NEUROAXIAL BLOCK

Spinal, Epidural, and Caudal Anesthesia

General considerations
Preoperative assessment is similar to that for general anesthesia.
The area where the block should be examined for potential difficulties or
pathology.
A history of abnormal bleeding and a review of the patient's medications
may indicate a need for additional coagulation studies.
Patients should be given a detailed explanation of the planned procedure,
with risks and benefits.
As with general anesthesia, patients should receive appropriate
monitoring and have an IV line in place. Oxygen, equipment for intubation
and positive-pressure ventilation, and drugs to provide hemodynamic
support should be available.
 Contraindications to neuraxial anesthesia

Absolute
Patient refusal.
Localized infection at skin puncture site.
Generalized sepsis (e.g., septicemia, bacteremia).
Coagulopathy
Increased intracranial pressure.
Relative
Localized infection peripheral to regional technique site.
Hypovolemia.
Central nervous system disease.
Chronic back pain.
 Spinal anesthesia
Spinal anesthesia involves administering local anesthetic into the subarachnoid space.
Anatomy
The spinal canal extends from the foramen magnum to the sacral hiatus.
Three interlaminar ligaments bind the vertebral processes together:
Superficially, the supraspinous ligament connects the apices of the
spinous processes.
The interspinous ligament connects the spinous processes on their
horizontal surface.
The ligamentum flavum connects the caudal edge of the vertebrae above
to the cephalad edge of the lamina below.
The spinal cord extends the length of the vertebral canal during fetal life, ends
at about L-3 at birth, and moves progressively cephalad to reach the adult
position near L-1 by 2 years of age. The conus medullaris, lumbar, sacral, and
coccygeal nerve roots branch out distally to form the cauda equina. Spinal
needles are placed in this area of the canal (below L-2), because the mobility
of the nerves reduces the danger of trauma from the needle.
CSF is a clear colorless fluid that fills the subarachnoid space.
 Table 16.1. Suggested minimum
cutaneous levels for spinal anesthesia

Operative Site Level

Lower extremities T-12

Hip T-10
Vagina, uterus T-10
Bladder, prostate T-10
Lower extremities with tourniquet T-8
Testis, ovaries T-8
Lower intraabdominal T-6
Other intraabdominal T-4
Spinal column curvatures that influence the spread of anesthetic solutions.
 The Advantages of Spinal Anaesthesia
Cost. Anaesthetic drugs and gases are costly and the latter often difficult to transport.
Patient satisfaction. If a spinal anaesthetic and the ensuing surgery are performed
skilfully, the majority of patients are very happy with the technique and appreciate the
rapid recovery and absence of side effects.
Respiratory disease. Spinal anaesthesia produces few adverse effects on the respiratory
system as long as unduly high blocks are avoided.
Patent airway. As control of the airway is not compromised, there is a reduced risk of
airway obstruction or the aspiration of gastric contents.
Diabetic patients. There is little risk of unrecognised hypoglycaemia in an awake patient.
Muscle relaxation. Spinal anaesthesia provides excellent muscle relaxation for lower
abdominal and lower limb surgery.
Bleeding. Blood loss during operation is less than when the same operation is done
under general anaesthesia.
Visceral tone. The bowel is contracted during spinal anaesthesia and sphincters are
relaxed although peristalsis continues. Normal gut function rapidly returns following
surgery.
Coagulation. Post-operative deep vein thromboses and pulmonary emboli are less
common following spinal anaesthesia.
 Epidural anesthesia
Epidural anesthesia is achieved by introducing local anesthetics into the epidural
space.
Anatomy. The epidural space extends from the base of the skull to the
sacrococcygeal membrane. Posteriorly, it is bounded by the ligamentum
flavum, the anterior surfaces of the laminae, and the articular processes.
Anteriorly, it is bounded by the posterior longitudinal ligament covering
the vertebral bodies and
Subarachnoid and epidural spaces.
Pemeriksaan keadaan anestesi

pin prick
alkohol

Diagram dermatom 13
Obat dan alat
14
 Posisi : lateral kiri

Desinfektan : betadin alkohol

15
 Infiltrasi lidokain 2 %

Tusuk L 3 - 4 atau L 4 5 ,
dengan jarum epidural no.18
16
Sasaran jarum

17
 Masukkan 2 3 ml obat anestesi lokal

18
 Masukkan kateter epidural

19
Aspirasi, hasil (-) cabut jarum
20
 Fiksasi kateter
21
 Masukkan lagi 3 ml obat anestesi lokal,
observasi 5 menit
Dosis fraksional 3-5 ml
Interval waktu 5 menit
alternatif lain : infus kontinyu 22
 Caudal anesthesia
Caudal anesthesia is obtained by placing local anesthetic into the epidural space in the
sacral region.
Anatomy. The caudal space is an extension of the epidural space. The sacral hiatus is
formed by the failure of the laminae of S-5 to fuse. The hiatus is bounded laterally by
the sacral cornua, which are the inferior articulating processes of S-5. The
sacrococcygeal membrane is a thin layer of fibrous tissue that covers the sacral hiatus.