2 Update in Anaesthesia

on patient condition, type of operation proposed, spinal anaesthesia. How to attain this requisite level
and the quiet self-confidence that comes with of skill and art is neatly described in this update on
experience using the champagne of anaesthetics: the subject. Read it and believe it.

SPINAL ANAESTHESIA - A Practical Guide Bleeding. Blood loss during operation is less than
when the same operation is done under general
Dr Chris Ankcorn, Lecturer in Anaesthesia, Kumasi, anaesthesia. This is as a result of a decreased blood
Ghana pressure and heart rate, and improved venous
Dr William F Casey FRCA, Consultant Anaesthetist, drainage which results in less oozing.
Gloucestershire Royal Hospital, Gloucester, UK Splanchnic blood flow. Because of its effect on
Spinal anaesthesia is induced by injecting small increasing blood flow to the gut, spinal anaesthesia
amounts of local anaesthetic into the cerebro-spinal reduces the incidence of anastomotic dehiscence.
fluid (CSF). The injection is usually made in the Visceral tone. The bowel is contracted by spinal
lumbar spine below the level at which the spinal anaesthesia and sphincters relaxed although
cord ends (L2). Spinal anaesthesia is easy to perform peristalsis continues. Normal gut function rapidly
and has the potential to provide excellent operating returns following surgery.
conditions for surgery below the umbilicus.
Coagulation. Post-operative deep vein thromboses
If the anaesthetist has an adequate knowledge of and pulmonary emboli are less common following
the relevant anatomy, physiology and spinal anaesthesia.
pharmacology, safe and satisfactory anaesthesia
can easily be obtained to the mutual satisfaction of Disadvantages of Spinal Anaesthesia
the patient, surgeon and anaesthetist. 1. When an anaesthetist is learning a new technique,
The Advantages of Spinal Anaesthesia it will take longer to perform than when he is more
practised, and it would be wise to let the surgeon
Cost. Anaesthetic drugs and gases are costly and know that induction of anaesthesia may be longer
the latter often difficult to transport. The costs than usual. Once competent, however, spinal
associated with spinal anaesthesia are minimal. anaesthesia can be very swiftly performed.
Patient satisfaction. If a spinal anaesthetic and the 2. Occasionally, it is impossible to locate the dural
ensuing surgery are performed skillfully, the space and obtain CSF and the technique has to be
majority of patients are very happy with the abandoned. Rarely, despite an apparently faultless
technique and appreciate the rapid recovery and technique, anaesthesia is not obtained.
absence of side-effects.
3. Hypotension may occur with higher blocks and
Respiratory disease. Spinal anaesthesia produces the anaesthetist must know how to manage this
few adverse effects on the respiratory system as situationsituation with the necessary resuscitative
long as unduly high blocks are avoided. drugs and equipment immediately to hand. As with
Patent airway. As control of the airway is not general anaesthesia, continuous, close monitoring
compromised, there is a reduced risk of airway of the patient is mandatory.
obstruction or the aspiration of gastric contents. 4. Some patients are not psychologically suited to
This advantage may be lost with too much sedation. be awake, even if sedated, during an operation.
Diabetic patients. There is little risk of They should be identified during the preoperative
unrecognised hypoglycaemia in an awake patient. assessment.
Diabetic patients can usually return to their normal
5. Even if a long-acting local anaesthetic is used, a
food and insulin regime soon after surgery as there
spinal is not suitable for surgery lasting longer than
is less sedation, nausea and vomiting.
approximately 2 hours. If an operation unexpectedly
Muscle relaxation. Spinal anaesthesia provides lasts longer than this, it may be necessary to convert
excellent muscle relaxation for lower abdominal to a general anaesthetic.
and lower limb surgery.
Update in Anaesthesia 3

6. There is a theoretical risk of introducing infec- Clotting disorders. If bleeding occurs into the
tion into the subarachnoid space and causing men- epidural space because an epidural vein has been
ingitis. This should never happen if equipment is punctured by the spinal needle, a haematoma could
sterilised properly and an aseptic technique is used. form and compress the spinal cord. Patients with a
7. A postural headache may occur postoperatively. low platelet count or receiving anticoagulant drugs
This should be rare: see later. such as heparin or warfarin are at risk. Remember
that patients with liver disease may have abnormal
Indications for Spinal Anaesthesia clotting profiles whilst low platelet counts as well
Spinal anaesthesia is best reserved for operations as abnormal clotting can occur in pre-eclampsia.
below the umbilicus e.g. hernia repairs, gynaeco- Hypovolaemia from whatever cause e.g. bleeding,
logical and urological operations and any operation dehydration due to vomiting, diarrhoea or bowel
on the perineum or genitalia. All operations on the obstruction. Patients must be adequately rehydrated
leg are possible, but an amputation, though pain- or resuscitated before spinal anaesthesia or they
less, may be an unpleasant experience for an awake will become very hypotensive.
patient. In this situation it may be kinder to supple-
ment the spinal with generous sedation or a light Any sepsis on the back near the site of lumbar
general anaesthetic. puncture.

Spinal anaesthesia is especially indicated for older Patient refusal. Patients may be understandably
patients and those with systemic disease such as apprehensive and initially state a preference for
chronic respiratory disease, hepatic, renal and en- general anaesthesia, but if the advantages of spinal
docrine disorders such as diabetes. Most patients anaesthesia are explained they may then agree to
with mild cardiac disease benefit from the the procedure and be pleasantly surprised at the
vasodilation that accompanies spinal anaesthesia outcome. If, despite adequate explanation, the
except those with stenotic valvular disease or un- patient still refuses spinal anaesthesia, their wishes
controlled hypertension. should be respected.

