•

Extracorporeal membrane oxygenation – a pump to prevent further lung damage, while limiting tidal
oxygenator performs gas exchange allows the volumes to 6-8ml/kg has been shown to reduce
lungs to be ‘rested’. Again, only available in mortality. In cases of refractory hypoxaemia PC-IRV
specialist centres. or ventilation in the prone position may improve blood
gases, but have not been proven to influence survival.
Summary
In addition there are many advanced techniques but
ARDS is diagnosed clinically on the basis of the acute many are only available in specialist centres, and
development of hypoxaemic respiratory failure, CXR none convincingly reduce mortality.
changes and non-cardiogenic pulmonary oedema,
References
on the background of a pulmonary or non-pulmonary
precipitating condition. ARDS may affect one in ten 1. Bernard GR, Artigas A, Brigham KL, et al. The American-
intensive care unit patients, and it carries a mortality European Consensus Conference on ARDS: definitions,
of 30-40%. mechanisms, relevant outcomes, and clinical trial
coordination. Am J Respir Crit Care Med 1994; 149: 818-
Pathologically ARDS is characterised by an 24.
inflammatory phase involving neutrophils and 2. Luce JM. Acute lung injury and the acute respiratory
cytokines, followed by a reparative process that may distress syndrome. Crit Care Med 1998; 26(2): 369-76.
end in fibrosis.
3. ARDSnet. Ventilation with lower tidal volumes as
Patients exhibit the signs and symptoms of pulmonary compared with traditional tidal volumes for acute lung injury
oedema, though features of the underlying condition and the acute respiratory distress syndrome. N Eng J Med
may influence the picture. 2000; 342: 1301-8.

Management consists of treating the underlying 4. Gattinoni L, Tognoni G, Pesenti A, et al. Effect of prone
condition, providing support for failing systems and positioning on the survival of patients with acute respiratory
failure. N Eng J Med 2001; 345: 568-73
early invasive ventilation. Limiting the Fi02 may help

ASSESSMENT OF SPINAL ANAESTHETIC BLOCK

Graham Hocking, Sir Charles Gairdner Hospital, Perth, Western Australia.

Spinal anaesthesia has the advantage that profound the theca, is impractical. Indirect indicators of spread
nerve block can be produced in a large part of the are used based on tests of neurological response.
body by the relatively simple injection of a small Some indicator of the degree and extent of nerve
amount of local anaesthetic. The practical technique block is needed before surgery can start.
has been described previously so will not be covered
again in this article [see Update 12]. However, Before moving on, think about what methods
the greatest challenge in spinal anaesthesia is to you know to test the extent of spinal anaesthetic
control the spread of local anaesthetic through block?
the cerebrospinal fluid (CSF) to provide a block What types of nerves are you studying for each
which is adequate for the proposed surgery without test you can think of?
unnecessary extensive spread, and increased risk of
complications. This article will cover the assessment
Many methods may be used to test a block, but
of spinal anaesthetic block. In an article in Update 23
they fall broadly into one of two groups: assessment
the factors that influence how the local anaesthetic
of either afferent (sensory), or efferent (motor or
spreads within the CSF, determining the extent of the
autonomic) function.
block, will be covered. Learning will be improved if
you try to answer the questions posed throughout the Afferent function
text before continuing on to the next section. Pinprick and cold are most commonly used, but
mechanical stimuli such as touch, skin pinch,
Introduction
pressure and gas jets can be used. Generally, loss
Studies of drug distribution usually involve
of sensation to cold occurs before pinprick, and both
measurements of concentration in a relevant body
of these before touch, each stage correlating with
fluid compartment over time. However, multiple
inhibition of C, Aδ and Aβ fibres respectively. Thus,
sampling of CSF at one level, let alone at the several
temperature perception is lost before pinprick, is
needed to build an image of drug distribution through
23
 generally at a higher level, and is usually assessed by sensation over the proposed site of surgery. This is
the application of ‘cold’ using alcohol skin prep, ice, usually reliable as anaesthetists gain confidence after
ethyl chloride, or a cold gel bag. Loss of vibration and repeated use of a technique.
proprioceptive sensation have also been used.
Cold, most commonly applied as an ethyl chloride
More definitive assessment of pain sensation has been spray, is popular, but usually defines a level of
attempted with tetanic stimulation using peripheral block above the level of ‘surgical’ anaesthesia, and
nerve stimulators, and transcutaneous electrical ethyl chloride is an atmospheric pollutant. Ice and
nerve stimulation, both of which correlate well with alcoholic skin prep may be used as alternatives.
surgical incision. Gentle pinprick has the advantages of being simple,
repeatable, reproducible and applicable. It also allows
Efferent function
discrimination between ‘sharp’ and ‘dull’ sensation
As a block extends cephalad, there is progressive
and more closely indicates the level of ‘surgical’
impairment of motor as well as sensory function. The
anaesthesia. Pinprick testing should be performed
commonest method of assessment is the modified
using a sterile needle which does not need to pierce
‘Bromage scale’.
the skin and is compared to a non-anaesthetised part
of the body (eg arm) so the patient can perceive the
Grade Definition difference?
0 No motor block I tested that the area of skin the surgeon planned to
1 Inability to raise extended cut through was numb using cold and pinprick but
leg; able to move knees the patient still got pain. Why did this happen?
and feet
Inadequacy of the test
2 Inability to raise extended An apparently “adequate” spinal may fail because the
leg and move knee; able to block has been tested using a stimulus of significantly
move feet different modality or intensity than the planned
3 Complete block of surgery. Pain during surgery can occur despite altered
motor limb sensation over the surgical site for a number of
reasons. A simple, single stimulus (e.g. pinprick, cold)
This gives no more than a crude mix of information may be blocked, but only accurately tests responses
on both the spread and degree of motor block in to that stimulus in the local area. Surgery involves
the lumbo-sacral distribution. Complete inability multiple forms of afferent stimulation and spinal cord
to straight leg raise (Bromage grade 3) implies the mechanisms may result in repeated stimuli (temporal
spinal anaesthetic block has reached the high lumbar summation), or stimuli from adjacent regions (spatial
segments and any surgery on the leg below the groin summation), evoking pain and leading to a “failed
should be able to proceed. block”. Intrathecal block is better than epidural at
inhibiting spatial summation and this partly explains
Thoracic nerve block paralyses the abdominal wall the more profound block produced. In addition,
and intercostal muscles, and can be quantified using demonstration of the segmental extent of block of
tests of pulmonary function. Although the effects are one modality does not enable accurate prediction of
proportional to height of block, they are too difficult any other. In general, however, loss of cold sensation
to test accurately to be used to identify the level is observed at a higher dermatomal level than pinprick
accurately. which in turn is higher than the level at which touch
Sympathetic block leads to cardiovascular changes. is lost, although there can be variation even in this
Hypotension and bradycardia are related to block observation.
height, but again do not accurately indicate the extent Anatomical innervation
of the block. Vasomotor responses can be used to When considering using regional anaesthesia for
detect neuronal integrity, and can be detected by surgery it is important to remember that the skin,
colour and temperature changes in the affected area muscles, bones and organs all have different nerve
but are less reliable signs and occur at a higher level supplies. Just because the area of skin a surgeon
of block, than sensory changes. cuts through is numb, does not mean that everything
underneath is anaesthetized. This arises due to the
Which of the methods described do you think you way the body develops and the spinal segmental
might be able to use on a regular basis ? level of innervation for dermatomes (skin innervation),
myotomes (muscle innervation) and organ innervation
Routine methods do not necessarily coincide. These deep sensations
Experienced clinicians may use very little formal are important to keep in mind. A good example to
testing, relying on early onset of lower limb weakness, illustrate this is when the dentist is working on your
expected cardiovascular changes and altered teeth under local anaesthesia. You can often be numb

