PRESENTATION

FACILITATED BY MADAM:
SAIMA MATEEN
GROUP MEMBERS:
Shahzad raza
Saba kaleem
Hanan
Asia

Regional Anesthesia

Spinal & Epidural Anesthesia

 Objectives
◦ Describe anatomy of spinal canal
◦ Identify anatomic landmarks for proper placement
of a spinal needle
◦ Define appropriate steps for placement of spinal,
epidural, or caudal needle
◦ Distinguish level of anesthesia after administration
of regional
◦ State factors affecting level and duration of spinal
vs. epidural block
◦ Explain potential complications and corresponding
treatments associated with administration of
regional anesthetics
Spinal Anatomy
 33 Vertebrae
◦ 7 Cervical
◦ 12 Thoracic
◦ 5 Lumbar
◦ 5 Sacral
◦ 4 Coccygeal
 High Points: C5 &
L5
 Low Points: T5 &
S2
Spinal Cord
 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
Saggital Sections
 Supraspinous
Ligament
◦ Outer most layer
 Intraspinous
Ligament
◦ Middle layer
 Ligamentum Flavum
◦ Inner most layer
 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)

Epidural Space
 Spinal Meninges
 Dura Mater
◦ Outer most layer
◦ Fibrous
 Arachnoid
◦ Middle layer
◦ Non-vascular
 Pia
◦ Inner most layer
◦ Highly vascular
 Sub Arachnoid
Space
◦ Lies between the
arachnoid and pia
 Vasoconstrictors
◦ Prolong duration of spinal block
◦ No increase in duration with lidocaine &
bupivacaine
◦ Significant increase with tetracaine (double
duration)

Spinal Pharmacology
Spinal Pharmacology
 Factors Effecting Distribution
◦ Site of injection
◦ Shape of spinal column
◦ Patient height
◦ Angulation of needle
◦ Volume of CSF
◦ Characteristics of local anesthetic
 Density
 Specific gravity
 Baracity
◦ Dose
◦ Volume
◦ Patient position (during & after)
  Anesthesia level is determined by patient
position

 Uptake of local anesthetic occurs by

diffusion

 Elimination determines duration of block

◦ Lipid solubility decreases vascular absorption
◦ Vasoconstriction can decrease rate of
Spinal Pharmacology
elimination
 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
 Decreased venous return to right atrium causes decreased
stretch receptor response
 Treatment
◦ Best way to treat is physiologic not
pharmacologic
◦ 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 is more effective than Phenylephrine

Hypotension
 Healthy Patients
◦ 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
Respiratory System
center
Spinal Technique
 Preparation &
Monitoring
◦ EKG
◦ NBP
◦ Pulse Oximeter
 Patient Positioning
◦ Lateral decubitous
◦ Sitting
◦ Prone (hypobaric
technique)
Spinal Technique
 Midline Approach
◦ Skin
◦ Subcutaneous tissue
◦ Supraspinous ligament
◦ Interspinous ligament
◦ Ligamentum flavum
◦ Epidural space
◦ Dura mater
◦ Arachnoid mater
 Paramedian or Lateral Approach
◦ Same as midline excluding supraspinous &
interspinous ligaments
Spinal Anesthesia Levels
 Indications & Advantages
◦ Full stomach
◦ Anatomic distortions of upper airway
◦ TURP surgery
◦ Obstetrical surgery (T4 Level)
◦ Decreased post-operative pain
◦ Continuous infusion

Spinal Anesthesia
Spinal Anesthesia
 Contraindications
◦ Absolute:
 Refusal
 Infection
 Coagulopathy
 Severe hypovolemia
 Increased intracranial pressure
 Severe aortic or mitral stenosis
◦ Relative:
 Use your best judgment
Spinal Anesthesia
 Complications
◦ Failed block
◦ Back pain (most common)
◦ Spinal head ache
 More common in women ages 13-40
 Larger needle size increase severity
 Onset typically occurs first or second day post-
op
 Treatment:
◦ Bed rest
◦ Fluids
◦ Caffeine
◦ Blood patch
 Fluid Test for CSF Return
◦ Clear
◦ Free flow
◦ Aspiration into syringe
◦ Litmus Paper
◦ Urine dip stick
◦ Temperature
◦ Taste… If you’re man enough…

