LOCAL ANESTHETICS

USED FOR SPINAL

ANESTHESIA

ABDIRAHMAN DAHIR WAIS

(BSN,ANESTHETIST)
Factors in Spread of Spinal Anesthetics

 Every clinician must take into account the four

categories of factors that may play a role in the
spread of local anesthetics in the subarachnoid
space.
 Factors include:
 Characteristics of local anesthetic
 Patient characteristics/medical conditions
 Technique of injection
 Characteristics of spinal fluid
Local Anesthetics in the US for Spinal Anesthesia

 Procaine
 Lidocaine
 Mepivacaine
 Tetracaine
 Levobupivacaine
 Bupivacaine
Categories of Local Anesthetics for Spinal
Anesthesia

 Those used for procedures that are < 90 minutes

(short acting).
 Those used for procedures that are > 90 minutes
(long acting).
 All medications used for spinal anesthesia should be
preservative free!
 Use medications specifically prepared for spinal
anesthesia.
Short Acting Spinal Local Anesthetics

 Procaine
 Lidocaine
 Mepivacaine
Procaine
 Oldest local anesthetic that is still used for spinal
anesthesia
 Ester
 Rapid onset 3-5 minutes
 Short duration approximately 60 minutes
Procaine Limitations
 Short acting (60 minutes)
 High frequency of nausea and vomiting
 Higher frequency of failed spinal anesthesia
 Despite short duration of action it has a slower time
to full recovery
 Increasing popularity since it has a low frequency
of Transient Neurological Symptoms
Procaine

Medication Preparation Dose Dose Dose

Lower Lower Upper
Limbs Abdomen Abdomen
Procaine 10% Solution 75 mg 125 mg 200 mg

Duration Plain Duration

Epinephrine
45 minutes 60 minutes
Lidocaine
 In the past was a popular spinal anesthetic for
procedures < 1.5 hours.
 Is an amide
 Rapid onset of 3-5 minutes
 Duration of action 60-75 minutes
 Common preparation 5% solution in 7.5% dextrose
Limitations of Lidocaine
 High incidence of Transient Neurological
Symptoms (TNS)
 Because of this complication the use of lidocaine
has greatly declined.
 Using concentrations less than 5% have not been
shown to reduce symptoms of TNS
Lidocaine

Medication Preparation Dose Dose Dose

Lower Lower Upper
Limbs Abdomen Abdomen
Lidocaine 5% Solution 25-50 mg 50-75 mg 75-100 mg

Duration Plain Duration

Epinephrine
60-75 minutes 60-90 minutes

5% concentration is no longer recommended due to risk of TNS…should

be diluted to 2.5% or less. This may reduce the risk.
Mepivacaine
 Becoming a popular alternative to lidocaine.
 May have a lower incidence of TNS
 Used in doses of 30-60 mg in a 2% concentration
(preservative free)
 Slightly longer acting than lidocaine
 Drug mass ratio of 1.3/1.0 when compared to
lidocaine
Mepivacaine
 Current use of mepivacaine is “off label”. The
FDA (United States) has not approved its use for
spinal anesthesia.
Long Acting Spinal Local Anesthetics

 Tetracaine
 Bupivacaine
 Ropivacaine
 Levobupivacaine
 Bupivacaine
Tetracaine
 Long history of clinical use
 Is an ester
 Available as niphanoid crystals (20 mg) that
requires reconstitution.
 First reconstitute the crystals with 2 ml of
preservative free sterile water
 Mix the 1% solution with equal volumes of 10% of
dextrose to yield a 0.5% solution
Tetracaine
 The final concentration will be 0.5% with 5%
dextrose.
 Alternatively tetracaine will come as a 1% solution
in a 2 ml vial.
 Once again mix it with an equal portion of 10%
dextrose to yield a 0.5% concentration with 5%
dextrose.
Tetracaine
 It is the longest acting spinal anesthetic
 Tetracaine plain will last 2-3 hours
 Addition of epinephrine or phenylephrine (0.5 mg)
will make it last up to 5 hours for lower extremity
surgical procedures
 Epinephrine can increase the duration of blockade
by up to 50%.
 Compared to bupivacaine tetracaine produces a
more profound motor block
Tetracaine

Medication Preparation Dose Dose Dose

Lower Lower Upper
Limbs Abdomen Abdomen
Tetracaine 1% Solution in 4-8 mg 10-12 mg 10-16 mg
10% glucose or
as niphanoid
crystals

