Spinal Anesthesia - 4

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Regional Anesthesia

Neuraxial blocks
 Spinal, epidural, and caudal blocks are also known as neuraxial anesthesia.
 Neuraxial blocks are used for operations all over the body from the neck to the
lower extremities
 Spinal anesthesia is a type of neuraxial anesthesia; local anesthetic (LA) is injected
into cerebrospinal fluid (CSF) in the lumbar spine to anesthetize nerves that exit the
spinal cord. Spinal anesthesia is most commonly used for anesthesia and/or analgesia
for a variety of lower extremity, lower abdominal, pelvic, and perineal procedures.
Vertebral column:
 Is formed from 33 vertebras:
7 cervical
12 thoracic
5 lumbar
5 sacral and
4 coccygeal.
The spinal cord
 Direct continuation of the medulla
 42-45 cm length
 Normally extends from the foramen magnum to the level of L1 in adults.
 In children, the spinal cord ends at L3 and moves up as they grow older. The
anterior and posterior nerve roots at each spinal level join one another and exit the
intervertebral foramina forming spinal nerves from C1 to S5
The spinal cord
 These lower spinal nerves form the cauda equina ("horse's tail").
 Therefore, performing a lumbar (subarachnoid) puncture below L1 in an adult
(lower border of L3 in a child) avoids potential needle trauma to the cord; damage to
the cauda equina is unlikely as these nerve roots float in the dural sac below L1 and
tend to be pushed away (rather than pierced) by an advancing needle.
The spinal cord
 Spinal cord is covered by the meninges, which is formed from three layers –
- The pia mater, which is the innermost layer, and is adherent to the spinal cord
- The arachnoid matter
- The dura mater which is the outer one

 The blood supply to the spinal cord and nerve roots is derived from a single
anterior spinal artery and paired posterior spinal arteries.
CSF

 Is a clear watery fluid.


 Produced in the brain and drained to the spinal canal to protect the cord and
brain against trauma
 Is found between the pia and subarachnoid in the subarachnoid space

 Epidural space is found between dura mater and ligamentum flavum


 Subdural space between the dura mater and arachnoid membrane and confluent
with the cranial subdural space
 Subarachnoid space between the arachnoid membrane and pia mater, contains the
CSF.
Instruments and Equipments

 Under aseptic technique and a sterile environment.


 Cap, masks, hand wash, sterile gloves are required.
 For a successful procedure, adequate preparation is requisite.
 space to accommodate patients and personnel.
 Monitors to assess the patient's circulation (blood pressure, continuous ECG),
oxygenation (continuous pulse oximetry), and temperature should be set up
and ready.
 If planning sedation, means to assist patient ventilation, oxygenation, and circulatory support should
be in place.
 Intravenous access should be established before starting.
 There are commercially available spinal anesthesia kits.
 Contents of kits usually include chlorhexidine with alcohol, drape, and local infiltrating anesthetic
(usually 1% lidocaine).
 Other contents include the spinal needle (Quincke, Whitacre, Sprotte, or Greene).
 3 ml and 5 ml syringes, and preservative-free spinal anesthetic solution.
 Solutions may range from lidocaine, ropivacaine, bupivacaine, procaine, or tetracaine.
 After the patient is in the proper position, the access site is identified by palpation.
 The space between 2 palpable spinous processes is usually the site of entry.
 The patient should wear a hat or cover for his/her hair to maintain asepsis.
 Strict aseptic technique is always necessary, achievable with chlorhexidine antiseptics with alcohol
content, adequate hand-washing, mask, and cap.