It is suitable for managing patients with trauma if Uncooperative patients. Although spinal
they have been adequately resuscitated and are not anaesthesia is suitable for children, their cooperation
hypovolaemic. In obstetrics, it is ideal for manual is necessary and this must be carefully assessed at
removal of a retained placenta (again, provided the pre-operative visit. Likewise, mentally
there is no hypovolaemia). There are definite advan- handicapped patients and those with psychiatric
tages for both mother and baby in using spinal problems need careful pre-operative assessment.
anaesthesia for Caesarean section. However, spe- Septicaemia. Due to the presence of infection in
cial considerations apply to managing spinal an- the blood there is a possiblity of such patients
aesthesia in pregnant patients (see later) and it is developing meningitis if a haematoma forms at the
best to become experienced in its use in the non- site of lumbar puncture and becomes infected.
pregnant patient before using it for obstetrics. Anatomical deformities of the patient’s back.
Contra-indications to Spinal Anaesthesia This is a relative contraindication, as it will probably
Most of the contra-indications to spinal anaesthesia only serve to make the dural puncture more difficult.
apply equally to other forms of regional anaesthe- Neurological disease. The advantages and
sia. These include: disadvantages of spinal anaesthesia in the presence
Inadequate resuscitative drugs and equipment. of neurological disease need careful assessment.
No regional anaesthetic technique should be at- Any worsening of the disease postoperatively may
tempted if drugs and equipment for resuscitation be blamed erroneously on the spinal anaesthetic.
are not immediately to hand. Raised intracranial pressure, however, is an absolute
contra-indication as a dural puncture may precipitate
coning of the brain stem.
4 Update in Anaesthesia

Reluctant surgeon. If a surgeon is unhappy Anatomy

operating on an awake patient or if he is relatively The spinal cord usually ends at the level of L2 in
unskilled, spinal anaesthesia may be better avoided. adults and L3 in children. Dural puncture above
Physiology of Spinal Anaesthesia these levels is associated with a slight risk of
Local anaesthetic solution injected into the damaging the spinal cord and is best avoided. An
subarachnoid space blocks conduction of impulses important landmark to remember is that a line
along all nerves with which it comes in contact, joining the top of the iliac crests is at L4 to L4/
although some nerves are more easily blocked than 5
others. Remember the structures that the needle will pierce
There are three classes of nerve: motor, sensory and before reaching the CSF (fig 1.).
autonomic. The motor convey messages for muscles The skin. It is wise to inject a small bleb of local
to contract and when they are blocked, muscle anaesthetic into the skin before inserting the spinal
paralysis results. Sensory nerves transmit sensations needle.
such as touch and pain to the spinal cord and from Subcutaneous fat. This, of course, is of variable
there to the brain, whilst autonomic nerves control thickness. Identifying the intervertebral spaces is
the calibre of blood vessels, heart rate, gut far easier in thin patients.
contraction and other functions not under conscious
control. The supraspinous ligament which joins the tips of
the spinous processes together.
Generally, autonomic and pain fibres are blocked
first and motor fibres last. This has several important The interspinous ligament which is a thin flat
consequences. For example, vasodilation and a band of ligament running between the spinous
drop in blood pressure may occur when the processes.
autonomic fibres are blocked and the patient may The ligamentum flavum is quite thick, up to about
be aware of touch and yet feel no pain when surgery 1cm in the middle and is mostly composed of
starts. elastic tissue. It runs vertically from lamina to
There are practical implications associated with lamina. When the needle is within the ligaments it
these physiological phenomena. will feel gripped and a distinct "give" can often be
felt as it passes through and into the epidural space.
- The patient should be well hydrated before the
local anaesthetic is injected and should have an The epidural space contains fat and blood vessels.
intravenous infusion in place so that further fluids If blood comes out of the spinal needle instead of
or vasoconstrictors can be given if hypotension CSF when the stylet is removed, it is likely that an
occurs. epidural vein has been punctured. The needle should
simply be advanced a little further.
- The site to be operated on should not be repeatedly
touched and the patient asked "Can you feel this?" The dura. After feeling a "give" as the needle
as this increases the patient’s anxiety. Often some passes through the ligamentum flavum, a similar
sensation of touch or movement remains and yet sensation may be felt when the needle is advanced
no pain is felt. It is better to pinch the skin gently a short distance further and pierces the dural sac.
either with artery forceps or fingers and ask if it is The subarachnoid space. This contains the spinal
painful. If it is not then surgery can begin. cord and nerve roots surrounded by CSF. An
injection of local anaesthetic will mix with the CSF
and rapidly block the nerve roots with which it
comes in contact.
Update in Anaesthesia 5

