Spinal Anasethesia

Spinal Anesthesia (SUBARACHNOID BLOCK)
It is one of the easiest and most reliable techniques of regional anesthesia. The
very small doses of local anesthetics used to produce spinal anesthesia are
devoid of direct systemic effects. In 1885 James Corning, an American
neurologist, was the first person to use cocaine intrathecally to treat some
neurological conditions. Augustus Bier, a German surgeon, was the first person
to use intrathecal cocaine to produce surgical anesthesia. In a classic paper
published in 1899, he described the failed attempt by his assistant Hildebrandt,
to perform a spinal anesthesia on him, and his successful spinal on Hildebrandt.
Both of them became the first patients suffering from post Dural puncture
headaches.
INDICATIONS
1. SAB is suitable for most surgical procedures below the level of the
umbilicus (T 10).
2. Typical operations include perineal surgery, abdominal gynaecological
procedures, prostatectomy, caesarean section and hernia repairs. Most hip and
knee joint replacements are performed under SAB.
3. Patients may choose to remain awake but light sedation is usually less
stressful for all concerned.
4. SAB is particularly suitable for elderly patients –especially those
suffering from cardiovascular and respiratory disease.
5. These patients tend to be less confused post operatively.
6. SAB is ideal for patients suffering from renal, hepatic and metabolic
disease (eg diabetes).
7. It is clearly better for mother and baby in obstetric anaesthesia.
8. SAB is a good choice when called upon to provide emergency anaesthesia
for lower limb surgery i
CONTRAINDICATIONS
These can be divided into absolute and relative contraindications:

2. Absolute
· Patient refusal
· Sepsis at site of lumbar puncture
· Coagulopathies or patients on anticoagulants.
2. Relative
· Hypovolaemia
· Aortic stenosis
· Septicaemia
· Raised intracranial pressure
· infants and young childern (experience)
· peripheral neuropathy
EQUIPMENT and Spinal tr ay:

· spinal needle( sized from 16 –30 gauge)
· 5ml syringe for the spinal anaesthetic solution.
· 2 ml syringe for local anaesthetic to be used for skin infiltration.
· selection of needles for drawing up the local anaesthetic solutions and
for infiltrating the skin.
· gallipots with a suitable antiseptic for cleaning the skin, eg chlorhexidine,
iodine, or methyl alcohol.
· Sterile gauze swabs for skin cleansing.
· . sticking plaster to cover the puncture site.
· The local anaesthetic to be injected intrathecally should be in a single use
ampoule. Never use local anesthetic from a multi-dose vial for
intrathecal injection.
· Sterile gloves.
· Other equipment:
1. 16 or 18 G intravenous cannula + intravenous fluid infusion.
2. Monitors (Pulse oximetry, ECG, BP).
3. Oxygen via mask or nasalprongs.
TECHNIQUE
Positioning the Patie nt:
Lumbar puncture for SAB may be performed with the patient sitting or in the lateral decubitus
position. If it is anticipated that lumbar puncture may be difficult, the midline is usually more
discernible with the patient in the sitting position, but the risk of hypotension in the sedated
patient or following development of the block is increased.
Te chnique of Lumbar Punctur e :
For the right-handed anaesthetist, the patient is positioned on the operating table in the left lat
eral position. The patient’ s back should lie along the edge of the table and must be vertical. A
curled position opens the spaces between the lumbar spinous processes. An assistant stands
in front of the patient to assist with positioning and to reassure the patient. The anaesthetist
must inform the patient before performing each part of the procedure. A line between the
iliac crests lies on the fourth lumbar spinous process; lumbar puncture should be performed
at the L3/ 4 or L4/ 5 space. A fullsterile technique (with gown, gloves and surgical drapes) is
adopted. All drugs should be drawn into syringes directly from sterile ampoules using a filter
needle to prevent the injection of glass particles into the subarachnoid space. A selection of
spinal needles ( 22–27 gauge) should be available. The skin and subcutaneous tissues are
infiltrated
with local anaesthetic using a smallneedle. The spinal needle is inserted in the midline, midway
between two spinous processes. In the well-positioned patient, the needle is directed at right
angles to the skin. Passage through the interspinous ligament and ligamentum flavum into the
spinal canal is appreciated easily with a 22-gauge needle, but these needles are now rarely
used because of the high incidence of postdural puncture headache. With some practice, these
structures are usually discernible with a 25G or 27G pencil-point needle, which all anaesthetists
should aspire to use. The use of an introducer (19-gauge needle) is advisable to brace the
smaller needles, which are
very flexible. When the needle tip has entered the spinal canal, the stilette is withdrawn from th
e needle and the hub is observed for flow of CSF; a needle with a transparent hub makes this
easier. A gentle aspiration test should be performed if a free flow of CSF is not observed, or
the needle carefully rotated through 90°. The three most common reasons for difficulty are
poor patient positioning, failure to insert the needle in the midline and directing the needle
laterally. When CSF is obtained, the syringe containing the local anaesthetic solution should be
carefully attached firmly to the needle, taking care not to displace the needle. Gentle aspiration
confirms the needle position and the solution is injected at a rate of 1 mL every 5–10 s.
Aspiration after injection confirms that the needle tip has remained in the correct place. Needle
and introducer are withdrawn together and the patient placed supine.
Factor s Affe cting Spr e ad

