Epidural Anesthesia:

Cervical Block,
Caudal Block, and WELA

Adwina Syafitri
030.11.008
Fakultas Kedokteran Universitas Trisakti

What is epidural anesthesia?

a regional anesthesia that blocks pain in a
particular region of the body
an injection into epidural space that
numbs the pain nerves

Spinal cord

a long, thin, tubular

bundle of nervous
tissue
Inside spinal canal and
surrounded by LCS
Wrapped by meninges

Meninges
Dura mater:
strong, inelastic
Arachnoid:
many blood
vessels
Pia mater:
sticking with
spinal cord

Epidural space

between the dura mater and the vertebral wall

containing fat, spinal nerve roots, blood vessels

The technique of epidural

anesthesia

The technique of epidural

anesthesia
1. Position: sitting position or
lateral decubitus
2. Injection site: L3-L4 or
according to needs
(cervical/thoracal/lumbal/caudal
)
3. Needles:

The technique of epidural

anesthesia
4. Identify the epidural space:
Loss of resistance
Hanging drop

5.Test dose - no effect

- spinal blockage
- HR until 20 30%

6.Injection of the anesthetic

Cervical block
sensory blockade of the superficial
cervical (C1/C4) and brachial plexus
(C5/T1-T2).
It is used both intraoperatively and in
the treatment of postoperative or
chronic pain.

Cervical
block
Position: sitting
position with the
head resting on the
examination table
Insert the needle in
between C7-T1 or
C6-C7
The volume of
anesthetic required
to block all the
cervical is 8-12ml
The use of
corticosteroid is
common for chronic
pain treatment

Cervical block
Indication:
1.Surgical: for neck, upper limb, and breast
surgery
2.Pain
Acute: acute herpes zoster, Raynaud's
disease, injury of the brachial plexus.
Chronic: herniated disc, spinal stenosis.

Cervical block
Absolute
Patient refusal
Bacterial infection
(systemic or localized)
Bleeding disorder
Intracranial
hypertension

Relative
Allergy to medications
Pregnancy
Medications which
increase bleeding risk
Hyperglycemia
Adrenal suppression
Immune compromise
CHF
Altered epidural
anatomy

Cervical block
Complication:
Paraplegia
High spinal
Toxicity
Hipotension
Respiratory distress

Caudal block
Injection of a local anesthetic into the caudal
canal, the sacral portion of the spinal canal.
Not common in adults, because:
Lumbar and thoracic epidural space is easier to
access in the adult
Sacral Hiatus is more difficult to identify and the
caudal space is more difficult to enter
Increased risk of injecting local anesthetic into
the fetus

Caudal block
The injection is through
sacral hiatus.
Locating sacral hiatus:
palpate the coccyx
sliding the palpating
finger in a cephalad
direction until a
depression in the skin is
felt.

Caudal block
Techniqu
e
1. a 22 gauge needle is directed at about 45 to
skin and inserted till a "click" is felt as the sacrococcygeal ligament is pierced.
2. Direct needle in a cephalad direction at an angle
approaching the long axis of the spinal canal
3. Aspirate
4. Test dose
5. Inject the local anesthetic

Caudal block
Dose for
pediatric
Armitage Formula:
0.5 ml/kg for a lumbosacral
block
1 ml/kg for a thoraco-lumbar
block
1.25 ml/kg for a midthoracic
block
0.25% Bupivacaine with
maximum safe dose 0.15-0.2
mg/kg/h in neonates and 0.20.3 mg/kg/h in infants

Scotts Calculation

Caudal block

Dose for adult

Bupivacaine 0.25%
20-30 ml for a block of the lower abdomen
15-20 ml for a block of lower limb and perineum

Caudal block
Indication
Surgery below the umbilicus such as:
Hernia repair
Lower limb surgery
Skin grafting
Procedures on the anus and rectum
Orthopedic surgery on the pelvic girdle
Obstetric Analgesia: 2nd stage or instrumental deliveries
Chronic pain, such as lower limb pain because of the
prolapse of intervertebral disc

Caudal block
Same with
cervical
block

Contraindicat
ion

Complication

Toxicity
Spinal block
Sepsis
Urinary
retention
- Hematoma
- Rectum
perforation

WELA (Walking Epidural Lumbar

Analgesia)
Is a pain-free delivery techniques
which mothers can still give birth
normally without pain, and they can
push and move so that they can
concentrate better during the birth
process
Performed when the uterus
contraction is present or if the cervix
has opened up to 2 cm.

WELA (Walking Epidural Lumbar

Analgesia)
Labor pain
Stage I: uterus contraction and cervix dilatation
(T10-L1)
Stage II: fetal head causing perineum distention
(S2-S4)
The local anesthetic is injected through L2-L3
or L3-L4 interspace into epidural space

To block T10 - S5

WELA (Walking Epidural Lumbar

Analgesia)
Requirements to perform WELA:
Patients will
Mother doesnt have a narrow pelvic or
gave birth with sectio cesarea before
Resuscitation tools present
Informed consent
Performed by specialist

WELA (Walking Epidural Lumbar

Analgesia)
Local anesthetic injection
Epidural bolus: a complete block (T10-S5)
0,125% Bupivacain or 0,225% Naropin
Inject bolus of 3ml 5ml 5ml Naropin 2 mg/ml
Continuous epidural infusion: 6-8 ml/ hour Naropin 2 mg/ml
Patient-Controlled Epidural Analgesia (PCEA): give the local
anesthetic through epidural catheter whenever the patient
feels the pain

WELA (Walking Epidural Lumbar

Analgesia)
Indication
1. Mother
Feeling severe labor pain
Long term stage I with
severe pain
Anxiety and fear
Patients will
Pre-eclampsia and
eclampsia
With respiratory disorder
2. Baby
Premature

Contraindication

Same with
cervical block

WELA (Walking Epidural Lumbar

Analgesia)
Complication
Hipotension
High spinal
Shivering
Nausea and vomiting
Toxicity