REGIONAL ANALGESIA

DR.
DR. KUSUMA
KUSUMA HARIMIN
HARIMIN ,SpAn
,SpAn

Departemen Anestesiologi
dan
Reanimasi RSMH/FK Unsri

TEKNIK R.A
I.

- INFILTRASI LOKAL
- BLOK LAPANGAN (FIELD BLOCK)
- BLOK SYARAF (NERVE BLOCK)
- TOPICAL BLOCK (PERMUKAAN)
- ANALGESIA REGIONAL INTRA VENA

II.

- SPINAL ANALGESIA

III. - EPIDURAL ANALGESIA

IV. - CAUDAL ANALGESIA

V.

- BRACHIAL BLOCK
- SUPRA CLAVICULAR
- AXILAR BLOCK
- INTERSCALENUS

VI. - PERIPHERAL BLOCKADE

N. RADIALIS
N. ULNARIS
N. MEDIANUS
VII.- BLOCK SYARAF SIMPATIS NERVUS
SYSTIM
- GANGLION STELLATE
- PLEXUS CILIARIS

ANALGESIA SPINAL
= LUMBAL = SUBARACHNOID
MENYUNTIKKAN OBAT LOKAL ANESTESI KEDALAM RUANG
SUBARACHNOID DI DAERAH VERTEBRA L2 L3, L3 L4, L4 L5,
SEHINGGA DIDAPAT ANALGESIA YANG BERSIFAT REVERSIBEL.

- POSISI :

DUDUK
MIRING FLEXI MAKSIMAL

- LAND MARK :
SIAS KI - KA
INTERSPACE
- TEKNIK :
MEDIAN
PARA MEDIAN
TAYLOR

- TEKNIK :

MEDIAN
PARA MEDIAN
TAYLOR

- OBAT OBAT L . A
LIDOCAINE 5 % IN. 7,5% DEXTROSE
BUPIVACAINE 0,5% HYPERBARIC
TETRACAINE

- OBAT OBAT L . A
LIDOCAINE 5 % IN. 7,5% DEXTROSE
BUPIVACAINE 0,5% HYPERBARIC
TETRACAINE

DOSIS DAN KETINGGIAN BLOK

DOSIS (mg)

Durasi (Lama) (Menit)

Sampai
Th 10

Th 4

50-60

75-100 mg

60

75-100

Tetracaine

6-8

10-16

70-90

100-150

Bupivacain

8-10

12-20

90-110

100-150

L.A
Lidocain 5%

Plain

0,2 mg
Epieprin

Obat obat memperpanjang kerja L A

Misal :

LIDOCAINE (R/ LIDONEST)

ADRENALIN 0,2 MG(BILAS)

SPUIT
CATAPRES 1 Ampul

CAMPUR DALAM

(bisa + 90 %)

Faktor faktor yang menentukan

ketinggian blok spinal analgesia
Karakteristik Pasien
Tempat Penyuntikan
Barbotage
Kecepatan Penyuntikan
Arah Bevel
Direction Of Injection (Jarum)

 Teknik Penyuntikan
Umur (Geriatri (tua))
Tinggi Pasien
Berat
Gender (Sex) ,
hamil
Tekanan Intra Abdominal
Konfigurasi kolumna Vertebralis (Anatomi)
Posisi

 Karakteristik Cairan LCS

Volume
Pressure = Tekanan ( Batuk, Valsava Manuver,
Mengejan
Density BD LCS 1,006

Karakteristik Cairan L. A
Density
Concentrasi
Volume
Temperatur
Vaso Contrictor

KOMPLIKASI SPINAL ANALGESIA

I. Dini : - Sirkulasi
- Hypotensi
- Bradycardi
- Respiarasi
> Apnoe
- Blok tinggi
- Hypotensi Berat
- Iskemi Mendulla
> Kesulitan Bicara
- Sesak
- GI Tract
> Nausea
- Hypotensi
> Muntah
- Hypoksia
- Tracksi Pada
Tr.Urinarus

II. Delayed (Kemudian / Lambat)

Spinal Head Ache ( Sakit Kepala)
Retensio Urine

Pencegahan :
1.Jarum Kecil No.25 ,27
2.Hydrasi Adekuat
3.Tusukan Sejajar Duramater

Spinal Head Ache Menahun

Obati dengan Epidural Blood Patch
( Darah 10 CC dimasukan dalam ruang
Epidural)
( Tambal )

Distribution of Local
Anaesthetics and Other
Adjuncts within the
Subarachnoid Space as
Demonstrated Visually by the
Glass Spine

Associate Professor Stephen Gatt, OAM, MOM,

Area Chair in Anaesthesia and Perioperative Medicine, South East Health,
Director of Anaesthesia, Prince of Wales Hospital
Head of Division, Anaesthesia and Intensive Care, Prince of Wales & Sydney Childrens Hospitals
Senior Staff Specialist (previously, Director of Anaesthesia), Royal Hospital for Women.
President of the Obstetric Anaesthesia Society of Asia and Oceania,
Sydney, Australia.

Workshop 2 Sanur Room - Gran Melia Jakarta

2nd. Annual Combined Meeting of the Indonesian Society of Obstetric
Anesthesia and Indonesian Society of Regional Anesthesia and Pain
Medicine in conjunction with Recent Advances in Anesthesia Symposia,
Jakarta, Indonesia, 2005.

History
1907: Glass Spine: Arthur Baker:
University College, London
1950: Lumbar Puncture & Spinal
Anaesthesia: MacIntosh, Oxford
1970s- : Popularised the
demonstration (including Asia): Len
Carrie, Oxford.