action. Lignocaine from multi-dose vials should

Ligamentum not be used for intrathecal injection as it contains
flavum potentially harmful preservatives.
Intervertebral disc
Superficial tissues Cinchocaine (Nupercaine, Dibucaine, Percaine,
Sovcaine). 0.5% hyperbaric (heavy) solution is
similar to bupivacaine.
Amethocaine (Tetracaine, Pantocaine, Pontocaine,
Decicain, Butethanol, Anethaine, Dikain). A 1%
solution can be prepared with dextrose, saline or
water for injection.
Mepivacaine (Scandicaine, Carbocaine,
Meaverin). A 4% hyperbaric (heavy) solution is
Ant. long.
similar to lignocaine.
ligament Spinal Anaesthesia and Common Medical
Supraspinous Post. long.
ligament ligament Vertebral body Conditions
Interspinous
ligament
Respiratory Disease. A low spinal block has no
effect on the respiratory system and is therefore
Figure 1. Section of lumbar vertebrae to show the ideal for patients with respiratory disease unless
ligaments.
they cough a lot. Frequent coughing results in less
than ideal conditions for the surgeon. A high spinal
block can produce intercostal muscle paralysis, but
Local Anaesthetics for Spinal Anaesthesia this does not usually create any problems, unless
Local anaesthetic agents are either heavier the patient is very limited by his respiratory disease.
(hyperbaric), lighter (hypobaric), or have the same Hypertension. Hypertension is not a contra-
specific gravity (isobaric) as the CSF. Hyperbaric indication to spinal anaesthesia but, ideally, it should
solutions tend to spread below the level of the be controlled before any anaesthetic is administered.
injection, while isobaric solutions are not influenced Hypertensive patients should have their blood
in this way. It is easier to predict the spread of spinal pressure closely monitored during the anaesthetic
anaesthesia when using a hyperbaric agent. Isobaric and any episode of hypotension vigorously treated.
preparations may be made hyperbaric by the addition
of dextrose. Hypobaric agents are not generally Sickle cell disease/trait. Spinal anaesthesia may
available. The other factors affecting the spread of be advantageous for patients with sickle cell disease.
local anaesthetic agents when used for spinal blocks Follow the same rules as for general anaesthesia:
are described later. ensure that the patient is well oxygenated, well
hydrated and not allowed to become hypotensive.
Bupivacaine (Marcaine). 0.5% hyperbaric (heavy) Consider warming the intravenous fluids and do
bupivacaine is the best agent to use if it is available. not allow the patient to become cold. Avoid the use
0.5% plain bupivacaine is also popular. Bupivacaine of tourniquets.
lasts longer than most other spinal anaesthetics:
usually 2-3 hours. Pre-operative Visit
Lignocaine (Lidocaine/Xylocaine). Best results Patients should be told about their anaesthetic during
are obtained with 5% hyperbaric (heavy) lignocaine the pre-operative visit. It is important to explain
which lasts 45-90 minutes. 2% lignocaine can also that although spinal anaesthesia abolishes pain,
be used but it has a much shorter duration of action. they may be aware of some sensation in the relevant
If 0.2ml of adrenaline 1:1000 is added to the area, but it will not be uncomfortable and is quite
lignocaine, it will usefully prolong its duration of normal. It should also be explained that their legs
6 Update in Anaesthesia

will become weak or feel as if they don’t belong to

them any more. They must be reassured that, if they
feel pain they will be given a general anaesthetic.
Premedication is not always necessary, but if a
patient is apprehensive, a benzodiazepine such as
5-10 mg of diazepam may be given orally 1 hour
before the operation. Other sedative or narcotic
agents may also be used. Anticholinergics such as
atropine or scopolamine (hyoscine) are unnecessary.
Pre-loading
All patients having spinal anaesthesia must have a
large intravenous cannula inserted and be given Extension
intravenous fluids immediately before the spinal.
The volume of fluid given will vary with the age of Figure 2. Effect of flexion and extension on the lumbar
the patient and the extent of the proposed block. A intervertebral space in the lumbar region.
young, fit man having a hernia repair may only This can best be achieved by sitting the patient on
need 500 mls. Older patients are not able to the operating table and placing their feet on a stool.
compensate as efficiently as the young for spinal- If they then rest their forearms on their thighs, they
induced vasodilation and hypotension and may can maintain a stable and comfortable position.
need 1000mls for a similar procedure. If a high
block is planned, at least a 1000mls should be given
to all patients. Caesarean section patients need at
least 1500 mls.
The fluid should preferably be normal saline or
Hartmann’s solution. 5% dextrose is readily
metabolised and so is not effective in maintaining Crest
the blood pressure. L3 of
L4 ileum
Positioning the Patient for Lumbar Puncture L5
Lumbar puncture is most easily performed when
there is maximum flexion of the lumbar spine.

Figure 3. Ideal sitting position for spinal anaesthesia.

Alternatively, the procedure can be performed with
the patient lying on their side with their hips and
knees maximally flexed. An assistant may help to
maintain the patient in a comfortable curled position.
The sitting position is preferable in the obese
whereas the lateral is better for uncooperative or
sedated patients. The anaesthetist can either sit or
kneel whilst performing the block.

