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Regional Anesthesia

The document provides an overview of regional anesthesia, including its techniques, indications, contraindications, risks, and benefits. It details spinal and epidural anesthesia, anatomy, pharmacology of local anesthetics, and potential complications associated with these procedures. Additionally, it discusses the assessment of block, cardiovascular responses, and the use of ultrasound in regional anesthesia.

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20 views57 pages

Regional Anesthesia

The document provides an overview of regional anesthesia, including its techniques, indications, contraindications, risks, and benefits. It details spinal and epidural anesthesia, anatomy, pharmacology of local anesthetics, and potential complications associated with these procedures. Additionally, it discusses the assessment of block, cardiovascular responses, and the use of ultrasound in regional anesthesia.

Uploaded by

S S
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Regional Anaesthesia

Techniques and Complications

Lt Col Dr Sunita Panta


Associate Professor
Department of Anaesthesiology
Shree Birendra Hospital
Specific Objectives
 Describe anatomy and physiology of spinal canal,
pharmacology of local anaesthetics.
 What are the techniques of Regional anaesthesia

 What are the indications and contraindications to


regional anesthesia?
 Describe risks and benefits of Regional anaesthesia.

 Explain potential complications and corresponding


treatments associated with administration of
regional anesthetics.
REGIONAL ANESTHESIA

 Local anesthetic applied around a peripheral nerve at any


point along the length of the nerve
 Produces sympathetic, sensory and motor block depending
upon dose, concentration and volume of LA.
 Regional anesthetic techniques categorized as follows
 Central Neuraxial blocks
 Spinal and Epidural anesthesia
 Peripheral nerve blocks

Neuraxial blocks
 Corning 1898
 Widely used prior to 1940
 Stopped
 Resurgence
Spinal Anaesthesia
 Technique of inducing regional
anaesthesia by injecting a small amount
of LA into the subarachnoid space
following a lumbar puncture below the
level where spinal cord ends , thereby
blocking spinal nerve roots.
ANATOMY
Spinal Anatomy
 33 Vertebrae
 7 Cervical
 12 Thoracic
 5 Lumbar
 5 Sacral
 4 Coccygeal
Anatomy
Anatomy
 The spine double “C” curve with cervical and lumbar region.
 Structure of the vertebra:
Anatomy
 The vertebrae are joined
together by intervertebral
disc by strong ant and post
longitudinal ligaments.
Saggital Sections
 Supraspinous Ligament
 Outer most layer
 Intraspinous Ligament
 Middle layer
 Ligamentum Flavum
Spinal Meninges
 Dura Mater
 Outer most layer
 Fibrous
 Arachnoid Mater
 Middle layer
 Non-vascular
 Pia Mater
 Inner most layer
 Highly vascular
 Sub Arachnoid Space
 between the
arachnoid and pia
Spinal Cord
 Adult
 Begins: Foramen Magnum
 Ends: L1
 Newborn
 Begins: Foramen Magnum
 Ends: L3
 Terminal End: Conus Medullaris
 Filum Terminale: Anchors in sacral region
 Cauda Equina: Nerve group of lower dural sac
Epidural Space
 Space that surrounds the spinal meninges
 Potential space
 Ligamentum Flavum
 Binds epidural space posteriorly
 Widest at Level L2 (5-6mm)
 Narrowest at Level C5 (1-1.5mm)
Physiology:
 Physiologic response to central blockade is
determined by the effects of interrupting the afferent
and efferent innervation of
 somatic (sensory and motor innervation)
 Somatic blockade:
 Prevention of pain.
 Skeletal muscle relaxation.
 visceral (autonomic nervous system).
Assessment of Block

 Assessment of Blockade
 Alcohol swab
 Most sensitive initial indicator to assess loss
of temperature
 Pin prick
 Most accurate assessment of overall sensory
block
Physiology:
Cardiovascular Effects
 Blockade of Sympathetic Preganglionic Neurons
 Send signals to both arteries and veins
 Predominant action is venodilation
 Reduces:
 Venous return
 Stroke volume
 Cardiac output
 Blood pressure
 T1-T4 Blockade
 Causes unopposed vagal stimulation
 Bradycardia
 Associated with decrease venous return &
cardioaccelerator fibers blockade
Respiratory System
 Appropriate spinal blockade has little effect on
ventilation
 High Spinal
 Decrease functional residual capacity (FRC)
 Paralysis of abdominal muscles
 Intercostal muscle paralysis interferes with
coughing and clearing secretions
 Apnea is due to hypoperfusion of
respiratory center
PHARMACOLOGY
Local Anesthetics
 Esters  Amides
 Procaine  Lidocaine
  Bupivacaine
Chlorprocaine
 Ropivacaine
 Tetracaine
 Mepivacaine
 Cocaine  Etidocaine
 Prilocaine
Characteristics of Local
Anesthetic Agents
Local Anesthetics & Baricity
 Hyperbaric
 Typically prepared by mixing local with dextrose
 Flow is to most dependent area due to gravity
 Hypobaric
 Prepared by mixing local with sterile water
 Flow is to highest part of CSF column
 Isobaric
 Neutral flow that can be manipulated by
positioning
Indications and
Contra-indications
Indications
 Full stomach
 Anatomic distortions of upper airway
 TURP surgery
 Obstetric surgery
Contraindications

❏ Absolute contraindications
 patient refusal
 infection at puncture site or underlying tissues
 uncorrected hypovolemia
 coagulation abnormalities

