ANESTESI REGIONAL

L FLORA SILAEN, SpAn

 Anesthesia

General Local
I.V Topical
I.M Infiltration
Inhalation Field Block
Nerve Block
Spinal
Epidural
Intra Venous

COMBINATION
 Mekanisme nyeri
Inflamasi/
Kerusakan jaringan Transduksi

Pelepasan Mediator
Alogen, Cytokines, Neurokines
Transmisi

Merangsang sistem sensori primer

Medula Spinalis Modulasi

tanduk dorsal

SSP

Sensasi Nyeri PERSEPSI

GENERAL ANESTHESIA :
 Impulse still reach to CNS
 Cortisol 
 Catecholamine 
 Tachycardia
 Blood sugar 

REGIONAL ANESTHESIA :
 Impulse less/not reach to CNS
 Segmental blockade T5 – L1
Block sympathetic system 
 Cortisol N / less 
 Catecholamine N / less 
General sensory
Anesthesia cortex
• All sensation loss cerebral
• Unconscious

Subarachnoid
Local/Regional
Anesthesia
• Partial sensation loss
• Conscious
Nerve Ending
Epidural Medulla Spinalis
ADVANTAGES :
 Simple, Cheap
 Non explosive
 No pollution
 Post op care relative easy
 Conscious  aspiration risk (-)
 Blood loss 
 Autonomic & endocrine response 
DISADVANTAGES :
 Patient prefer unconscious
 Not practical if several injection are
needed
 Fear that the effect of drug vanished the
surgery not finished
 Side effect so severe  death
Local Anesthetic Agent
1. Ester Compound
 Cocaine
 Procaine / Novocaine
 Tetracaine / Pontocaine
2. Amide Compound
 Xylocaine / Lidocaine
 Prilocaine / Citanest
 Bupivacaine / Marcaine
 Etidocaine / Duranest
 Ropivacaine
 Levo Bupivacaine
 Intermediate chain
(Ester or amide linkage)

N H+

Benzene ring Quaternary amine

(Lipophilic) (Hydrophilic)
 Metabolism Allergy

ESTER.C Hydrolyzed in (+)

Plasma PABA
(Ps.Choline)

AMIDE.C Degradation (-)

in the Liver
Anesthetic Profile of Local Anesthetic is depend
on :
 Lipid solubility  intrinsic potency
 The Higher lipid sol  Higher potency
 Procaine L.S. = 1
 Bupivacaine L.S. = 30
 Etidocaine L.S. = 140
 90 % Axolemma consist of lipid

 Protein binding
 Higher Protein binding  Longer duration
 Procaine P.B. = 5
 Bupivacaine P.B. = 95
 10 % axolemma consist of protein
 p Ka
P Ka as pH at which its ionized and non
ionized are in complete equilibrium
L.A. with pKa closer to tissue pH  more
rapid onset
 p Ka lidocaine = 7,7
 Bupivacaine = 8,3
 Intrinsic vasodilator activity
 Influence potency and duration of action
 Degree of vascular absorption is related to
blood flow through the area
 All local anesthetic  vasodilation except
Cocaine
Base upon potency and duration of action
1. Low Potency & short duration o.a.
 Procaine
 chloroprocaine
2. Intermediate potency & duration o.a.
 Lidocaine
 Mepivacaine
 Prilocaine
3. High potency & long duration o.a.
 Bupivacaine
 Tetracaine
 Etidocaine
Toxicity of local anesthetic (0,2 – 1,5%)

 1. Systemic toxicity
Excitation
CNS
Depression
Hypotension
CVS
CV collaps
 Local irritation
Neural damage Chloroprocaine

Miscellanous
Allergy Ester compound
Met.Hb.emia Prilocaine
Addiction Cocaine
 Systemic toxicity
L.A. agent are relatively free of side
effect, if :
1. In appropriate dosage  toxic excessive
dose
2. In appropriate anatomical location  toxic
reaction  following :
- accidental i.v. injection
- subarachnoid inj. of large dose
 Systemic toxicity

 CNS is more susceptible than CVS

 Adverse effect involving CVS tend to be

more serious and more difficult to
manage
 CNS toxicity
CNS is more susceptible to the systemic
actions of L.A. than CVS

 Tinnitus
 Light headedness
 Confusion
 Circumoral numbness
 Drowsiness  unconscious
 Twitching & tremors muscles of face & distal
extremities  convulsion
 Respiratory arrest
 Bupivacaine : Etidocaine : Lidocaine =
4 : 2 : 1

 Convulsive threshold is inversely related to

the PaCO2 level.

