Regional and Local

anesthesia
Dr Salma Almusaed
Knowledge of anatomy for neuraxial
blockade is essential!

▪ 7 cervical vertebrae
▪ 12 thoracic vertebrae
▪ 5 lumbar vertebrae
▪ Sacrum
▪ Coccyx
Locating prominent cervical and thoracic
vertebrae (Landmarks) We jwiosiswi.si
o C2: First palpable vertebra
Located just below the occiput; known as the axis

o C7: Most prominent cervical vertebra

Easily felt at the base of the neck; known as the vertebra prominins

o T7: Corresponds with the tip of the scapula

When the patient’s arms are at their sides, the inferior angle of the scapula generally aligns
with the T7 spinous process

24 ilae crest
v41 o d 245
 Vertebral Anatomy
▪ Each vertebra consists of the following
structures:

o Pedicle
o Transverse process
o Articular facet (synovial joints )
o Spinous process
 Vertebral Anatomy

▪ Spinal Nerve Exit:

o Form the intervertebral foramina, through

which spinal nerve roots exit the vertebral
column.
▪ Intervertebral Discs:

o Vertebrae are connected to one

another by intervertebral discs,
which provide cushioning and
flexibility to the spine.
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Termination of Spinal Cord
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o In adults : at L1.
o Infants: at L3
o Safe level for spinal anesthesia : below L2.

second lumbar
Interlaminar spaces are larger in the
lower lumbar region.

Yank
If an anesthesia provider finds it
challenging at one level it is important to
remember that moving down one space
may provide a larger space.
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acording
typ of syngr
 Membranes that surround the spinal cord
Brain
▪ Pia mater
highly vascular, covers the spinal cord
and brain.

▪ Arachnoid mater
non vascular, barrier to the migration of
medications in and out of the CSF.

▪ Dura mater
Extends to S2.
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spinal A
 Epidural Space Anatomy
▪ Extends from the foramen magnum to the sacral hiatus

▪ Surrounds the dura mater anteriorly, laterally, and most importantly

to us posteriorly.

I
 Ligamentum Flavum
▪ Posterior to the epidural space

▪ The distance from the skin to the epidural space typically ranges from 3 to 8 cm.

▪ Thickness of the ligamentum flavum in the thoracic area it can range from 3-5 mm
and in the lumbar it can range from 5-6 mm.

✓ These measurements for guiding epidural needle placement and avoiding

complications.
EW X2
 Indication For Epidural Anesthesia
• Injection Levels: Can be performed at lumbar, thoracic, or cervical spine levels.

• Uses:
❑ Operative anesthesia
❑ Obstetric analgesia (e.g., during labor)
❑ Postoperative pain control
❑ Chronic pain management
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Spinal anesthesia :
• Spinal anesthesia : archnoid
sup
Definition: Injection into the CSF at the level below ( L2 ) ,where the spinal cord
ends.
Is GOLT
spinalcord11

• Indication:
❑ Surgeries below the umbilicus:
hernia repairs, gynaecological, urological operation, orthopedics, Any operation on
the perineum or genitalia.
Contraindications spinal & epidural anesthesia

1. Refusal
2. Infection
3. Coagulopathy & anticoagulated patient
4. Hypotension / hypovolemia
5. Increased intracranial pressure
6. Severe aortic or mitral stenosis
7. Known allergy to opioid or local anesthetic
 spinalneedle

F of
Spinal needles type

cutting tip, higher

PDPH risk

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Palpation of Spinous Process
Csf

spinal
 Medications commonly used

▪ Opioid
Fentanyl +Morphine
(affect the pain transmission at the opioid receptors)

▪ L.A
Bupivacaine (marcaine)
(inhibits the pain impulse transmission in the nerves)
 I iI Isi jdllsslb.is w Partal Block
II I complete
Sensory assessment iris 21cg
• Use cold ice cube method

Motor assessment (Bromage Score)

• Commonly used in epidural and spinal anesthesia to:
• Monitor block effectivenes
 Complications

▪ Failed block
▪ Back pain
▪ Tomatecause
Post Dural puncture headache (PDPH)
▪ Epidural hematoma or abscess
▪
▪
Meningitis
Neurological deficit c
▪ Bradycardia--- Cardiac arrest

hypotention
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22 24 sale PDPH
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▪ Develop 12-48 hours after spinal anesthesia.
▪ Larger needle size increase severity
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Fswords
▪ Headache worse upright, improve when lying supine.

