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Neuraxial Blockade: Epidural Anesthesia

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Essentials of Regional Anesthesia

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Abstract

The first epidural injection was performed in 1901 by Jean-Athanase Sicard and Ferdinand Catheline through caudal route. Touhy needle was developed for continuous spinal catheter technique and later adapted for epidural anesthesia by Manual Martinez Curbelo. Its popularity increased due to the possible serious neurological sequelae of spinal injections and the availability of long-acting local anesthetic agents such as bupivacaine. As a result of its versatility, it certainly remains a popular regional anesthetic technique in the USA and UK.

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Author information

Authors and Affiliations

  1. Pain Management, Epsom and St. Helier University Hospitals NHS Trust, Carshalton, UK

    Sreekumar Kunnumpurath MBBS, MD, FRCA, FFPMRCA

  2. Anaesthetics, Guys and St. Thomas’ NHS Foundation Trust, London, UK

    Suneil Ramessur MBBS, BSc(Hons), FRCA, FFPMRCA

  3. Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK

    Adam Fendius MBBS, BSc(Hons), DipIMC, FRCA

  4. Department of Anesthesiology, Yale University, New Haven, CT, USA

    Nalini Vadivelu MBBS, MD, DNB

  5. Anaesthetics, St George’s University Hospital, London, UK

    Jasmina Perinpanayagam BSc(Hons), MBBS, FRCA

Authors
  1. Sreekumar Kunnumpurath MBBS, MD, FRCA, FFPMRCA
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  2. Suneil Ramessur MBBS, BSc(Hons), FRCA, FFPMRCA
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  3. Adam Fendius MBBS, BSc(Hons), DipIMC, FRCA
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  4. Nalini Vadivelu MBBS, MD, DNB
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  5. Jasmina Perinpanayagam BSc(Hons), MBBS, FRCA
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Editor information

Editors and Affiliations

  1. Department of Anesthesiology, Louisiana State University School of Medicine, New Orleans, Louisiana, USA

    Alan David Kaye

  2. Department of Anesthesiology Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA

    Richard D. Urman

  3. Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, USA

    Nalini Vadivelu

Review Questions

Review Questions

  1. 1.

    Regarding epidural analgesia the following statement is correct:

    1. (a)

      Reduces postoperative mortality

    2. (b)

      There is a reduction in venous thrombosis

    3. (c)

      It increases catecholamine release

    4. (d)

      Can lead to metabolic dysfunction

  2. 2.

    Epidural space extends from:

    1. (a)

      Cranial cavity to sacral foramina

    2. (b)

      Foramen magnum to lower border of L2

    3. (c)

      Foramen magnum to sacrococcygeal ligament

    4. (d)

      Foramen magnum filum terminale

  3. 3.

    Epidural space is thinnest in:

    1. (a)

      Cervical region

    2. (b)

      Thoracic region

    3. (c)

      Lumbar region

    4. (d)

      Caudal region

  4. 4.

    Regarding surface markings, the following statement is NOT true:

    1. (a)

      Vertebra prominence corresponds to C8 vertebra

    2. (b)

      Inferior angle of the scapula corresponds to T7 vertebra

    3. (c)

      Superior aspect of iliac crest corresponds to L4 vertebra

    4. (d)

      Posterior superior iliac spine corresponds to S2 vertebra

  5. 5.

    When performing thoracic epidural injection:

    1. (a)

      It is always performed by a paramedian approach

    2. (b)

      Midline approach is impossible because of the acute angulation of the thoracic spinous processes

    3. (c)

      It is possible to perform it by inserting the needle in the midline at an acute angle

    4. (d)

      Motor blockade produced at this level can paralyze the diaphragm

  6. 6.

    When performing a caudal epidural injection, the structures through which the needle passes through are:

    1. (a)

      Skin, subcutaneous tissue, supraspinous ligament, interspinous ligament, and ligamentum flavum

    2. (b)

      Skin, subcutaneous tissue, sacrococcygeal membrane and ligamentum flavum

    3. (c)

      Skin, subcutaneous tissue, interspinous ligament, and sacrococcygeal membrane

    4. (d)

      Skin subcutaneous tissue and sacrococcygeal membrane

  7. 7.

    A 75-year-old man with a history of ischemic heart disease (IHD) is undergoing hip arthroplasty under epidural. His base line heart rate and mean arterial pressure (MAP) prior to anesthesia were 75/min and 100 mm of Hg, respectively. After administration of epidural you notice that his heart rate has dropped to 55/min and MAP to 50 mm of Hg. Choose the most logical intervention:

    1. (a)

      There is no need for any intervention as the reduction in heart rate has reduced the myocardial oxygen demand

    2. (b)

      Atropine is indicated for bradycardia

    3. (c)

      Hypotension need not be treated as it helps to reduce blood loss

    4. (d)

      Treat hypotension as the reduction in myocardial oxygen demand will be offset by reduced oxygen supply secondary to hypotension

  8. 8.