 Cleaning always starts from the chosen site of approach in circles and then away from the site.
 Allow time for the cleaning solution to dry.
 In the spinal kit, the drape placement is on the patient's back to isolate the area of access.
 Local anesthetic (usually about 1 ml 1% lidocaine) is used for skin infiltration.
Site of injection:
 Adult:

 L3 - L4 ( Largest interspace) or L4 - L5
 A line drawn between the highest points of
iliac crests (Tuffier’sline)
Patient position:

 There are 3 positions in which the patient may be:

 *Sitting position
 Legs hanging over the side of the bed
 Assistant keep the patient from swaying
 Curve patient’s back like a (C)
 *Lateral position
 Needs to be parallel to the edge of the bed
 Legs flexed up to the abdomen
 Forehead flexed down towards knees
 *Prone position
 (Chosen for anorectal surgery
 Use hypobaric solution
 CSF will not drip from the hub of the needle
 - Spinal needles are commercially available in an array of sizes (16–30 gauge), lengths, and
bevel and tip designs.
 All should have a tightly fitting removable stylet that completely occludes the lumen to
avoid tracking epithelial cells into the subarachnoid space.
 Broadly, they can be divided into either sharp (cutting)-tipped or blunt-tipped needles.
 The most common are:

 The Quincke needle is a cutting needle with end injection.


 The Whitacre and other pencil-point needles have rounded points and side injection.
 The Sprotte is a side-injection needle with a long opening.

 Are designed to be less traumatic to the dura itself, apparentely splitting or spreading rather than
cutting the longitudinal fibers and thus promoting more rapid sealing of the dural hole and reduce the
incidence of postdural puncture headache.
 The gauge of spinal needles is also important, smaller needles create smaller holes and less transdural
leak, but they are more difficult to insert and aspirate.
 The 25 gauge needle is the size most frequently used preferably with a rounded bevel.
 Spinal catheters: now not used due to the relationship between these catheters and the cuada equina
syndrome
Factors affecting the level of block:

 Isobaric:
 Stays where you put it
 LA has the same density or specific gravity as CSF (1.003 – 1.008)
 Normal saline

 Hypobaric:
 Floats up – lighter than CSF
 LA has density or specific gravity that is less than CSF (< 1.003).
 Sterile water

 Hyperbaric:
 Settles to dependent aspect of the subarachnoid space
 Heavier than CSF.
 LA has density or specific gravity that is greater than CSF (> 1.008).
 Dextrose
 - Patient position during injection and immediately after can affect the spread
lateral or up and down
 - Dose of the drug: as the dose is high the level of block will be high
 - Site of injection: as the site of injection is high the level will be high
 Others:
 - Age with advanced age there will be a decrease in CSF volume
 - Intra abdominal pressure increases the height of block
 - Drug volume
high volumes produce high level block
MECHANISM OF ACTION

 The principal site of action for neuraxial blockade is the nerve root.
 Local anesthetic is injected into CSF (spinal anesthesia) or the epidural space
(epidural and caudal anesthesia) and bathes the nerve root in the subarachnoid space
or epidural space, respectively.
 By interrupting the transmission of painful stimuli and abolishing skeletal muscle
tone, neuraxial blocks can provide excellent operating conditions. Sensory blockade
interrupts both somatic and visceral painful stimuli, whereas motor blockade
produces skeletal muscle relaxation.
 Interruption of efferent autonomic transmission at the spinal nerve roots can
produce sympathetic and some parasympathetic blockade
MIDLINE APPROACH

 The spine is palpated and the patient's body position is examined to ensure that
the plane of the back is perpendicular to that of the floor.
 The depression between the spinous processes of the vertebra above and below the
level to be used is palpated; this will be the needle entry site.
 The needle is introduced in the midline.
 The needle will be directed slightly cephalad.
 As the needle courses deeper, it will enter the supraspinous and interspinous
ligaments, felt as an increase in tissue density.
 As the needle penetrates the ligamentum flavum an obvious increase in resistance
is usually encountered.
 For spinal anesthesia, the needle is advanced further through the epidural space
and penetrates the dura–subarachnoid membranes as signaled by free flowing CSF.
PARAMEDIAN APPROACH

 The paramedian technique may be selected if subarachnoid block is difficult,


particularly in patients who cannot be positioned easily (e.g., severe arthritis,
kyphoscoliosis, or prior lumbar spine surgery)
 2 cm lateral to the inferior aspect of the superior spinous process of the desired
level.
 The needle is directed and advanced at a 10–25° angle toward the midline.
 Supraspinous and interspinous ligaments are not pierced.