▪ Treatment:

1. Bed rest
2. Fluids
3. Caffeine
4. Epidural Blood patch

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of headach
 Hypotension

Primary Treatment:
•Increase Cardiac Preload
• Give additional IV fluids rapidly
• or uterine displacement (in pregnant patients)

Secondary Treatment (Pharmacologic):

•Vasopressors to increase blood pressure:
• Ephedrine (mixed alpha and beta agonist) — increases heart rate and cardiac output
• Phenylephrine (pure alpha agonist) — used when bradycardia is not an issue
Local anesthetics
 Mechanism of action
Block sodium (Na⁺) channels to prevent nerve depolarization, stopping pain signals.

Lipid Solubility:
→ Determines potency (more soluble = more potent).
→ Plasma protein binding affects duration of action (more binding = longer effect).
Added to local anesthetics to prolong effect

Vasoconstrictor (e.g., epinephrine) Added:

Prolongs anesthetic effect
Reduces risk of systemic toxicity
Minimizes bleeding during surgery
 Esters: Increase risk for allergic reaction due to paraaminobenzoic acid
produced through ester-hydralysis

Amides: Greater risk of plasma toxicity due to slower metabolism in liver

commonest
drugused
is
 Applications of local anesthesia
• Nerve block: (e.g., dental and other minor surgical procedures)

• Topical application: To skin for analgesia (e.g., benzocaine) or mucous

membranes (for diagnostic procedures)

• Spinal & epidural anesthesia

• Local infiltration: At end of surgery to produce long-lasting post-surgical analgesia

(reduces need for narcotics)

• I/V infusion: For control of cardiac arrhythmias (e.g., lidocaine for ventricular
arrhythmias)
LIDOCAINE: The most commonly used amide type local anesthetic.
• Rapid onset and a duration of 60-75 minutes, extended with epinephrine for up to 2 hours.
• Metabolized in the liver and excreted by the kidneys.
• Contraindicated in patients with a known sensitivity.
• Has also antiarrhythmic action.

BUPIVACAINE:
• Onset of action is slower than lidocaine and anesthesia is long acting - 2-4 hours, extended with
epinephrine for up to 7 hours.
• More cardio-toxic than lidocaine and ropivacine and difficult to treat.
• Metabolized in the liver and excreted by the kidneys
• Contraindication: known hypersensitivity
 ¾
ROPIVACAINE 15 -
③ :
• Less toxic, long-lasting LA.
• Undergoes extensive hepatic metabolism, with only 1% of the drug eliminated unchanged in the
urine.
• Ropivacaine is slightly less potent than bupivacaine.
 JÉ
Local Anesthetic Toxicity
▪ Exceeding the maximum save dose
( Bupivacaine 2mg/kg),
Lidocaine (5mg/kg).

▪ Intravascular injection
 LAST (CNS)

▪ Initially:
circumoral numbness dizziness, tinnitus,visual change.

▪ Later:
drowsiness, disorientation, slurred speech, loss of consciousness, convulsions &
finally respiratory depression
 LAST (CVS)

▪ Tachycardia & Hypertension

▪ Hypotension
▪ Wide QRS
▪ VF
▪ Cardiac arrest
 Treatment of
toxicity
• Call for help
• Stop giving the local anesthetic
• Keep the airway open and give oxygen
• Get IV access
• Control seizures (use benzodiazepines) fast
• Start IV lipid emulsion maintreatment
• Dysrhythmias: As per ACLS protocol
THANK YOU