Flexion
Update in Anaesthesia 7

Factors Effecting the Spread of the Local Knees drawn up to chest

Anaesthetic Solution Hips vertical

A number of factors effect the spread of the injected

local anaesthetic solution within the CSF and the
ultimate extent of the block obtained. Among these
are:
- the baricity of the local anaesthetic solution
- the position of the patient Back in flexion
at edge of table Shoulders vertical
- the concentration and volume injected
- the level of injection Female
- the speed of injection
The specific gravity of the local anaesthetic solution
can be altered by the addition of dextrose.
Concentrations of 7.5% dextrose make the local
anaesthetic hyperbaric (heavy) relative to CSF and
Male
also reduce the rate at which it diffuses and mixes
with the CSF. Isobaric and hyperbaric solutions
both produce reliable blocks. The most controllable
blocks are probably produced by injecting
hyperbaric solutions and then altering the patient’s
position.
Figure 4. Note how the level of the subarachnoid space
If a patient is kept sitting for several minutes after varies between male and female
the injection of a small volume of a hyperbaric Although the level of injection will obviously effect
solution of local anaesthetic, a classical saddle which dermatomes are blocked, spinal injections
block of the perineum will result. The spinal column tend to be performed only in the lower lumbar
of patients lying on their side is rarely truly region. The extent of the block is influenced more
horizontal. Males tend to have wider shoulders by the volume injected and the position of the
than hips and so are in a slight "head up" position patient than the actual interspace at which the
when lying on their sides, whilst for females with injection occurs.
their wider hips, the opposite is true. Regardless of
the position of the patient at the time of injection The speed of injection has a slight effect on the
and whatever the initial extent of the block obtained, eventual extent of the block. Slow injections result
the level of the block may change if the patient’s in a more predictable spread while rapid injections
position is altered within twenty minutes of the produce eddy currents within the CSF and a
injection. somewhat less predictable outcome.

The quantity of local anaesthetic (in milligrams) Finally, increased abdominal pressure from
injected will determine the quality of the block whatever cause (pregnancy, ascites etc) can lead to
obtained whilst its extent will also be determined engorgement of the epidural veins, compression of
by the volume in which it is injected. Large volumes the dura and hence a reduction in the volume of the
of concentrated solutions will, thus, produce dense CSF. A given quantity of local anaesthetic injected
blockade over a large area. into the CSF might then be expected to produce a
more extensive block.
8 Update in Anaesthesia

Quantities of Local Anaesthetics to Use Table 2.

The degree of spinal blockade needed, as measured
by the height of the block, will depend on the Type of block Hyperbaric Plain Hyperbaric
operation to be performed. Bupivacaine Bupivacaine Lignocaine

Saddle block, 2ml 3ml 1ml

eg operations
Table 1. on genitalia,
perineum
Level Surgical Procedure
Lumbar block, 3-3.5ml 3-3.5ml 2ml
T4-5 (Nipple) Upper abdominal surgery eg operations
T6-8 (Xiphisternum) Lower abdominal surgery incl. on legs
caesarean section, renal
surgery, hernia Mid-thoracic 3-4ml 3-4ml 2ml
T10 (Umbilicus) Prostatic and vaginal surgery block, eg hernia,
incl. forceps delivery, hip hysterectomy
surgery
L1 (Groin) Lower limb surgery
S2 (Perineum) Perineal and rectal surgery The volumes of local anaesthetic shown in Table 2
should be considered only as a guideline. The lower
volumes suggested should generally be injected in
For certain blocks, less local anaesthetic is needed
particularly small people. More may have to be
when hyperbaric rather than plain solutions are
given if the resultant block is not high enough for
used. Special considerations apply to obstetric
the proposed operation. Hyperbaric agents are more
patients and so the following chart does not apply
reliable when trying for a mid-thoracic block.
to them (see later section).
Preparation for Lumbar Puncture
Assemble the necessary equipment on a sterile
C2
surface. It will include:
C2,3 A spinal needle. The ideal would be 24-25 gauge
C3,4 with a pencil point tip to minimise the risk of the
TH2
TH3 patient developing a post-spinal headache.
TH4 C
TH5 TH2
TH6
5,6 An introducer, if using a fine gauge needle as they
TH7 TH1,2 are thin and flexible, and therefore difficult to
TH8
TH9 direct accurately. A standard 19 gauge (white)
TH10 C5,6
TH11
TH12
C8 TH1 disposable needle is suitable for use as an introducer.
L1 A 5ml syringe for the spinal anaesthetic solution.
C5,6
L12 A 2 ml syringe for local anaesthetic to be used for
C6,7,8 skin infiltration.
S2,3 C8 TH1 A selection of needles for drawing up the local
L2,5
anaesthetic solutions and for infiltrating the skin.
A gallipot with a suitable antiseptic for cleaning
L3,4 the skin, eg chlorhexidine, iodine, or methyl alcohol.
L5 S1,2
Sterile gauze swabs for skin cleansing.
A sticking plaster to cover the puncture site.
L5 S1
L S1,2
4,5