24
for pain but the sensation of deep pressure can still often still feel something happening (sometimes felt
be very uncomfortable. This is often the sensation as pressure) although it should not be painful. A gentle
people get despite “good” superficial blocks. Either surgeon will be able to help minimize this.
the spinal anaesthesia has to be extensive enough
Operations on the lower limbs do not tend to suffer
to block the sensations from deep structures or the
from this problem in the clinical setting.
patient warned they may experience some sensation
of pressure during the procedure. The diagram gives a guide to the level of spinal
dermatomes and the level required for anaesthesia of
Can you think of an operation where this is very some of the abdominal organs.
obvious? Summary
When does checking the level of skin numbness 1. Decide on the highest level of innervation that
mislead? will need to be blocked for the proposed surgery
remembering that the underlying organs and
During caesarian section, although the skin cut peritoneum may come from higher spinal segments.
usually occurs as a low midline incision (T12/L1), 2. Check for lower limb weakness as an early indicator
the structures underneath have spinal segmental that the injection was correct. Inability to straight leg
innervations much higher. The uterus is innervated by raise suggests the block will cover at least all the
T10 and the peritoneum has innervations as high as lumbar segments.
T4. This is why a patient should ideally be numb up
as far as her nipple line (T4-5) if she is to not feel pain 3. Cold can be used but will usually demonstrate
during this operation. The same principle is true of blocked segments higher than those with surgical
other operations within the abdomen. Since peritoneal anaesthesia. Pinprick will generally be closer to the
innervation may not be completely blocked in some level of surgical anaesthesia.
patients, it is important to warn them that they will 4. To be completely happy that surgery can be
performed painlessly it is wise to ensure that the level
Diagram of Dermatones of testing to cold or pinprick is at least 2-3 segments
higher than that needed. This will provide a margin for
error and also ensure that the operative site does not
regain sensation too quickly.
Further Reading
Hocking G, Wildsmith JAW. Intrathecal drug spread. British
C2,3
Journal of Anaesthesia 2004;93:568-78
C3,4
TH2 Ankorn C, Casey WF. Spinal Anaesthesia – a practical guide
Peritoneum
TH3
2000; Update in Anaesthesia, 12: 21-34
TH4
TH5
TH6 Casey WF. Spinal Anaesthesia – a practical guide 1993;
TH7 Update in Anaesthesia, 3: 2-15
TH8

Uterus / Bladder
TH9
TH10
Before leaving this article, make sure you can answer the
TH11 questions below.
TH12

L1
Questions
L1,2 1. What types of nerves are tested by cold, pinprick
S2,3
and touch?
2. Is the sensation of cold sensation lost above or
L2,5 below the level that pain could be felt on surgical
incision?
3. What test is the best predictor of whether an area
is numb enough to be cut?
L3,4
4. Why is the anaesthesia from a spinal block more
L5, S1,2
profound than with an epidural?
5. What level of spinal segmental innervation are
the uterus, bladder, appendix and peritoneum?
L5, S1
L4,5
The answers can all be found in the text of this
S1,2
article.

25