Regional Anesthesia

Fatiş Altındaş
Dept. of Anesthesiology
Regional anesthesia - Definition
„ Renders a specific area of the body, e.g. foot,
arm, lower extremities insensating to stimulus of
surgery or other instrumentation
„ Eliminates sensation in a limited region of the
body
„ Interferes with impulse transmission in
peripheral or spinal cord nerves
„ There is no loss of consciousness
Benefits of Regional Anesthesia
„ Provide anesthesia for a surgical procedure
„ Unsurpassed quality of analgesia post-
operatively or during labor and delivery
„ Reduction in stress response
„ Improves regional blood flow
„ Diagnosis or therapy for patients with chronic
pain syndromes
Regional anesthesia - types
„ Central neuraxial blockade
…Epidural
…Spinal
„ Peripheral nerve block
…minor: single nerve
…major: multiple nerves or plexus
„ Infiltration
„ Topical
…skin
…mucous membranes
Central Blocks: Spinal, Epidural

„These blocks are also known

neuroaxial anesthesia
„Performing as a single injection or
with a catheter to allow intermittent
boluses or continuous infusion
„The principal site of action for
central blocks is the nerve roots
„Injecting local anesthetic into CSF
or the epidural space
Anatomy of the vertebral column

„ Spinal cord and its

nerve roots lie within
the vertebral column
„ Spinal cord extends
from the foramen
magnum to level of L1
in adults and L3 in
children
Spinal cord
„ Spinal cord is covered by meninges
…Pia mater
…Arachnoid mater
…Dura mater
CSF is contained between the pia and arachnoid mater
in the subarachnoid space
Indications: Uses

„Central blocks may be used for nearly

any procedure below the neck
„As a primary anesthetic technique
…Lower abdominal, inguinal
…Urogenital, rectal
…Lower extremity surgery
Indications-cont.
„The choice of anesthesia is determined by
the patients
…Discussing risks and benefits
…Obtaining informed consent
…Suitability of the technique for the type of
surgery
…The surgeon’s preference
…The experience of the anesthetist
…Physiologic and mental state
Contraindications
Absolute Relative
„ Infection at the site of
injection „ Sepsis
„ Patient refusal „ Uncooperative patient
„ Coagulopathy or bleeding „ Preexisting neurologic
diathesis
deficits
„ Severe hypovolemia
„ Increased ICP …Demyelinating lesions
„ Severe aortic stenosis „ Severe spinal deformity
„ Severe mitral stenosis
Technical considerations
„They should only be performed in
facility where all the equipment and
drugs needed for intubation and
resuscitation are immediately
available
„Monitoring for surgical anesthesia is
the same as for general anesthesia
…Blood pressure, heart rate , pulse
oximetry
Central Blocks- Spinal
„ Advantages
…Technically easy (LP technique)
…High success rate, rapid onset
„ Disadvantages
…“high spinal”
…hypotension due to sympathetic block
…post dural puncture headache
Central Blocks- Epidural

„Performing at the cervical, thoracic,

lumbar or sacral levels.
„Widely used for surgical anesthesia,
obstetric analgesia, postoperative
pain control and chronic pain
management
„Epidural anesthesia is slower in onset
(10-20 minutes)
„It is not as intense as spinal
anesthesia
Effects of central blocks
„Sempathetic blockade
…Vasodilation
…Hypotension
„Sensory blockade
…Interrupts both somatic and visceral painful
stimuli
„Motor blockade
Advantages of central blocks
„Morbidity –and mortality may be reduced
by neuroaxial blockade
…Incidence of venous thrombosis
…Pulmonary embolism
…Cardiac complications in high risk patients
…Bleeding and transfusion requirements
…Pneumonia and respiratory depression
Complications of neuroaxial blocks