Figure 5. Diagram of dermatones

Update in Anaesthesia 9

The local anaesthetic to be injected intrathecally that the needle is inserted and stays in the midline
should be in a single use ampoule. Never use local and that the bevel is directed laterally. It is angled
anaesthetic from a multi-dose vial for intrathecal slightly cephalad (towards the head) and slowly
injection. Spare equipment and drugs should be advanced. An increased resistance will be felt as
readily available if needed. the needle enters the ligamentum flavum, followed
Performing the Spinal Injection by a loss of resistance as the epidural space is
entered. Another loss of resistance may be felt as
It is assumed that the patient has been adequately the dura is pierced and CSF should flow from the
prepared, has had the procedure fully explained, needle when the stylet is removed. If bone is
has reliable intravenous access, is in a comfortable touched, the needle should be withdrawn a
position and that resuscitation equipment is centimetre or so and then re-advanced in a slightly
immediately available. more cephalad direction again ensuring that it stays
1. Scrub and glove up carefully. in the midline.
2. Check the equipment on the sterile trolley.
3. Draw up the local anaesthetic to be injected
intrathecally into the 5ml syringe, from the ampoule
opened by your assistant. Read the label. Draw up
the exact amount you intend to use, ensuring that
your needle does not touch the outside of the
ampoule (which is unsterile).
4 Draw up the local anaesthetic to be used for skin
infiltration into the 2ml syringe. Read the label. 10o
(A) Direction
5. Clean the patient’s back with the swabs and of needles for
antiseptic ensuring that unsterile skin is not touched midline approach
by your gloves. Swab radially outwards from the
proposed injection site. Discard the swab and repeat
several times making sure that a sufficiently large
area is cleaned. Allow the solution to dry on the
skin.
6. Locate a suitable interspinous space. You may
have to press hard to feel the spinous processes in
an obese patient.
7. Raise an intradermal wheal of local anaesthetic
with a disposable 25 gauge needle at the proposed 15o
puncture site.
8. Insert the introducer if using a 24-25 gauge 15o
needle. Ideally it should be advanced into the
interspinous ligament but care should be exercised (B) Direction of needle
for lateral approach
in thin patients that an inadvertent dural puncture
does not occur.
10. If a 25 gauge spinal needle is being used, be
9. Insert the spinal needle (through the introducer, prepared to wait 20-30 seconds for CSF to appear
if applicable). Ensure that the stylet is in place so after the stylet has been withdrawn. If no CSF
that the tip of the needle does not become blocked appears, replace the stylet and advance the needle
by a tiny particle of tissue or clot. It is imperative a little further and try again.
10 Update in Anaesthesia

11. When CSF appears, take care not to alter the This is performed by inserting the spinal needle
position of the spinal needle as the syringe of local about 1cm lateral to the mid line at the level of the
anaesthetic is being attached. The needle is best upper border of a spinous process, then directing it
immobilised by resting the back of the non-dominant both cephalad and medially. If bone is contacted it
hand firmly against the patient and by using the is likely to be the vertebral lamina. It should then be
thumb and index finger to hold the hub of the possible to "walk" the needle off the bone and into
needle. Be sure to attach the syringe firmly to the the epidural space, then advance through it to
hub of the needle; hyperbaric solutions are viscous pierce the dura (fig. 6 ).
and resistance to injection will be high, especially Assessing the Block
through fine gauge needles. It is, therefore, easy to
spill some of the local anaesthetic unless care is Some patients are very poor at describing what they
taken. do or do not feel, therefore, objective signs are
valuable. If, for example, the patient is unable to lift
12. Aspirate gently to check the needle tip is still his legs from the bed, the block is at least up to the
intrathecal and then slowly inject the local mid-lumbar region.
anaesthetic. When the injection is complete,
withdraw the spinal needle, introducer and syringe It is unnecessary to test sensation with a sharp
as one and apply a sticking plaster to the puncture needle and leave the patient with a series of bleeding
site. puncture wounds. It is better to test for a loss of
temperature sensation using a swab soaked in either
Practical Problems ether or alcohol. Do this by first touching the
The spinal needle feels as if it is in the right patient with the damp swab on the chest or arm
position but no CSF flows. Wait at least 30 (where sensation is normal), so that they appreciate
seconds, then try rotating the needle 90 degrees and that the swab feels cold. Then work up from the legs
wait again. If there is still no CSF, attach an empty and lower abdomen until the patient again
2ml syringe and inject 0.5-1ml of air to ensure the appreciates that the swab feels cold.
needle is not blocked then use the syringe to aspirate If the replies are inconsistent or equivocal, the
whilst slowly withdrawing the spinal needle. Stop patient can be gently pinched with artery forceps or
as soon as CSF appears in the syringe. fingers on blocked and unblocked segments and
Blood flows from the spinal needle. Wait a short asked if they feel pain. Using this method, there is
time. If the blood becomes pinkish and finally rarely any difficulty in ascertaining the extent of the
clear, all is well. If blood only continues to drip, block.
then it is likely that the needle tip is in an epidural Surgeons should be dissuaded from prodding the
vein and it should be advanced a little further or patient and asking "can you feel this?". Surgeons
angled more medially to pierce the dura. and patients should be reminded that when a block
The patient complains of sharp, stabbing leg is successful, a patient may still be aware of touch
pain. The needle has hit a nerve root because it has but will not feel pain.
deviated laterally. Withdraw the needle and redirect Problems with the Block
it more medially away from the affected side.
No apparent block at all. If after 10 minutes the
Wherever the needle is directed, it seems to patient still has full power in the legs and normal
strike bone. Make sure the patient is still properly sensation, then the block has failed probably because
positioned with as much lumbar flexion as possible the injection was not intrathecal. Try again.
and that the needle is still in the mid-line. If you
think that you are not in the midline check with the The block is one-sided or is not high enough on
patient which side they feel the needle. Alternatively, one side.
if the patient is elderly and cannot bend very much a). When using a hyperbaric solution, lie the patient
or has heavily calcified interspinous ligaments, it on the side that is inadequately blocked for a few
might bebetter to attempt a lateral approach to the minutes and adjust the table so that the patient is
dura. slightly "head down".
Update in Anaesthesia 11