Glass spine

Expansion chamber
Thoracic concavity + lumbar convexity
Specific gravity, density and baricity
Contents of subarachnoid space
Surface landmarks

Baricity
Hyperbaric
Specific Gravity >1.009
eg. Bupivacaine 0.5% Heavy (8% dextrose)

Isobaric
Specific Gravity 1.003-1.009
Hypobaric
Specific Gravity <1.003

Density
Plain 2% chloroprocaine*

Hyperbaric

Density:1.00123g/mL

Plain 3% chloroprocaine*

Hyperbaric

1.00257

Hypobaric

1.00004

can be used without dextrose

Plain 2% lignocaine

has to have dextrose added to make it hyperbaric

[relative to CSF at 37oC]

* preservative free
*antoxidant free

Anesth Analg Jan 2004

98(1):70-74, 2004
Spinal chloroprocaine solutions: density
at 37 degrees C and titration
Na KB, Kopacz DJ
Virginia Mason, Seattle, WA

Density of Bupi Ropi - Levobupi

Density decreases with increasing
temperature
Density increases with the addition of
dextrose
Levobupi 0.5% denser than bupi 0.5% and
ropi 0.5% at 23oC and 37oC (with & without
dextrose
Levobupi 0.75% is isobaric at 37oC
McLeod GA: Density of spinal anaesthetic solutions of
bupivacaine, levobupivacaine and ropivacaine with & without
dextrose. BJA 93:5:749, Nov 2004.

What determines LA spread in the

Subarachnoid Space
Gravity
Volume
Mass
Baricity

Position

Speed of injection
Size of the needle
MCQ
AnaesthesiaUK
Pain Resources, 2004

MALE SUPINE

FEMALE SUPINE

ISOBARIC
TETRACAINE

L3-4

Solution Spread

Supine

HYPERBARIC
TETRACAINE
L3-4
Solution Spread
Head down

HYPERBARIC
TETRACAINE
L3-4
Solution Spread
Supine

HYPERBARIC
TETRACAINE
L3-4
Solution Spread
Saddle block

Intrathecal Spread & Body Habitus

Term Parturients

Height

Sitting Position

BMI*

Fentanyl + Bupivacaine
low dose

Weight

Labour analgesia

Can J Anaes Sep 2003

50(7):689-693
Body habitus does not influence spread of sensory blockade
after the intrathecal injection of a hypobaric solution in term
parturients
Wong CA, Cariaso D, Johnson EC, Leu D, McCarthy RJ
Northwestern, Chicago, Illinois

No effect on
sensory analgesia
extent*

* <1 segment at extremes of BMI

Continuous Spinal Catheter

Levobupi & Ropi Isobaric
Advantages
Incremental dosing
Less haemodynamic changes
Smaller dose than for single shot:
Levobupivacaine MLAD

11.7mg (95%CI:11.1-12.4)

Ropivacaine MLAD

12.8mg (95%CI:12.2-13.4)

BJA Feb 2005

94(2):239-242
Minimum effective local anaesthetic dose of isobaric
levobupivacaine and ropivacaine administered via a spinal
catheter for hip replacement
Sell A, Olkkola KT, Jalonen J, Aantaa R
Tartu, Estonia

Demonstration 1 Lying CS
Hyperbaric
Lateral position to Supine
(extension to mid thoracic)
(slight head down: +1-2 segments)

Waxoline rhodamine
then, turned to the side + head down
(extensive additional cranial spread)

Demonstration 2 Saddle
Block
Hyperbaric
Sitting
Saddle block
Waxoline rhodamine

Demonstration 3
CS

Sitting

Hyperbaric
Sitting to supine
(intense caudal spread)
(limited cranial spread and less intense upper level)

Waxoline rhodamine

Demonstration 4 Isobaric
hip
Isobaric
Lateral to supine
(effect of temperature, coughing)
(sometimes high, L1 -> T1)

Methylene blue

Demonstration 5 Continuous
spinal
28-32G microspinal catheter
22G spinal needle
1cc syringe
Useless for surgery
Cauda equina syndrome
High local concentrations

Miscellaneous
Barbotage
minor effect through 27G spinal
needles

Small needles
little effect on spread

EVE
epidural volume extension

SECTION 2

SOME TIPS FOR A

SUCCESSFUL &
SAFE
EPIDURAL/CSE
BLOCK

FULL GOWN
FULL SCRUB
MASK, GLOVES, etc

APPLYING THE PREP

WHICH PREP?
HOW TO STOP GETTING
PREP ALL OVER THE
SETUP

BEWARE OF PREP SOLUTION

CONTAMINATION
COVER YOUR SYRINGES, NEEDLES
AND MEDICATIONS

ONCE YOU
DEFINE THE
MIDLINE, NEVER
LET GO OF IT

HAVE EVERYTHING READY AND

CHECKED BEFORE YOU PUT THE SKIN
LOCAL INTO THE PATIENTS BACK
TIME IT TAKES TO PERFORM AN
EPIDURAL =
TIME OF SKIN L.A. => TIME OF
REMOVAL OF EPIDURAL NEEDLE

Position Patient
Drape Carefully

BACKHAND
PULLTHRO
Technique

THOSE
ACCURSED
WINGS

SPRAY & SECURE

Ropivacaine/fentanyl Polybag
Lignocaine 2% w. Adrenalin
#11 Bard Parker knife blade

AWFUL

BAD TROLLEY SETUP

LOSS OF
RESISTANCE
DEVICES ARE NOT
ALL MADE EQUAL

KNEEL
IDENTIFY TUFFIERS LINE
IDENTIFY THE MIDLINE
HOLD THE MIDLINE & LEVEL