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The Used of Epidural Anesthesia for Pain

Management
By :
Tiara Eka Mayasari, S.Ked
Nuraidah, S.Ked
Nur Suci Trendi Asih, S.Ked

Advisor :
dr. H. Zulkifli, SpAn.KIC.M.Kes.MARS
L/O/G/O

ANESTHESIOLOGY AND INTENSIVE CARE DEPARTMENT


MEDICAL FACULTY OF SRIWIJAYA UNIVERSITY
MOHAMMAD HOESIN GENERAL HOSPITAL
PALEMBANG 2016
Outline
Background

What is pain?

Review the anatomy

Epidural Anesthesia
Epidural anesthesia in
labour

Conclusion
Background
Pain is one of the bad consequences after surgery can
be anticipated
Effective pain managementImprove the patients
comfort overcome the systemic effect
Widely used of epidural anesthesia for pain management
Intraoperative, postoperative, acute and chronic pain,
during labor
Popular, decrease mortality and morbidity due to pain
Pain
Pain is unpleasant sensory and emotional experience
associated with actual or potential tissue damage

Cause uncomfort, decrease satisfaction, increase


hospitalized costs, bad outcome: increase immobility
morbidity and mortality
Pain Management
Opioid drugs
Non-opioid drugs
Neuroaxial Blockade
Patient controlled analgesia
Peripheral nerve Blockade
TENS (transcutaneus and percutaneus electrical nerve
stimulation)
Psychology intervention
Cont

Used Multimodal analgesia

Epidural anesthesia for


pain management
Anatomy

The spinal column(vertebrae) consists of:


- 7 cervical vertebrae
-12 thoracic vertebrae
-5 lumbar vertebrae
- 5 bones (that are joined, or "fused," together in adul
to form the bony sacrum
- 4 bones fused together to form the coccyx or tailbone
Epidural Space

Epidural Space:
Saccus duralis, spinal nerve roots ,
blood vessels, fat and lymphatic
tissue
Epidural Anasthesia

Neuroaxial anesthetic technique


Used widely as the sole anesthetic
Combinatian with general or spinal anesthetic
Pain management acute or chronic,
intraoperative or postoperative
Indication

Hip and Knee Surgery


Vascular surgery of lower extremity
Labor epidural analgesia, Cesarean Delivery
Pain management in postoperative patients
Analgesia in acute and chronic pain
Contraindication
Absolute Relative
Patient refusal Hypovolemia
Infection at the site CNS disease
Sepsis Chronic back pain
Coagulopathy Patient with antiplatelet
Allergy to local anesthetic drug consumption
Increased intracranial
pressure
Advantage
RCTsignificantly decrease of pain intensity and lower
incidence of posoperative pain after 2-6 months than
intravenous morphin
Continuous effect by inserting the catheter good for
postoperative pain management
Long surgical procedure
Labor epidural analgesia, spontaneous delivery without
pain
Disadvantage
Uncomfortable position during insert the catheter
Long onset of action: 20-30 minute after administration
Severe headache in few days 1/100 women
Procedure
Equipment
Similar to general anesthesi: machine, drugs
Epidural needle: touhy epidural needle 17-18 gauge

Patient position
Identification of epidural space
Level of blockade
Dose test
Identification of epidural space technique

Loss of Resistence Technique


2-5 ml of air or saline is drawn into the syringe, with
constant pressure, the needle is advanced through the
ligamentum flavum. Loss of resistence occurs once the
needle enters the epidural space.

Hand Position
Cont
Hanging drop technique
Once the interspinous ligament has been entered then
stylet has been removed, the hub of the needle be filled
with solution so that a drop hangs from its outside
opening. The needle is then slowly advanced deeper. As
long as the tip of the needle remains within the
ligamentous structures, the drop remains hanging.
Epidural Anesthesi drugs
Local

Opioid
Single Dose (mg) Onset analgesia (min) Effectivity (hour)

Epidural

Morfin 1-6 30 6-24

Extended Release 5-15


Morphine
Fentanyl 0,025-0,1 5 2-4
Local anesthesia drugs
Ropivacaine: bupivacaine and mepivacaine homologue,
myocard depression and CNS toxicity effect lower than
bupivacaine. Combination ropivacaine 0,08% and
fentanyl 2 mcg /mL give effective analgesia effect in
labor. Motoric blockade is minimal.

Levobupivacaine: same with bupivacaine

Lidocaine : amida group with intermediete acting


Opioids
Morphin: Long onset
Fentanyl dan sufentanyl: adequate analgesia, high
potency and penetration to spinal cord.
Mechanism of Epidural Anesthesi

Local anesthesi
Direct action to the spinal nerve rootblockade

Change nerve conductionsodium channel blockade


Opioid groups
Diffusion to neural structures through
duramaterarachnoid membranespinal canal
posterior horn of medula spinalis (opiod receptor)

Inhibit signal to brain


Complication
Dural punction
Catheter insertion pass the blood vessels
Subarachnoid injection
CNS and cardiovascular toxicity cause convulsion and
cardiac arrest
Overdose of local anesthesia
Spinal cord injury
Bleeding
Cont
Postoperative complication

Headache post dural punction


Infection
Epidural hematom
Advantage used of epidural anesthesia for pain
management
Epidural anesthesia decrease stress response due to
surgery procedure by supress symphatic and
somatosensory input.

Epidural Anesthesia application Pain management


Epidural anesthesia in labour

Pain Mechanism during labour


1st stage of labor is primarily visceral pain resulting from
uterine contractions and cervical dilation
Pain intensity increases with progressive cervical dilation
and with increasing intensity and frequency of uterine
contractions
usually initially confined to the T11T12 dermatomes
during the latent phase but eventually involves the T10
L1 dermatomes as labor enters the active phase.
Epidural alone or in combination is currently the most
popular methods of pain relief during labor and delivery
Provide excellent analgesia while allowing the mother to
be awake and cooperative during labor
Advantage: a).
Postoperative Pain Management

Why is it important?
Stress response after surgery
Stress response after surgery pain morbidity such
as cardiovascular and respiratory complication especially
in elderly
Bad pain control after surgery
Morbidity
Cost
Take time for hospitalized
Conclusion

Pain as one of problem in many patients after surgery,


has so many bad effects but it can be managed.
Epidural anesthesia was used not only for surgery
procedure but also for pain management in many cases
Pain management with this procedure as a sole
anesthesia or combination with other modalities can
improve patients comfort and decrease the systemic
effects of pain