b). When using an isobaric solution, lie the patient It is generally considered good practice for all
on the side that is blocked. (Moving a patient patients undergoing surgery under spinal
around in any way at all in the first 10-20 minutes anaesthesia to be given supplemental oxygen by
following injection will tend to increase the height face mask at a rate of 2-4 litres/minute, especially
of the block). if sedation has also been given.
Block not high enough. Treatment of Hypotension
a). When using a hyperbaric solution, tilt the Hypotension is due to vasodilation and a functional
patient head down whilst they are supine (lying on decrease in the effective circulating volume. The
the back), so that the solution can run up the lumbar treatment is, therefore, to reverse the vasodilatation
curvature. Flatten the lumbar curvature by raising with vasoconstrictor drugs and increase the
the patients knees. circulating volume by giving fluids. All hypotensive
b). When using a plain solution turn the patient a patients should be given OXYGEN by mask until
complete circle from supine to prone (lying on the the blood pressure is restored.
front) and back to supine again. A simple and effective way of rapidly increasing
Block too high. The patient may complain of the patient’s circulating volume is by raising their
difficulty in breathing or tingling in the arms or legs thus increasing the return of venous blood to
hands. Do not tilt the table "head up". (See later the heart. This can either be done manually by an
under ‘Treatment of a total spinal.’) assistant or by tilting the lower half of the operating
table. Tilting the whole operating table head down
Nausea or vomiting. This may occur with high will also achieve the same effect, but is unwise if a
spinal blocks which may be associated with hyperbaric spinal anaesthetic has been injected in
hypotension. Check the blood pressure and treat the preceding 15 minutes as it will result in the
accordingly. (See later) block spreading higher and the hypotension
Shivering. This occurs occasionally. Reassure the becoming more severe. If an isobaric spinal
patient and give oxygen by mask. solution has been used, tilting the table at any time
will have very little effect on the height of the block.
Monitoring
Increase the speed of the intravenous infusion to
It is essential to monitor the respiration, pulse and
maximum until the blood pressure is restored to
blood pressure closely. The blood pressure can fall
acceptable levels and, if the pulse is slow, give
precipitously following induction of spinal
atropine intravenously. Vasoconstrictors should be
anaesthesia, particularly in the elderly and those
given immediately if the hypotension is severe, and
who have not been adequately preloaded with fluid.
to patients not responding to fluid therapy.
Warning signs of falling blood pressure include
pallor, sweating or complaining of nausea or feeling Vasopressors
generally unwell. Ephedrine is probably the vasopressor of choice.
A moderate fall in systolic blood pressure to, say, It causes peripheral blood vessels to constrict and
80mmHg in a young fit patient or 100mmHg in an raises the cardiac output by increasing the heart rate
older patient is acceptable, provided the patient and the force of myocardial contraction. It is safe
looks and feels well and is adequately oxygenated. for use in pregnancy as it does not reduce placental
blood flow.
Bradycardia is quite common during spinal
anaesthesia particularly if the surgeon is Ephedrine is generally available in 25 or 30 mg
manipulating the bowel or uterus. If the patient ampoules. It is best diluted to 10mls with water for
feels well, and the blood pressure is maintained, injections and then given in increments of 1-2ml
then it is not necessary to give atropine. If, however, (2.5-6mg) titrated against the blood pressure. Its
the heart rate drops below 50 beats per minute or effect generally lasts about 10 minutes and it may
there is hypotension, then atropine 300-600mcg need repeating. Alternatively, the ampoule may be
should be given intravenously. added to a bag of intravenous fluid and the rate of
infusion altered to maintain the desired blood
pressure.
12 Update in Anaesthesia

It can also be given intramuscularly but its onset Bradycardia - give atropine
time is delayed although its duration is prolonged.
Increasing anxiety - reassure.
Larger doses are necessary when it is given
intramuscularly. Numbness or weakness of the arms and hands,
indicating that the block has reached the cervico-
Other Vasopressors
thoracic junction.
Metaraminol (Aramine). It is supplied in 10mg
Difficulty breathing - as the intercostal nerves are
ampoules and should be diluted and used
blocked the patient may state that they can’t take a
incrementally (1-5mg) as with ephedrine. It has a
deep breath. As the phrenic nerves (C 3,4,5) which
slower onset time (at least 2 minutes after
supply the diaphragm become blocked, the patient
intravenous injection) but lasts longer (20-60
will initially be unable to talk louder than a whisper
minutes)
and will then stop breathing.
Methoxamine (Vasoxine). It is available in 20mg
Loss of consciousness.
ampoules and is best diluted before injection.
Suitable adult doses are 2.5-5mg. It is a pure Action:
peripheral vasoconstrictor and reflex bradycardia, Ask for help - several pairs of hands may be useful!
needing treatment with atropine can occur.
Intubate and ventilate the patient with 100%
Phenylephrine. A pure peripheral vasoconstrictor oxygen.
which is available in 10mg ampoules. Dilute before
use. Suitable adult doses for intravenous use are Treat hypotension and bradycardia with
100-200mcg which last about 15 minutes. A reflex intravenous fluids, atropine and vasopressors as
bradycardia may occur. described earlier. If treatment is not started quickly
the combination of hypoxia, bradycardia and
Noradrenaline (Levophed). A powerful vasocon- hypotension may result in a cardiac arrest.
strictor available in 2mg ampoules which must be
diluted in 1000ml of intravenous fluid before use. Ventilation will need to be continued until the
It is then given at an initial rate of 2-3ml/minute and spinal block recedes and the patient is able to
thereafter titrated against the blood pressure. Control breathe again unaided. The time this will take will
the infusion with the utmost care. depend on which local anaesthetic has been injected.