Spinal Anesthesia
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
 Spread of Local Anesthetics
◦ First to cauda equina
◦ Laterally to nerve rootlets and nerve roots
◦ May defuse to spinal cord
◦ Primary Targets:
 Rootlets
 Roots
 Spinal cord

Spinal Anesthesia
Epidural Anatomy
 Safest point of
entry is midline
lumbar
 Spread of epidural
anesthesia parallels
spinal anesthesia
◦ Nerve rootlets
◦ Nerve roots
◦ Spinal cord
Epidural Anesthesia
 Order of Blockade
◦ B fibers
◦ C & A delta fibers
 Pain
 Temperature
 Proprioception
◦ A gamma fibers
◦ A beta fibers
◦ A alpha fibers
Epidural Anesthesia
 Test Dose: 1.5% Lido with Epi
1:200,000
◦ Tachycardia (increase >30bpm over resting
HR)
◦ High blood pressure
◦ Light headedness
◦ Metallic taste in mouth
◦ Ring in ears
◦ Facial numbness
◦ Note: if beta blocked will only see increase in
BP not HR
 Bolus Dose: Preferred Local of Choice
◦ 10 milliliters for labor pain
◦ 20-30 milliliters for C-section
 Distances from Skin to Epidural Space
◦ Average adult: 4-6cm
◦ Obese adult: up to 8cm
◦ Thin adult: 3cm
 Assessment of Sensory Blockade
◦ Alcohol swab
 Most sensitive initial indicator to assess loss of
temperature
◦ Pin prick
 Most accurate assessment of overall sensory block
Epidural Anesthesia
 Complications
◦ Penetration of a blood vessel
◦ Hypotension (nausea & vomiting)
◦ Head ache
◦ Back pain
◦ Intravascular catheterization
◦ Wet tap
◦ Infection

Epidural Anesthesia
 Caudal Anesthesia
 Anatomy
◦ Sacrum
 Triangular bone
 5 fused sacral vertebrae
 Needle Insertion
◦ Sacrococcygeal
membrane
◦ No subcutaneous bulge
or crepitous at site of
injection after 2-3ml
 Post Operative Problems
◦ Pain at injection site is most common
◦ Slight risk of neurological complications
◦ Risk of infection
 Dosages
◦ S5-L2: 15-20ml
◦ S5-T10: 25ml

Caudal Anesthesia
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, & 5th
toe
◦ Deep perineal nerve
 Continuation of common perineal nerve
Ankle Block
Brachial Plexus
 Musculocutaneous
Nerve

 Median Nerve

 Ulnar Nerve

 Radial Nerve
 Axillary Block
 Position
◦ Head turned away
from arm being
blocked
◦ Abduct to 90º
◦ Forearm is flexed to
90º
◦ Palpate brachial
artery for pulse
Axillary Block
 Advantages
◦ Provides anesthesia for forearm & wrist
◦ Fewer complications than a supraclavicular
block
 Limitations
◦ Not for shoulder or upper arm surgery
◦ Musculocutaneous nerve lies outside of the
sheath and must be blocked separately
 Complications
◦ Intravascular injection
◦ Elevated bleeding time increases risk for
hematoma
  Dosing
◦ Lidocaine 1% 30-40ml

