepivacaine
Long Acting: bupivacaine, etidocaine,
ropivacaine, levobupivacaine

Short Acting 2chloroprocaine

Ester local anesthetic

Initially associated with disconcerting
neurotoxicity (adhesive arachnoiditis)
when administered in the intrathecal
space (inadvertently)
Attributed to bisulfate concentrations

Short Acting 2chloroprocaine

1985 bisulfate content decreased

1987 preservative free solution introduced
1996 bisulfate free solution available
Since the change in formulation no more
reports of neurotoxity.
However the other preparations may be
available so you need to read labels!
Large volumes of local anesthetic injected
inadvertently into the subarachnoid space
may still cause neurotoxicity

Short Acting 2chloroprocaine

Other problem, in the past, was patient

complaints of back pain after large doses
of > 25 ml of local anesthetic
Formulations contained EDTA, thought
that it leached calcium out of the
muscle and resulted in hypocalcemia.
The preservative free formulations do
not appear to cause back pain after
large doses have been used

Short Acting 2chloroprocaine

Best suited for short procedures

Good agent for the outpatient
Available in concentrations of 2% (for
procedures that do not require absolute
muscle relaxation) and 3% which
provides for dense muscle relaxation.
2-chloroprocaine will interfere with the
action of epidurally administered opioids

Short Acting 2chloroprocaine

Intermediate Acting
Lidocaine

Prototypical amide local anesthetic

1.5-2% concentrations used for surgical
anesthesia
Epinephrine will prolong the duration of
action by 50%
Addition of fentanyl will accelerate the
onset of analgesia and create a more
potent/complete block

Intermediate Acting
Lidocaine

Intermediate Acting
Mepivacaine

Similar to lidocaine
Amide local anesthetic used in similar
concentrations
Lasts about 15-30 minutes longer than
lidocaine
Epinephrine will prolong the duration of
action by 50%

Intermediate Acting
Mepivacaine

Long Acting Bupivacaine

Long acting amide local anesthetic

0.5-0.75% concentrations used for
surgical anesthesia
0.125-.25% used for epidural analgesia
Epinephrine will prolong duration of
action but not to the extent of lidocaine,
mepivacaine, and 2-chloroprocaine

Long Acting Bupivacaine

0.75% concentration should not be used in OB

In 1983 the FDA came out with this
recommendation
There were several cardiac arrests due to
inadvertent intravascular injection in OB
patients
Bupivacaine (as well as etidocaine) are more
likely to impair the myocardium and
conduction system with toxic doses than other
local anesthetics

Long Acting Bupivacaine

Bupivacaine has a high degree of protein

binding and lipid solubility which
accumulate in the cardiac conduction
system and results in the advent of
refractory reentrant arrhythmias

Long Acting Bupivacaine

Long Acting
Levobupivacaine

S isomer of bupivacaine
Used in the same concentrations
Clinically acts just like bupivacaine with
the exception that it is less cardiac toxic

Long Acting
Levobupivacaine

Long Acting Ropivacaine

Long acting amide local anesthetic

Mepivacaine analogue
Used in concentrations of 0.5-1% for surgical
anesthetic
Used in concentrations of 0.1-0.3% for
analgesia
Ropivacaine is unique among local
anesthetics since it exhibits a
vasoconstrictive effect at clinically relevant
doses

Long Acting Ropivacaine

Similar to bupivacaine in onset, duration,

and quality of anesthesia
Key differences include: in doses for
analgesia there is excellent sensory
blockade with low motor blockade and it
is less cardiotoxic than bupivacaine

Long Acting Ropivacaine

Long Acting Etidocaine

Long acting amide local anesthetic

Not used clinically very often due to the
profound motor blockade it induces
When used for surgical anesthesia it is
used in a concentration of 1%

Long Acting Etidocaine

Epidural Additives

Epinephrine will increase the duration of action

of all epidurally administered local anesthetics.
There is a large variability among local
anesthetics as to the degree of increase
The greatest effect is found with lidocaine,
mepivacaine, 2-chloroprocaine.
Lesser effects found with bupivacaine,
levobupivacaine, etidocaine
Minimal effects have been found with
ropivacaine

Epidural Additives

Epi vs phenylephrine
Epi is more effective in reducing peak
blood levels
Phenylephrine does not appear to
reduce the peak blood levels

Epidural Additives

Carbonation of local anesthetics has been

touted to improve the quality of epidural
blocks due to increased penetration of
connective tissue and intraneural diffusion
Studies are ambivalent
Carbonation may not improve quality or
onset; may lead to increased blood levels
of local anesthetic; result in a higher
incidence of hypotension when compared
to non carbonated local anesthetics

Epidural Additives

Sodium bicarbonate can be added to

lidocaine, mepivacaine, and 2chloroprocaine
Addition will increase the amount of free
base which increases rate of diffusion
and speeds onset
Studies have found that when added to
1.5% lidocaine speeds onset of blockade
and results in a more solid block

Epidural Additives

Generally 1 meq of bicarbonate is added

to 10 ml of local anesthetic (i.e. lidocaine,
mepivacaine, 2-chloroprocaine)
The addition of bicarbonate to
bupivacaine is not as popular. Usually 0.1
ml of bicarbonate is added to 10 ml of
bupivacaine
Bupivacaine precipitates occurs at a pH >
6.8

Epidural Additives

Mixing long acting and short acting local

anesthetics may not have much
advantage for epidural anesthesia
Many choices for local anesthetics and
additives

References

Brown, D.L. (2005). Spinal, epidural, and caudal anesthesia. In R.D. Miller Millers Anesthesia, 6th edition.
Philadelphia: Elsevier Churchill Livingstone.

Burkard J, Lee Olson R., Vacchiano CA. Regional Anesthesia. In Nurse Anesthesia 3rd edition. Nagelhout, JJ &
Zaglaniczny KL ed. Pages 977-1030.

Kleinman, W. & Mikhail, M. (2006). Spinal, epidural, & caudal blocks. In G.E. Morgan et al Clinical
Anesthesiology, 4th edition. New York: Lange Medical Books.

Niemi, G., Breivik, H. (2002). Epinephrine markedly improves thoracic epidural analgesia produced by smalldose infusion of ropivacaine, fentanyl, and epinephrine after major thoracic or abdominal surgery: a
randomized, double-blind crossover study with and without epinephrine. Anesthesia and Analgesia, 94, 15981605.

Reese CA. Clinical Techniques of Regional Anesthesia: Spinal and Epidural Blocks. 3 rd edition. AANA
Publishing, 2007.

Visser L. Epidural Anaesthesia. Update in Anaesthesia. Issue 13, Article 11. 2001.

Warren, D.T. & Liu, S.S. (2008). Neuraxial Anesthesia. In D.E. Longnecker et al (eds) Anesthesiology. New
York: McGraw-Hill Medical.