PaCO2  convulsive threshold

pH  convulsive threshold
 CVS toxicity
 Cardiac :
- Negative inotropic action
more potent  more depress contractility  more difficult to
resuscitate
- Ventricular fibrillation
 bupivacaine

 Vascular : biphasic action

- Lower dose  vasoconstriction
- increase dose  vasodilatation

No correlation between L.A. potency and

vascular smooth muscle effect
 Hypotension initially as a result of
decrease in SV  CO

Later on vasodilatation  CV collaps

 Neurological Blockade
 Peripheral :
- Topical
- Infiltration
- Field block
- Nerve block
- I.V. Regional Anesthesia
 Central :
- Spinal
- Epidural
 Spinal Anesthesia
L.A  Subarachnoid space
 Anterior horn blockade
 Posterior horn blockade

Small nerve fiber  large fiber

 Autonom
 Sensoris (pain)
 Temperature
 Motoric
 Proprioceptic
 Autonomic blockade 2 – 3 segments
above analgesic level

 Motoric blockade 2 – 3 segments under

analgesic level
Indication
 Abdominal surgery esp. lower abdomen
 Hernia Inguinalis
 Lower extrimities surgery
 Vesica urinaria and prostatic surgery
 Obgyn surgery
 Contraindication
 Absolute :
- refusal of the patient’s
- local infection
- coagulopathy
Relative :
- Sepsis
- Neurological disease
- Technical problems
- Hypovolemia
 Advantages
 Conscious
 Relaxation (+)
 Pulmonary post. op. complication <<
 Blood loss
 Disadvantages
 Hypotension
 Durante & post op nausea & vomiting
 Post op headache
 Disturb respiration  high level
 Urinary retention
 Technique
 Lateral / sitting position
 Approach : midline / lateral
 Level of injection : iliac crest L – R  L4-5
 Needle is advanced until duramater is pierced 
CSF flow back
 The higher the dose the greater the height of block
 Lower abdominal surgery  T 8-10  1,8 – 2 cc
 Higher abdominal surgery  T 4-5  2 – 2,5 cc
 Management
 Fluid : 0,5 – 1 L
 Post injection :
- Test analgesic
- Respiratory monitor
 O2 by mask
 assist. ventilation
 - Hypotension
 fluids
 ephedrine 5 – 10 mg i.v
- High risk patient’s 
early ephedrine drips
 If necessary :
- diazepam / midazolam
- Hypnotic
- N2O/O2
- Light G.A
 Post Spinal Headache
 Due to leakage of CSF  smaller the
needle  less PSH
 G.N 25  3,5% ; 27  1% ; 29  < 1%
Th/ :
 Laid flat 24 hrs
 Analgesic agent
 Autolog epidural blood patch
 Epidural Analgesia
 Thoracal, lumbar, caudal
 Indication / contraindication = spinal
 Anatomy
 Duramater is begine from foramen magnum
and end at S2 level
 Posterior to the dura lies lig. Flavum
 Diameter 0,5 cm at L2
 Content of epidural space :
- fat
- vascular vessel
- lymph vessel
- areolar tissue
- spinal nerve roots
 Detection of epidural space using tuohy
needle :
- Loss of resistance
- Hanging drop
Dose : 1 – 1.5 ml / segment
Injection begin with 3 ml of test dose
consist of lidocaine 2 % + adrenaline 1
: 200.000
Complication
 Penetrate duramater
 Post spinal headache
 Total spinal

 Systemic reaction
 Spinal advantages
 Less time to perform eq. technique
easier
 Less doses
 More rapid onset
 Better quality sensory & motor block
 Epidural advantages :
 Segmental block
 No PSH
 Hypotension is not abrupt
 Less motoric block
 Can be used for post op. pain catheter
 Epidural disadvantages :
 More difficult
 Larger doses
 Systemic reaction 
 Total spinal if not in proper place
 Caudal Block
 Indication : perineal surgery

 Contraindication = epidural

 Technique :
1. Prone position
2. Cornu sacralis
3. Hiatus sacralis
4. Penetrate sacrococcygeal membrane
 Disadvantages

 Difficult to reach
higher level of analgesia
 Systemic reaction could be (+)
 Brachial plexus block
 Supraclavicular

 Axillary
 Nerve block at the elbow
 N. ulnaris

 N. medianus + N. radialis

 Wrist block