◦ Etidocaine 1% 30-40ml

◦ Bupivacaine 0.5% 30-40ml

 Note 40ml is most common dose

Axillary Block
Other Blocks
 Basic Labs:
◦ Platelet counts >50,000 (minimum), prefer
>100,000
◦ Prothrombin time (PT) & Partial thrombin time
(PTT)
 Note that PT & PTT require approx. 60-80% loss of
coagulation activity before becoming abnormal
◦ Thrombin time
Regional
◦ Hemoglobin Anesthesia
& Hematocrit in the
Anticoagulated
◦ Bleeding time Patient
Regional Anesthesia in the
Anticoagulated Patient
 Heparin: Reverse with FFP or Protamine
◦ IV discontinue 4 hours prior to block
◦ SQ can block one hour prior to dose
◦ Do not D/C cath until 4 hours after heparin
D/C’d & obtain normal lab values
 Lovenox (LMWH): No Reversal
◦ Stop 10 days prior to surgery
◦ Post op D/C cath 2 hours prior or 10 hours
after first dose
 Coumadin: Reverse with Vit K or FFP
◦ Stop 7 days prior to surgery
◦ Check PT/INR
Regional Anesthesia in the
Anticoagulated Patient
 Plavix: No Reversal
◦ Stop 5-10 days prior to surgery
 NSAIDS: No Reversal
◦ May be safe for regional block
◦ Ideal to stop 5 days prior to surgery
 ASA: No Reversal
◦ Stop 7-10 days prior to surgery
 Objectives
◦ Classify each local as an ester or amide
◦ State the mechanism of action for local anesthetics
◦ State the metabolism for esters & amides
◦ Identify ranking of absorption by arterial flow for give
anatomic regions
◦ Discuss how lipid solubility and vasoconstriction
affect the potency and duration of locals
◦ Discuss the etiology of an allergic reaction to local
Local Anesthetics
anesthetics
◦ Understand how pKa effects speed of onset of locals
 Speed of Onset
◦ Based on pKa
 Lower pKa equals more un-ionized at pH 7.4
 Un-ionized drug penetrates lipid bilayer of nerve
◦ More un-ionized form of local equals faster penetration,
which equals quicker onset of action
 Local anesthetics + NaHCO3 (High pH) =
more un-ionized

Local Anesthetics
Local Anesthetics
  Esters  Amides
◦ Procaine ◦ Lidocaine
◦ Chloroprocaine ◦ Mepivacaine
◦ Bupivacaine
◦ Tetratcaine
◦ Etidocaine
◦ Cocaine ◦ Prilocaine
◦ Ropivacaine

 Metabolism  Metabolism
◦ Hydrolysis by ◦ Liver
psuedo-
Local Anesthetics
cholinesterase
enzyme
 Toxicity & Allergies
◦ Esters: Increase risk for allergic reaction due
to para-aminobenzoic acid produced through
ester-hydralysis

◦ Amides: Greater risk of plasma toxicity due to

slower metabolism in liver

Local Anesthetics
Local Anesthetics

 Potency
◦ The greater the
oil/water partition
coefficient the
greater the lipid
solubility
◦ The more lipid
soluble the greater
the potency
 Duration of Action
◦ The degree of protein binding is the most
important factor
◦ Lipid solubility is the second leading
determining factor
◦ Greater protein bound + increase lipid
solubility = longer duration of action

Local Anesthetics
Characteristics of Local
Anesthetic Agents
Local Anesthetics
 Determinants of Blood Concentrations
◦ Loss of local anesthetic is primarily through
vascular absorption
 Vasoconstrictors decrease the rate of
absorption & increase duration of action
 Ranking rate of absorption by arterial blood
flow
◦ Highest to lowest
 Tracheal
 Intercostal muscles
 Caudal
 Paracervical
 Epidural
 Brachial plexus
 Subarachnoid
 Subcutaneous
Local Anesthetics & Baracity
 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
◦ Very predictable spread
◦ Increased dose has more effect on duration
than dermatomal spread
 Note: Be cognizant of high & low regions
of spinal column
Mechanism of Action
 Un-ionized local
anesthetic
defuses into
nerve axon & the
ionized form
binds the
receptors of the
Na channel in the
inactivated state
Dermatomes of the Body
 Key Dermatomes &
Levels
◦ C1-C2: Oops…
◦ C3,4,5: Keep the
diaphragm alive…
◦ T1-T4: Cardioaccelerator
◦ T4: Nipple line
◦ T6: Xyphoid process
◦ T10: Umbilicus
◦ S2,3,4: Keep the penis
off the floor…
 Spinal Injection
◦ Sympathetic block is 2-6 dermatomes higher
than sensory block
◦ Motor block is 2 dermatomes lower than
sensory block

Sensory vs. Motor Blockade

 Metabolism
◦ Ester locals are metabolized by plasma
psuedocholinesterase
◦ Amide locals are metabolized by the liver
 Toxicity
◦ Determined by blood concentration of local
anesthetics

Metabolism & Toxicity

Manifestation of Lidocaine
Toxicity