REGIONAL ANESTHESIA

Regional Anesthesia
1. 2. 3.

Spinal Epidural Peripheral Nerve Block

BASIC ANATOMY
1.

2.

Spinal Canal - from the foramen magnum to the sacral hiatus Vertebral Column 33 vertebrae 7 cervical 12 thoracic 5 lumbar 5 sacral 4 coccygeal fused

REGIONAL ANESTHESIA
Contents of Spinal Column 1. Spinal cord 2. Subarachnoid space 3. Epidural space 3 Membranes of SC 1. Pia mater 2. Arachnoid mater 3. Dura mater

LIGAMENTS 1. Anterior and Posterior ligaments - between the anterior and posterior aspects of vertebral bodies 2. Supraspinatous ligament - from the 7th cervical vertebrae to sacrum - maximum thickness at lumbar area

3. Interspinous ligament - extends between the spinous process 4. Ligamentum Flavum - yellow elastic fiber, runs from anterior and inferior aspects of each vertebral lamina below - most dense at lumbar area

SPINAL NERVES 1. Somatic Spinal Nerves - dermatome 2. Dorsal and Ventral Spinal Nerves Roots 3. Preganglonic Sympathetic Nerve Fibers 4. Cervical Nerves BLOOD SUPPLY 1. Anterior artery 2. 2 Posterior arteries supply the dorsal portion of the spinal cord 3. Artery of Adamkiewics - highly variable - most common on the left and enters the vertebral canal through the L1 intervertebral formen. - supply the lower 2/3 of SC - damage will produce bilateral lower extremity motor loss

PREOPERATIVE EVALUATION
1.

Surgical Considerations
Sugested Minimum Dermatome Levels for Spinal or Epidural Anesthetics Site of Operation Lower Extremity Hip Prostate or Bladder Testes Herniorrhaphy Intraabdominal Levels Required T12 T10 T10 T6 T4 T4

PREOPERATIVE EVALUATION
3. Contraindication Absolute: 1. Patient Refusal 2. Infection at site 3. Increased ICP 4. bleeding diathesis

Relative Contraindication: 1. Sepsis 2. Preexisting Neurologic deficits 3. Cardiac Disease - mitral stenosis, idiopathic hypertropic subaortic stenosis, and aortic stenosis 4. Abnormal Coagulation

SPINAL ANESTHESIA
-

Accomplished by injecting local anesthetic solution into the CSF contained within subarachnoid space. Indications: Abdominal Surgery - General surgery - Obstetric and Gynecologic Urologic and Rectal Surgery Lower extremities

SPINAL ANESTHESIA
Patient Position 1. Lateral - lateral decubitus position 1. Sitting 2. Prone

Layers traversed by the Spinal needle: 1. Skin 2. Subcutaneous Ligament 3. Supraspinous Ligament 4. Infraspinous Ligament 5. Ligamentum flavum 6. Epidural Space 7. Dura 8. Subarachnoid Space

SPINAL ANESTHESIA
Spinal Needles 1. open-ended (beveled or cutting) 2. Closed tapered-tip pencil-point needle with side port (guage 24- or 25-)

SPINAL ANESTHESIA
Approach 1. Midline 2. Paramedian elderly with calcified ligaments or patient point of cutaneous needle insertion is typically 1 cm lateral to the midline -skin - quadratus lumborum muscle - Ligamentum flavum - Epidura - Dura - subarachnoid space - does not traverse the supra and infraspinous ligament

SPINAL ANESTHESIA
3. Taylor Approach - paramedian technique to access L5-S1 - spine needle is passed from a point 1cm caudad and 1 cm medial to the posterior superior iliac spine and advanced cephalad at a 55-degree angle with medial orientation based on the width of the sacrum.

SPINAL ANESTHESIA
Anesthetic Injection Checklist: 1. Position 2. SAAS 3. Skin Infiltation 4. Free flow of CSF 5. Paresthesia(-)

SPINAL ANESTHESIA
LEVEL AND DURATION Factors affecting the spread of local anesthetic: Baricity Contour of the spinal Cord Position of the patient Drug Dosage Site of Injection

1. 2. 3. 4. 5.