„Range from bothersome to crippling

and life-threatining
„Result from medication introduced or
the needle used to perform the
procedure
Complications-cont.
Needle Medication=LA
„ Backache „ High blokade
„ Headache „ Systemic toxicity
„ Nerve injury „ Local toxicity
„ Vascular injury „ Infection
„ Infection
Plexus Blockade
„ Injection of local anesthetic adjacent to a plexus,
e.g cervical, brachial or lumbar plexus
„ Uses: surgical anesthesia or post-operative
analgesia in the distribution of the plexus
„ Procedures on the arm, shoulder, trunk or legs
„ Advantages: large area of anesthesia with
relatively small dose of agent
… Disadvantages: - technically complex, potential for
toxicity and neuropathy
„ Brachial plexus
„ C5 through C8 and
T1
„ Anesthesia of the
shoulder and upper
extremity
Topical Anesthesia
„ Application of local anesthetic to mucous
membrane - cornea, nasal/oral mucosa
„ Uses : - awake oral or nasal intubation,
superficial surgical procedure
…Advantages :
„technically easy
„minimal equipment
…Disadvantages :
„potential for large doses leading to toxicity
Local/Field Anesthesia =Infiltration

„ Application of local subcutaneously to

anesthetize distal nerve endings
„ Uses: - Suturing, minor superficial surgery, line
placement, more extensive surgery with
sedation
„ Advantages: - minimal equipment, technically
easy, rapid onset
… Disadvantages: - potential for toxicity if large field
Bier Block
„ Injection of local anesthetic intravenously
for anesthesia of an extremity
„ Uses - any surgical procedure on an
extremity
„ Advantages: - technically simple, minimal
equipment, rapid onset
…Disadvantages: - duration limited by
tolerance of tourniquet pain, toxicity
Peripheral nerve block
„ Injecting local anesthetic near the course
of a named nerve
„ Uses: - Surgical procedures in the
distribution of the blocked nerve
„ Advantages: - relatively small dose of
local anesthetic to cover large area; rapid
onset
…Disadvantages: - technical complexity,
neuropathy
Local Anesthetics - Definition

„A substance which
reversibly inhibits nerve
conduction when applied
directly to tissues at non-
toxic concentrations
Local Anesthetics

„ Mechanism of action is by reversibly blocking

sodium channels to prevent depolarization
„ Anesthetic enters on axioplasmic side and
attaches to receptor in middle of channel
Local Anesthetics

„Linear molecules that have a lipophilic and

hydrophilic end (ionizable)
…low pH-- more in ionized state and unable to
cross membrane
…adding sodium bicarb-- more in non-ionized
state
Local Anesthetics

„Two groups: esters and amides

…esters metabolized by plasma cholinesterase
…amides metabolized by cytochrome p-450
Local anesthetics - Classes
Esters Amides
„ Cocaine „ Bupivacaine
„ Chloroprocaine „ Lidocaine
„ Procaine „ Ropivacaine
„ Tetracaine „ Etidocaine
„ Mepivacaine
Local anesthetics - Duration
„ Determined by rate of elimination of agent
from site injected
„ Factors include lipid solubility, dose given,
blood flow at site, addition of
vasoconstrictors (does not reliably prolong
all agents)
„ Some techniques allow multiple injections
over time to increase duration, e.g.
epidural catheter
Precautions
„Epinephrine combinations should not be
used where circulation may be
compromised by vasoconstriction
…fingers
…toes
…ears
…nose
…penis
Local Anesthetics - Allergy
„True allergy is very rare
„Most reactions are resulted from
ester class
„Ester hydrolysis (normal
metabolism) leads to formation of
PABA
Local Anesthetics – Toxicity
Tissue toxicity
„ Rare
„ Occurs if administered in high enough
concentrations (greater than those used
clinically)
„ Usually related to preservatives added to
solution
Systemic toxicity
„ Related to blood level of drug
… Absolute overdose
… Accidentally intravascular injection
„ All LA produce a similar picture of toxicity
„ Degree of disturbances caused by toxicity
… Potency of drugs: lipid solubility
… Pharmacokinetics properties
„ The rate of rise of plasma levels
„ The peak level
„ The fraction of unbound drug in the circulation
 Toxic effects
Lignocaine plasma conc. (mcg/mL) 30
CVS depression
25
Respiratory arrest
20
Coma=CNS collaps
15
Convulsions
Unconciousness
10 Muscular twitching
Tinnitus
5 Visual disturbance
Ligthheadedness
Numbness of tongue + Metallic taste
0
Prevention and Treatment of Toxicity

„Primarily from intravascular injection or

excessive dose -- anticipation
…aspirate often with slow injection
…ask about CNS toxicity
…have monitoring available
…prepare with resuscitative equipment, CNS-
depressant drugs, cardiovascular drugs
…ABC’s
Treatment of Toxicity
Hoping without disability