❏ Relative contraindications
 Bacteremia
 preexisting neurological disease
 aortic/mitral valve stenosis,
 previous spinal surgery
 severe/unstable psychiatric disease or emotional instability
RISKS AND BENEFITS
Advantages
 Preserves airway
 Verbal communication with patient
 Better for patient with respiratory illness
 Excellent muscle relaxation
 Better recovery
 Postop analgesia
 Less expensive
 No atmospheric pollution
 Less cardiac complication in high risk patients
 Early return of GI function
 Less blood loss,, DVT and metabolic changes
 Alternative to GA
Disadvantages
 Discomfort
 Cardiovascular effects
 Potential for nerve damage
 Urinary retention
 Complications
Techniques
PREPARATION FOR REGIONAL
ANESTHESIA

❏ Thorough pre-op evaluation and assessment of patient


❏ Technique explained to patient
❏ IV sedation may be indicated before block
- children, apprehensive
❏ Monitoring should be as extensive as for general
anesthesia
Needles
Spinal Anesthesia

 Relatively small LA dose injected into subarachnoid


space in the dural sac surrounding the spinal cord and
nerve roots

 Anatomical landmark:
 line joining iliac crests cross L3-L4 interspace
Spinal Technique
 Midline / Paramedian Approach
 Skin
 Subcutaneous tissue
 Supraspinous ligament
 Interspinous ligament
 Ligamentum flavum
 Epidural space
 Dura mater
 Arachnoid mater
 Sub arachnoid space
Spinal Anesthesia Levels
Epidural Anesthesia
 LA deposited in epidural space
 Solutions injected here spread in all directions of the
potential space; Specific gravity of solution does not
affect spread
 Initial blockade is at the spinal roots followed by
diffusion into the subarachnoid space through the dura
 Distances from Skin to Epidural Space
 Average adult: 4-6cm
 Larger dose of LA used
Caudal Anesthesia
 Anatomy
 Sacrum
 Triangular bone
 5 fused sacral vertebrae
 Needle Insertion
 Sacrococcygeal membrane
 No subcutaneous bulge or
crepitus at site of injection
Spinal vs. Epidural Anesthesia
❏ Spinal
•Easier to perform
Smaller dose of LA required (usually < toxic IV dose)
• Rapid blockade (onset in 2-5 minutes)
• Hyperbaric LA solution - position of patient important
❏ Epidural
• Technically more difficult; greater failure rate
• Larger volume/doses of LA (usually > toxic IV dose)
• Significant blockade requires 10-15 minutes
• Slower onset of side effects
Complications
 Technique Related  Drug Related
 Headache  Local nerve toxicity
 Backache  Systemic toxicity
 Nerve Injury  High blockade
 Vascular injury
 Infection
Complications of Spinal Anaesthesia

 Backache
 Post dural puncture headache
 High/ total spinal
 Cardiac arrest
 Systemic Toxicity
 Neurological damage
 Infection
 Spinal/ EpiduralHaematoma
 Urinary Retention
 Shivering
CARDIOVASCULAR
RESPONSE
 Exaggerated Cardiovascular response
 Hypotension
 Bradycardia
Hypotension
 Treatment
 Primary Treatment
 Increase the cardiac preload
 Large IV fluid bolus within 30 minutes prior to spinal
placement, minimum 1 liter of crystalloids
 Secondary Treatment
 Pharmacologic
 Ephedrine
 Mephentermine
Bradycardia
 Especially High Spinal
 Inhibition of cadioaccelerator fibres
 Treatment:
 Inj Atropine 0.6 mg IV
Systemic Toxicity

❏ Occurs by accidental intravascular injection, LA overdose,


or unexpectedly rapid absorption
❏ Systemic toxicity manifests itself mainly at CNS and CVS
❏ CNS effects first appear to be excitatory due to initial block
of inhibitory fibres; subsequently, block of excitatory fibres
❏
Post Dural Puncture Headache
PDPH
 More common in women
 Larger needle size increase severity
 Onset typically occurs after 48 hours
 Treatment:
 Bed rest
 Fluids
 Caffeine
 Blood patch
Blood Patch

 Increase pressure of CSF by placing blood in


epidural space
 If more than one puncture site use lowest site due
to rosteral spread
 May do no more than two
 95% success with first patch
 Second patch may be done 24 hours after first
❏ Epidural anesthesia
 Failure of technique
 Cardiovascular effects
 Systemic toxicity of LA
 Accidental subarachnoid injection leading to total
spinal anesthesia
 Catheter complications (shearing, kinking, vascular
or subarachnoid placement)
 Epidural or subarachnoid hematoma
PERIPHERAL NERVE
BLOCKS
Blocks
Brachial Plexus
 Musculocutaneous
Nerve

 Median Nerve

 Ulnar Nerve

 Radial Nerve
Ankle Block
 Blockade of 5 Nerves
 Tibial nerve
 Largest
 Heal & medial side sole of foot
 Superficial perineal nerve
 Branch of common perineal
 Dorsal (top) portion of foot
 Saphenous nerve
 Branch of femoral nerve
 Medial side of leg, ankle, & foot
 Sural nerve
 Branch of posterior tibial nerve
 Posterior lateral half of calf, lateral side of foot, & 5 th toe
 Deep perineal nerve
 Continuation of common perineal nerve
Ankle Block
Ultrasound in regional anaesthesia

 Decrease the time taken to perform a block


 Lower the dose of local anaesthetic required for a
block
 Avoidance of an intraneural injection
 Confirmation of local anaesthetic spread
 Confirmation of catheter placement.
THANK YOU

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