SPINAL ANESTHESIA
Baricity 1. Hypobaric < 0.997 @ 37C - procedures on the rectum, perineum and anus or in the lateral decubitus position - reduce venous pooling in the legs - limits the cephalad spread of the local anesthetics 2. Isobaric 0.998 1.007 @ 37C - produce more localized blocks extending only to the thoracic dermatomes - appropriate for lower extremity and urologic procedures 3. Hyperbaric >1.008 @ 37C - most commonly selected -ability to achieve greater cephalad spread of anesthesia -

SPINAL ANESTHESIA
Adjuvants 1. Vasoconstrictors - added to increase the duration of spinal anesthesia - epinephrine - phenylephrine 1. Opioids and other Analgesics Agent
-

Improves sensorimotor blockade Provides postoperative anesthesia Fentanyl short surgical procedures Morphine provide effective control of postoperative pain for roughly 24 hours

SPINAL ANESTHESIA
CHOICE OF LOCAL ANESTHETIC Duration of Action Potential Adverse Side Effects SHORT-DURATION 1. Lidocaine 2. Cnloroprocaine LONG-DURATION 1. Bupivacaine 2. Tetracaine

SPINAL ANESTHESIA
Documentation of Anesthesia
SENSORY LEVEL NECESSARY FOR SURGICAL PROCEDURES Sensory Level S2-S5 L2-L3(knee) L1-L3 (Inguinal Ligament) T10 (umbilicus) Type of Surgery Hemorrhoidectomy Foot Surgery Lower Extremity Hip Surgery Transurethral resection of the prostate Vaginal Delivery Lower Abdominal Surgery Appendectomy Upper Abdominal Surgery Cesarian Section

T6-T7 (xiphoid process) T4 (nipple)

CONTINUOUS SPINAL ANESTHESIA

Levels and significant of Sensory Block Cutaneous Level Fifth Digit Inner Aspect of the arm and forearm Apex of axilla Nipple Tip of the Xiphoid Umbilicus Inguinal Ligament Segment Level C8 T1-2 T3 T4-5 T7 T10 T12 Significance All cardioaccelrator fibers block Some degree of cardioaccelerator block Easily determined landmark Possibility of cardioaccelarator block Splanchnics(t5-L1) may be blocked Sympathetic NS block limited to the legs No sympatheti nervous system block

Outer Side of the foot

S1

Confirms block of the most difficult root to anesthesize

SPINAL ANESTHESIA
SEQUENCE OF NEURAL BLOCKADE 1. Sympathetic block or Autonomic block 2. Loss of pain and temperature sensation 3. Loss of propioception 4. Loss of touch and pressure sensation 5. Motor paralysis

SPINAL ANESTHESIA
SYMPATHETIC BLOCKADE Preganglionic Sympathetic blockade Arteriolar and Venous Dilatation Increased Vascular Capacitance Pooling of Blood Decreased Venous Return Decreased Cardiac Output

SPINAL ANESTHESIA
COMPLICATIONS Hypotension (<90mmHg) Bradycardia Post Spinal Headache High Spinal Nausea Urinary Retention Backache Neurologic Sequelae Hypoventilation

SPINAL ANESTHESIA
HYPOTENSION MANAGEMENT 1. Modest head down position (5 to 10 degrees) 2. Adequate Hydration 3. Sympathomimetics: Ephedrine (5-10mg IV) HIGH SPINAL TREATMENT 1. Maintenance of airway and ventilation 2. Circulatory support ( sympathomimetics and intravenous fluid administration) 3. Head Down Position

EPIDURAL ANESTHESIA
EPIDURAL ANESTHESIA - injection of local anesthetic into the epidural space - neural blockade: spinal nerve roots - anesthesia occurs more slowly and develops in segmental manner

EPIDURAL ANESTHESIA
Indications: - All indications for spinal anesthesia - Prolong post-op pain relief Epiduara Needles: 1. Tuohy needle 2. Weiss needle 3. Crawford needle

EPIDURAL ANESTHESIA
Epidural Catheters: 1. Bullet tipped 2. Multiorifice Epidural Kit: 1. 17- to 18- gauge needle 2. 19- to 20- gauge catheter 3. Finder needle 3.8 cm

EPIDURAL ANESTHESIA
TECHNIQUE 1. Thoracic Epidural - paramedian approach 2. Lumbar and low thoracic epidural - midline and paramedian approach