    All of the following are true regarding epidural blockade except:

    1. (a)

      A reduction in heart rate can be due to blockade of cardioaccelerator fibers

    2. (b)

      A reduction in heart rate can be due to baroreceptor-mediated reflex bradycardia

    3. (c)

      Reduction in blood pressure due to vasodilatation reduced venous return and reduced adrenal cortical secretions

    4. (d)

      Selective lumbar or thoracic blockade has the benefit of providing hemodynamic stability as a result of compensatory vasoconstriction in unblocked segments

  9. 9.

    Which of the following effect is NOT caused by epidural blockade?

    1. (a)

      Parasympathetic blockade leading to reduction in blood pressure and nausea

    2. (b)

      Small, contracted bowel

    3. (c)

      Increased upper GI motility

    4. (d)

      Increased GI secretions

  10. 10.

    Electrodes for spinal cord stimulation are place in:

    1. (a)

      Subarachnoid space

    2. (b)

      Subdural space

    3. (c)

      Intrathecal space

    4. (d)

      Epidural space

  11. 11.

    The following is an absolute contraindication for epidural blockade:

    1. (a)

      Coagulopathy

    2. (b)

      Patient refusal

    3. (c)

      A bleeding patient

    4. (d)

      A septic patient

  12. 12.

    You are performing an epidural catheter insertion for labor analgesia. The epidural space is identified at a depth of 6 cm. A catheter is then passed and on withdrawing the Touhy needle the marking at the skin corresponds to 15 cm. The length of catheter remaining inside the epidural space probably is:

    1. (a)

      15 cm

    2. (b)

      10 cm

    3. (c)

      9 cm

    4. (d)

      11 cm

  13. 13.

    The structures negotiated by a Touhy needle during the paramedian approach are:

    1. (a)

      Skin, subcutaneous tissue, paraspinous muscles, and ligamentum flavum

    2. (b)

      Skin, subcutaneous tissue, interspinous ligament, and ligamentum flavum

    3. (c)

      Skin, subcutaneous tissue, paraspinous muscles, and interspinous ligament

    4. (d)

      Skin, subcutaneous tissue, supraspinous ligament, and ligamentum flavum

  14. 14.

    When epinephrine is used as an additive in epidural anesthesia:

    1. (a)

      The dose of local anesthetic should be reduced to avoid drug toxicity

    2. (b)

      It increases the depth of neural blockade

    3. (c)

      There is a rapid systemic absorption of the drugs injected which is indicated by an increase in heart rate

    4. (d)

      A sudden increase in heart rate indicates successful epidural deposition of the drug

  15. 15.

    The following statement is NOT true regarding PDPH:

    1. (a)

      CSF pressure is low

    2. (b)

      The treatment of choice is immediate blood patch

    3. (c)

      Can present with cranial nerve symptoms

    4. (d)

      Its relation to posture is characteristic

Answers

  1. 1.

    b—Epidural analgesia reduces the stress response to surgery by providing effective analgesia, which is beneficial for cardiovascular, respiratory, and metabolic functions. There is a reduction in postoperative hypercoagulable state, which in turn reduces the incidence of deep vein thrombosis. Though there is a reduction in postoperative morbidity, there is no evidence for reduction in mortality after surgery.

  2. 2.

    c

  3. 3.

    a—It is 2 mm in thickness at the cervical region and 5–6 mm in the lumbar region.

  4. 4.

    a—There is no C8 vertebra though there is C8 nerve root.

  5. 5.

    c—Though paramedian approach is relatively easy to perform, a midline approach can also be used to administer thoracic epidural injection. Motor blockade at thoracic level does not affect diaphragmatic function as the innervation of diaphragm is by the phrenic nerve, which originates at cervical level (C3–C5).

  6. 6.

    d—There is no ligamentum flavum over the sacral hiatus as it fuses with the caudal lamina.

  7. 7.

    d—Though reduction in heart rate reduces myocardial oxygen demand, oxygen supply will be maintained only if MAP is maintained. In the presence of IHD, it is safe not to allow the MAP to drop below 20% of the base line value.

  8. 8.

    c—Reduction in blood pressure is due to a reduction in adrenal medullary secretions.

  9. 9.

    a—Sympathetic blockade leads to unopposed vagal dominance.

  10. 10.

    d

  11. 11.

    b—All the others are relative contraindications.

  12. 12.

    c

  13. 13.

    a—Paramedian approach avoids both supraspinous and interspinous ligaments, and hence, it is easier by this approach in the elderly who may have calcified ligaments.

  14. 14.

    b—Epidural epinephrine produces local vasoconstriction and decreases systemic absorption of local anesthetic, and hence, a higher dose of local anesthetic can be used. A sudden increase in heart rate indicates the intravascular injection of the drug (into epidural veins).

  15. 15.

    b—First line of treatment for PDPH is bed rest, simple analgesics, and hydration. If this fails then epidural blood patch is indicated.

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Kunnumpurath, S., Ramessur, S., Fendius, A., Vadivelu, N., Perinpanayagam, J. (2018). Neuraxial Blockade: Epidural Anesthesia. In: Kaye, A., Urman, R., Vadivelu, N. (eds) Essentials of Regional Anesthesia. Springer, Cham. https://doi.org/10.1007/978-3-319-74838-2_12

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  • DOI: https://doi.org/10.1007/978-3-319-74838-2_12

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-74837-5

  • Online ISBN: 978-3-319-74838-2

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