Adrenaline/Epinephrine. Available as 1mg/ml Once the airway has been controlled and the
(1:1,000) and 1mg/10ml (1:10,000) ampoules. circulation restored, consider sedating the patient
Dilute 1ml of 1:1,000 adrenaline to at least 10ml with a benzodiazepine as consciousness may return
with saline and give increments of 50mcg (0.5ml of before muscle power.
1:10,000) repeating as necessary. Monitor the effect General Postoperative Care
of adrenaline closely - it is a very powerful drug but
The patient should be admitted to the recovery
only lasts a few minutes.
room as with any other anaesthetised patient. In the
Treatment of Total Spinal event of hypotension in the recovery room, the
Although rare, total spinals can occur with nurses should know to elevate the legs, increase the
frightening rapidity and result in the death of the rate at which intravenous fluids are being
patient if not quickly recognised and treated. They administered, give oxygen and summon the
are more likely to occur when a planned epidural anaesthetist. Further doses of vasoconstrictors or
injection is, inadvertently, given intrathecally. The fluids may be required, particularly if surgical
warning signs that a total spinal block is developing bleeding continues.
are: Patients should be advised as to how long their
Hypotension - treat as detailed above. Remember spinal block will last and be told to remain in bed
that nausea may be the first sign of hypotension. until full sensation and muscle power has returned.
Update in Anaesthesia 13

Complications of Spinal Anaesthesia As the sacral autonomic fibres are among the last to
recover following a spinal anaesthetic, urinary
Headache: a characteristic headache may occur
retention may occur. If fluid pre-loading has been
following spinal anaesthesia. It begins within 12-
excessive, a painful distended bladder may result
24 hours and may last a week or more. It is postural,
and the patient may need to be catheterised.
being made worse by raising the head and relieved
by lying down. It is often occipital and may be Permanent neurological complications are
associated with a stiff neck. It is frequently extremely rare. Many of those that have been
accompanied by nausea, vomiting, dizziness and reported were due to the injection of inappropriate
photophobia. drugs or chemicals into the CSF producing
meningitis, arachnoiditis, transverse myelitis or
It is more common in the young, in females and
the cauda equina syndrome with varying patterns
especially in obstetric patients. It is thought to be
of neurological impairment and sphincter
caused by the continuing loss of CSF through the
disturbances.
hole made in the dura by the spinal needle. This
results in descent of the brain and traction on its If inadequate sterile precautions are taken, bacterial
supporting structures. meningitis or an epidural abscess may result
although it is thought that most such abscesses are
The incidence of headache is related directly to the
caused by the spread of infection in the blood.
size of the needle used. A 16 gauge needle will
cause headache in about 75% of patients, a 20 Finally, permanent paralysis can occur due to the
gauge needle in about 15% and a 25 gauge needle "anterior spinal artery syndrome". This is most
about 3%. It is, therefore, sensible to use the likely to affect elderly patients who are subjected
smallest needle available especially in high risk to prolonged periods of hypotension and may result
obstetric patients. in permanent paralysis of the lower limbs.
As the fibres of the dura run parallel to the long axis It used to be thought that bedrest for 24 hours
of the spine, if the bevel of the needle is parallel to following a spinal anaesthetic would help reduce
them, it will part rather than cut them and therefore, the incidence of headache, but this is now no longer
leave a smaller hole. Make a mental note of which believed to be the case. Patients may get up once
way the bevel lies in relation to the notch on the hub normal sensation has returned, if surgical
and then align it appropriately. It is widely considerations so allow.
considered that pencil-point needles (Whiteacre or Treatment of spinal headache : Pateints with
Sprotte) make a smaller hole in the dura and are spinal headaches prefer to remain lying flat in bed
associated with a lower incidence of headache than as this relieves the pain. They should be encouraged
conventional cutting-edged needles (Quincke). to drink freely or, if necessary, be given intravenous
fluids to maintain adequate hydration. Simple
analgesics such as paracetamol, aspirin or codeine
Quincke may be helpful as may measures to increase intra-
abdominal and hence epidural pressure such as
lying prone. Caffeine containing drinks such as tea,
coffee or Coca-Cola are often helpful. Prolonged or
severe headaches may be treated with epidural
blood patch performed by aseptically injecting 15-
20ml of the pateint's own blood into the epidural
space. This then clots and seals the hole and prevents
further leakage of CSF.
Pencil

Figure 7. Patterns of spinal needle tips.