EPIDURAL ANESTHESIA
Identification of Epidural Space 1. Engagement of the needle tip in ligamentum flavum 2. Loss-of-Resistance technique 3. Hanging Drop technique

EPIDURAL ANESTHESIA
LAYERS TRAVERSED BY EPIDURAL NEEDLE: 1. Skin 2. Subcutaneous Tissue 3. Supraspinous ligament 4. Interspinous ligament 5. Ligamentum flavum

EPIDURAL ANESTHESIA
Administration of Local Anesthetic: 1. Single-Shot epidural Anesthesia 2. Continuous Epidural Anesthesia 3. Caudal Anesthesia Factors affecting the spread of anesthesia 1. Dose 2. Site of injection

EPIDURAL ANESTHESIA
Factors affecting the duration of anesthesia: 1. Choice of local aneshetic a. Chloroprocaine (rapid onset and short duration) b. Lidocaine (intermediate onset and duration) c. Bupivacaine, Levobupicaine, Ropivacaine (slow onset and prolonged duration)

EPIDURAL ANESTHESIA
Factors affecting hthe duration of anesthesia: 2. Adjuvants a. Epinephrine b. Opioids c. Sodium Bicarbonate Failed Epidural Anesthesia Local anesthetics solution is not delivered into the epidural space Spread of local anesthetics is inadequate to cover the relevant dermatomes False loss of resistance Advancement of the catheter through intervertebral foramen

EPIDURAL ANESTHESIA
Sequence of Neural Blockade 1. Sympathetic Nervous System Blockade 2. Motor Block 3. Catabolism

EPIDURAL ANESTHESIA
COMPLICATIONS Hypotension (<90mmHg) Bradycardia Post Spinal Headache High Spinal Nausea Urinary Retention Backache Neurologic Sequelae Hypoventilation Accidental dural pincture (wet tap) and headache Accidental subarachnoid injection local anesthetic toxicity

COMBINED SPINAL-EPIDURAL ANESTHESIA

- combines the rapid onset and intense sensory anesthesia of the spinal anesthetic with the ability to supplement and extend the duration of the block afforded by an epidural catheter.

CAUDAL ANESTHESIA
-

Special form of epidural anesthesia, with access through sacral hiatus Sacral hiatus is located 5cm from the tip of coccyx Failure rate of 10 to 15% More useful in pediatric patients

PERIPHERAL NERVE BLOCK

Used for anesthesia, post operative analgesia, and diagnosis and treatment of chronic pain syndrome PREPARATION FOR NERVE BLOCKS - Same as general anesthesia or neuroaxial anesthesia - Preoperative medication - Appropriate monitors, equipment and drugs available for adverse reaction
-

PERIPHERAL NERVE BLOCK

FACTORS IN CHOICING LOCAL ANESTHETICS 1. Desired Onset 2. Duration 3. Degree of Conduction Block

PERIPHERAL NERVE BLOCK

Local Anesthetic Agent and
Local Anaesthetics Lidocaine Mepivacaine Ropivacaine Bupivacaine 1%-5% 0.5% 0.375%-0.5% Duration 10-20 minutes to 2-3 hours 6-8 hours Surgical anesthesia

PERIPHERAL NERVE BLOCK

Specific Block Techniques 1. Paresthesias - radiating electric shock-like sensations that can occur during regional anesthetic procedures. 2. Nerve Stimulation - common way of identifying peripheral nervesthat carry mixed populationof sensory and motor fibers. CATHODAL STIMULATION - block needle - cathode -another lead on the body anode - 0.5mA indicates sufficient proximity of the block needle to the nerve .

PERIPHERAL NERVE BLOCK

TYPE OF PERIPHERAL NERVE BLOCK A. Brachial Plexus Block 1. Interscalene Block 2. Supraclavicular Block 3. Musculocutaneous Nerve Block 4. Intercostobrachial Nerve Bolock 5. Distal Nerve Block of the Arm 6. Ulnar Nerve Block 7. Radial Nerve Block

PERIPHERAL NERVE BLOCK

B. Blocks of the Thoracic and Abdominal Walls 1. Intercostal Nerve Block 2. Block of the Inguinal Region C. Block of the Inguinal Region D. Nerves Block to the Lower Extremity 1. Lumbar Plexus Block 2. Femoral Nerve Block 3. Lateral Femoral Cutaneous Nerve Block 4. Sciatic Nerve Block