Duration Plain Duration

Epinephrine
90-120 minutes 120-240 minutes
Bupivacaine
 Long acting amide
 Slow onset (5-10 minutes…isobaric may be longer)
 When compared to tetracaine a more profound
motor blockade and a slightly longer duration of
action are noted.
 Available in hyperbaric form in concentrations of
0.5-0.75% with 8.25% dextrose
Bupivacaine
 Isobaric concentrations range from 0.5% to 0.75%
 With isobaric formulations it appears that total mg
dose is more important than the total volume
 Bupivacaine

Medication Preparation Dose Dose Dose

Lower Lower Upper
Limbs Abdomen Abdomen
Bupivacaine 0.5-0.75% Isobaric 4-8 mg 10-12 mg 10-16 mg
Solution

0.5-0.75% Hyperbaric
Solution in 8.25%
Dextrose

Hypobaric Solution
Bupivacaine

Duration Plain Duration

Epinephrine
90-120 minutes 100-150 minutes
Ropivacaine
 Amide
 Less toxicity to CV than bupivacaine…important
for epidural administration.
 For spinal anesthesia it takes 1.8-2 times the dose
of bupivacaine for similar levels of blockade
 Subarachnoid block use is “off label” in the United
States
Levobupivacaine
 Amide
 S isomer of bupivacaine
 Bupivacaine is a stereoisomer (racemic solution of
S and R forms)
 Stereoisomer is a mirror image of the same
compound…each exert some unique effects
 R isomer of bupivacaine is more cardiotoxic than
the S form
Levobupivacaine
 For spinal anesthesia there are no additional
benefits
 Same dosing as with bupivacaine
Hypobaric, Isobaric & Hyperbaric Spinal
Anesthetic Solutions
Definitions
 Density- weight of 1 ml of solution in grams at a
standard temperature
 Specific Gravity- density of a solution in a ratio
compared to the density of water
 Baracity- ratio of comparing the density of one
solution to another
 Hypobaric Solution

 Must be less dense than CSF (1.0069)

Tetracaine as a hypobaric solution
 Mix 1% tetracaine with equal portions of
preservative free sterile water.
 This will create a solution with a baracity of less
than 0.9977
 For anorectal and hip repairs a dose of 4-6 mg is
adequate.
 The “surgical site” should be positioned “up” as
this is where the solution will gravitate
Bupivacaine as a hypobaric solution

 Isobaric bupivacaine should be warmed up to 37

degrees C.
 The solution will act hypobaric as opposed to
isobaric
Isobaric Solutions
 Bupivacaine, ropivacaine & levobupivacaine in
concentrations of 0.5-0.75% (plain solutions
without dextrose)
 Tetracaine can be used as an isobaric solution. To
create this solution the niphanoid crystals are
mixed with cerebral spinal fluid (CSF) and the
desired dose is administered.
Hyperbaric Solutions
 The most commonly used “type” of solution
 Height is affected by patient position during
injection and after injection
 For a “saddle” block the patient should be kept
sitting for 3-5 minutes to allow for “settling”.
Hyperbaric Solutions
 If patient is placed supine the medication will move
cephalad to the dependent area of the
thoracolumbar curve.
 Lateral position- the medication will move to the
dependent area. If patient is left in this position for
5 minutes then turned supine the block will be
higher and denser in the dependent side when
compared to the non-dependent side.
Spinal Anesthetic Additives
 Epinephrine is generally added in doses of 01.-0.2
mg
 Phenylephrine is generally added in doses of 1-2
mg
 Additives may prolong the spinal block by
decreasing uptake of the local anesthetic and weak
analgesic properties (alpha 2 adrenergic effects)
Spinal Anesthetic Additives
 Unfounded concerns of spinal cord ischemia in
normal patients when usual doses are administered
Epinephrine will prolong:

 Procaine
 Bupivacaine
 Tetracaine
 Lidocaine
Phenylephrine will prolong:

 Tetracaine
 Lidocaine
Medication Preparation Dose Dose Dose
Summary Lower
Limbs
Lower
Abdomen
Upper
Abdomen

Procaine 10% Solution 75 mg 125 mg 200 mg

Lidocaine 5% Solution in 7.5% 25-50 mg 50-75 mg 75-100 mg
dextrose
Tetracaine 1% Solution in 10% 4-8 mg 10-12 mg 10-16 mg
glucose or as niphanoid
crystals

Bupivacaine 0.5-0.75% Isobaric 4-10 mg 12-14 mg 12-18 mg

Solution

0.5-0.75% Hyperbaric
Solution in 8.25%
Dextrose

Hypobaric Solution
Summary

Medication Duration Plain Duration Epinephrine

Procaine 45 minutes 60 minutes
Lidocaine 60-75 minutes 60-90 minutes
Tetracaine 90-120 minutes 120-240 minutes
Bupivacaine 90-120 minutes 100-150 minutes