Local anesthesia/anesthetics epidural administration

Central neural blockade. The anesthetic is injected within the spaces surrounding the spinal cord10 (Fig. 12-2). Specifically, the term epidural nerve blockade refers to injection of the drug into the epidural space—that is, the space between the bony vertebral column and the dura mater. A variation of epidural administration known as a caudal block is sometimes performed by injecting the local anesthetic into the lumbar epidural space via the sacral hiatus (see Fig. 12-2). Spinal nerve blockade refers to injection within the subarachnoid space— that is, the space between the arachnoid membrane and the pia mater. Spinal blockade is also referred to as intrathecal anesthesia because the drug is injected within the tissue sheaths surrounding the spinal cord (intrathecal means within a sheath see Chapter 2). 

A 61-year-old woman taking amitriptyline 25 mg/day underwent oophorectomy for ovarian cancer under combined general and epidural lumbar anesthesia. After the administration of the local anesthetic she developed hypotension refractory to high doses of ephedrine and dopaminergic drugs. Control was achieved with noradrenaline 200 pg. 

Epidural anesthesia is administered by injecting local anesthetic into the epidural space. Located outside the spinal cord on its dorsal surface, the epidural space contains fat and is highly vascular. Therefore, this form of anesthesia can be performed safely at any level of the spinal cord. Furthermore, a catheter may be placed into the epidural space, allowing for continuous infusions or repeated bolus administrations of anesthetic. 

Amide-type agents include articaine, lidocaine, bupivacaine, prilocaine, mepivacain and ropiva-caine. These are metabolized in the liver by microsomal enzymes with amidase activity. The amide group is preferred for parenteral and local use. If by accident rapidly administered intravascularly these agents, especially bupivacaine but also lidocaine, can produce serious and potentially lethal adverse effects including convulsions and cardiac arrest. They can more easily accumulate after multiple administrations. Intravenous lidocaine is sometimes used for regional anesthesia, for infiltration procedures, for the induction of nerve blockade and for epidural anesthesia. However, it is also used as an antiarrhythmic. Bupivacaine is a long-acting local anesthetic used for peripheral nerve blocks and epidural anesthesia. 

Finally, therapists may work with patients who are receiving central neural blockade in the form of an epidural or spinal injection. These procedures are common during natural and caesarean childbirth and in some other surgical procedures. Administration of local anesthetics into the spaces around the spinal cord are also used to treat individuals with severe and chronic pain—that is, patients recovering from extensive surgery, patients who have cancer, or patients with other types of intractable pain. In these situations, therapists may notice that an indwelling catheter has been placed in the patient s epidural or subarachnoid space to allow repeated or sustained administration of the spinal anesthesia. 

In a careful meta-analysis, 29 randomized, controlled studies of the incidence of transient radicular irritation were identified (243). Lidocaine and mepivacaine were identified as the two local anesthetics that most commonly cause transient radicular irritation, while prilo-caine, bupivacaine, and ropivacaine had the lowest incidences. Owing to insufficient data, definitive statements could not be made about the effects of the baricity of the local anesthetic, the concentration, and the effect of vasoconstrictors, although all these factors seemed not to be relevant. With regard to intrathecal ropivacaine, the incidence in the formal studies was zero. However, there has been one previous report after intrathecal administration, and one report of transient radicular irritation following epidural anesthesia with ropivacaine the symptoms resolved within 24 hours (244). 

Pain and hyperthermia at the injection site can be reduced by pre-administration neural blockade, and administration during general anesthesia. Ideally, Adlea may he applied to patients receiving anesthesia and post-operative analgesia with epidural and peripheral neural blockade catheters. Residual pain may be controlled with local application of ice packs, local anesthetic infiltration, and oral acetaminophen. 

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