14 Update in Anaesthesia

Other Complications In the absence of hypovolaemia due to bleeding,

spinal anaesthesia is a simple and safe alternative to
As the sacral autonomic fibres are among the last to
general anaesthesia for manual removal of a retained
recover foloowing a spinal anaesthetic, urinary
placenta. It does not produce uterine relaxation and
retention may occur. If fluid pre-loading has been
if this is required, a general anaesthetic with a
excessive, a painful distended bladder may result
volatile agent may be preferred.
and the patient may need to be catherised.
Technique
Permanent neurological complications are
extremely rare. Many of those that have been Spinal anaesthesia is performed and managed in
reported were due to the injection of inappropriate pregnant patients in the same way as in non-pregnant
drugs or chemicals into the CSF producing patients but with a number of special considerations.
meningitis, arachnoiditis, transverse myelitis or the It is generally recommended that obstetric patients
cauda equina sundrome with varying patterns of should be pre-loaded with not less than 1500 mls of
neurological impairment and sphincter disturbances. a crystalloid solution before the dural puncture is
If inadequate sterile precautions are taken bacterial performed.
meningitis or an epidural abscess may result Although spinal anaesthesia is not contra-indicated
although it is thought that most such abscesses are in the presence of mild pre-eclampsia, remember
caused by the spread of infection in the blood. that such patients may have altered clotting function
Finally, permanent paralysis can occur due to and are relatively hypovolaemic. There is always a
'anterior spinal artery syndrome'. This is most likely chance that a pre-eclamptic patient may suddenly
to affect elderly patients who are subjected to fit and anticonvulsant drugs (diazepam or
prolonged periods of hypotension and may result in thiopentone) must be immediately available. The
permanent paralysis of the lower limbs. advantages and disadvantages of spinal versus
general anaesthesia will have to be carefully
Spinal Anaesthesia in Obstetrics considered for each patient.
There are several reasons for preferring spinal Pregnant women need smaller volumes of spinal
anaesthesia to general anaesthesia for caesarean anaesthetic solution than non-pregnant women in
sections. Babies born to mothers having spinal (or order to obtain a given height of block. For a
epidural) anaesthesia may be more alert and less caesarean section, anaesthesia should extend to T6
sedated as they have not received any general (about the bottom of the sternum) to be completely
anaesthestic agents through the placental circulation. successful. This can usually be achieved with the
As the mother's airway is not compromised, there is following regimes, although the hyperbaric agents
a reduced risk of aspiration of gastric contents are more predictable:
causing chemical pneumonitis (Mendelson's
syndrome).
Many mothers also welcome the opportunity of 2.0-2.5 ml of a hyperbaric solution of 0.5%
being awake during the delivery and being able to bupivacaine or
feed their child as soon as the operation is complete. 2.0-2.5 ml of an isobaric solution of 0.5%
There are, however, also disadvantages. It may be bupivacaine or
difficult to perform the spinal injection as lumbar 1.4-1.6 ml of a hyperbaric solution of 5%
flexion may be impeded by the pregnant uterus and, lignocaine or
if labour has started, the mother may be unable to
remain still when having contractions. Unless small 2.0-2.5 ml of an isobaric solution of 2% lignocaine
gauge needles (25 gauge) are used, the incidence of with added adrenaline (0.2 ml of 1:1000)
post-spinal headache may be unacceptably high. If anaesthesia is required for a forceps delivery,
Spinal anaesthetics for caesarean section should 1.0ml of a hyperbaric solution injected with the
not be performed until the anaesthetist has mother in the sitting position is usually adequate.
accumulated sufficient experience in their
performance with non-pregnant patients.
Update in Anaesthesia 15

Anaesthesia to T10 is needed for removal of a As with all patients undergoing surgery under spinal
retained placenta. This can be obtained by injecting anaesthesia, oxygen should be given during the
1.5mls of a hyperbaric solution with the patient operation. As hypotension commonly occurs despite
sitting and then lying her down. fluid preloading, many anaesthetists routinely give
Positioning of the Pregnant Patient a dose of vasoconstrictor intravenously. Ephedrine
is the favoured vasoconstrictor as it does not cause
Pregnant patients should never lie supine as the constriction of the uterine blood vessels. If it is not
gravid uterus will compress the vena cava and, to a available, one of the other vasoconstrictors discussed
lesser extent the aorta (aorto-caval compression) previously should be used as untreated hypotension
resulting in hypotension. They should, instead, can seriously damage the unborn infant.
always lie with a lateral tilt. This can be achieved
either by tilting the whole table or by inserting a After delivery of the baby, syntocinon is the oxytocic
wedge under the patients right hip. The uterus is of choice as it is less likely to produce maternal
displaced slightly to the left and the vena cava is not nausea and vomiting than ergometrine.
compressed (see Update No. 2).

CONTROL OF HEART RATE contraction. If there is any disease of the conducting

Dr I Kestin, Consultant Anaesthetist, Derriford system of the heart, then this process may be
Hospital, Plymouth. interfered with and the heart rate altered. If, for
example, there is disease of the AV node, then there
The heart will beat independently of any nervous or is an electrical block between the atria and the
hormonal influences. This spontaneous rhythm of ventricles. The ventricles will beat with their own
the heart (called intrinsic automaticity) can be inherent rhythm, which is much slower, usually 30-
altered by nervous impulses or by circulatory 50 beats per minute.
substances, like adrenaline. The muscle fibres of
the heart are excitable cells like other muscle or
nerve cells, but have a unique property. Each cell in Superior vena cava
the heart will spontaneously contract at a regular
rate because the electrical properties of the cell Aorta
membrane spontaneously alter with time and
regularly "depolarise". This means the reversal of
the electrical gradient across the cell membrane Left bundle branch
Sinoatrial
that causes muscle contraction or passage of a node
nervous impulse. Muscle fibres from different parts
of the heart have different rates of spontaneous Left anterior
depolarisation; the cells from the ventricle are the fascicle
Internodal
slowest, and those from the atria are faster. pathways
The coordinated contraction of the heart is produced Atrio-
because the cells with the fastest rate of ventricular Left
depolarisation "capture" the rest of the heart muscle node posterior
cells. These cells with the fastest rate of fascicle
Bundle of His
depolarisation are in the sinoatrial node (SA node),
the "pacemaker" of the heart, found in the right
Right bundle branch
atrium. As the SA node depolarises, a wave of
Purkinje system
electrical activity spreads out across the atria to
produce atrial contraction. Electrical activity then
passes through the atrioventricular node (AV node) Figure 1. Conducting system of the heart.
and through into the ventricles via the Purkinje
fibres in the Bundle of His to produce a ventricular