· The baricity of the local anaesthetic solution
· position
· Dosage , concentration
· volume injected
· the level of injection
· Speed of injection
· Abdominal pressure.
Complications:
1.Immediate complications :
- hypotension
- total spinalblock
- systemic toxicity
2.Late complications :
- post dural puncture headache (PDPH).
- Cranial nerve palsy.
- focal neurologicaldeficit .
- bacterial meningitis .
- Risk of heamtoma(clotting defects)…......
- Neurologicalinjury(cauda equina)…………….
- Urine retension
- Nausea and vomiting
- Shivering
v Treatment of spinal Hypotension:

Hypotension is due to vasodilatation and a functional decrease in the effective circulating
volume.
1.vasoconstrictor drugs:
· Ephedrine: 2.5-6mg titrated against the blood pressure. Its effect
generally lasts about 10 minutes and it may need repeating.
It can also be given intramuscularly but its onset time is delayed although its
duration is prolonged..
· Phenylephrine.
· Noradrenaline
· Adrenaline/Epinephrine.
2.All hypotensive patients should be given OXYGEN by mask until the blood
pressure is restored.
3. raising their legs thus increasing the return of venous blood to the heart.
spinal anaesthetic has been injected in the preceding 15 minutes as it will result
in the block spreading higher and the hypotension becoming more severe.
4.Increase the speed of the intravenous infusion to maximum until the blood
pressure is restored to acceptable levels .
5. pulse is slow, give atropine intravenously.
v Post Dural puncture headache ( PDPH):

A characteristic headache may occur following spinal anaesthesia. It begins
within 24-72 hours and may last a week or more . It is postural, being made
worse by standing or even raising the head and relieved by lying down. It is
often occipital and may be associated with a stiff neck. Nausea, vomiting,
dizziness and photophobia frequently accompany it. It is more common in the
young, in females and especially in obstetric patients.It is thought to be caused
by the continuing loss of CSF through the hole made in the dura by the spinal
needle. This results in traction on the meninges and pain.
The incidence of headache is related directly to the size of the needle used. A
16 gauge needle will cause headache in about 75% of patients, a 20 gauge
needle in about 15% and a 25 gauge needle in 1-3% . As the fibers of the dura
run parallel to the long axis of the spine, if the bevel of the needle is parallel to
them, it will part rather than cut them and therefore, leave a smaller hole.
v Treatment of post spinal headache:

.
1. Remain lying flat in bed as this relieves the pain.
2. They should be encouraged to drink freely or, if necessary, be given
intravenous fluids to maintain adequate hydration.
3. Simple analgesics such as paracetamol, aspirin or codeine may be helpful,
4. Increased intra-abdominal and hence epidural pressure. (Abdominal
binder).
5. Caffeine containing drinks such as tea, coffee or Coca-Cola are often helpful.
6. Prolonged or severe headaches may be treated with epidural blood patch
performed by aseptically injecting 15-20ml of the patient's own blood into the
epidural space. This then clots and seals the hole and prevents further leakage
of CSF.
7. It used to be thought that bedrest for 24 hours following a spinal anaesthetic
would help reduce the incidence of headache, but this is now no longer
believed to be the case.

Spinal Anasethesia

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Spinal Anesthesia (SUBARACHNOID BLOCK)

These can be divided into absolute and relative contraindications:

EQUIPMENT and Spinal tr ay:

Te chnique of Lumbar Punctur e :

Factor s Affe cting Spr e ad

v Treatment of spinal Hypotension:

v Post Dural puncture headache ( PDPH):

v Treatment of post spinal headache:

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