 ASSESSING LEVEL OF BLOCKADE
 With knowledge of the sensory dermatomes (see Image 1), the sensory level
achieved by a block can be assessed by a blunted needle (pinprick), whereas the level
of sympathectomy is assessed by measuring skin temperature sensation.
Indications for blocks:

 - Operation on the lower part of the body such as:

 Lower abdominal surgery


 Inguinal region surgery
 Urogenital surgery
 Rectal surgery
 Lower extremities surgery
Contraindications:

 There are absolute and relative contraindications

 Absolute:

 -local infection
 -patient refusal
 -bleeding disorders
 -severe hypovolemia
 -increased intracranial pressure
 -severe valvular disease (aortic and mitral stenosis)
 Relative:

 - Sepsis
 -uncooperative patient
 -mild stenotic valvular disease
 -spinal deformity
 -preexisting neurological disease

 Controversial

 -previous back surgery


 -complicated surgery …. Prolonged surgery and risk of major blood loss
Complications:
 Total spinal anesthesia:

 Total spinal anesthesia can occur following attempted epidural/caudal anesthesia if


there is inadvertent intrathecal injection.
 Spinal anesthesia ascending into the cervical levels causes severe hypotension,
bradycardia, and respiratory insufficiency. Unconsciousness, apnea, and hypotension
resulting from high levels of spinal anesthesia are referred to as a "high spinal" or
"total spinal."
 When respiratory insufficiency becomes evident, in addition to supplemental
oxygen, assisted ventilation, intubation, and mechanical ventilation may be necessary.
 Hypotension can be treated with rapid administration of intravenous fluids, a
head-down position, and aggressive use of vasopressors.
 Bradycardia should be treated early with atropine.
 Postdural puncture headache:
 Any breach of the dura may result in a postdural puncture headache (PDPH).
 Typically, PDPH is bilateral, frontal or retroorbital, and occipital and extends into the neck.
 It may be throbbing or constant and associated with photophobia and nausea.
 The hallmark of PDPH is its association with body position.
 The pain is aggravated by sitting or standing and relieved or decreased by lying down flat.
 The onset of headache is usually 12–72 h following the procedure
 Untreated, the pain may last weeks.
 PDPH is believed to result from leakage of CSF from a dural defect and decreased intracranial
pressure.
Postdural puncture headache:

 Loss of CSF at a rate faster than it can be produced causes traction on structures
supporting the brain, particularly the dura and tentorium. Increased traction on
blood vessels also likely contributes to the pain.
 The incidence of PDPH is strongly related to needle size, needle type, and patient
population. Factors that increase the risk of PDPH include young age, female sex, and
pregnancy.
 Conservative treatment involves recumbent positioning, analgesics, intravenous or
oral fluid administration, and caffeine. Keeping the patient supine will decrease
the hydrostatic pressure driving fluid out the dural hole and minimizing the
headache.
Postdural puncture headache:

 Analgesic medication may range from acetaminophen to NSAIDs.


 Hydration and caffeine work to stimulate production of CSF.
 Caffeine further helps by vasoconstricting intracranial vessels.
 Stool softeners and soft diet are used to minimize straining.
 Headache may persist for days despite conservative therapy.

 An epidural blood patch is a very effective treatment for PDPH.


 It involves injecting 15–20 mL of autologous blood into the epidural space at, or
one interspace below, the level of the dural puncture.
 Anterior spinal artery syndrome:

 Anterior spinal artery syndrome has been reported following neuraxial anesthesia, presumably due to
prolonged severe hypotension together with an increase in intraspinal pressure.

 Urinary retention:

 Local anesthetic block of S2–S4 root fibers decreases urinary bladder tone and inhibits the voiding
reflex. Epidural opioids can also interfere with normal voiding.
 These effects are most pronounced in male patients.
 Backache:

 As a needle passes through skin, subcutaneous tissues, muscle, and ligaments it causes varying degrees
of tissue trauma. A localized inflammatory response with or without reflex muscle spasm may be
responsible for postoperative backache.

 Neural injury:

 The nerve roots or spinal cord may be injured. The latter may be avoided if the neuraxial blockade is
performed below L1 in adults and L3 in children.

 Spinal cord damage

 Cauda equina syndrome


 Bleeding:

 Needle or catheter trauma to epidural veins often causes minor bleeding in the spinal canal although
this is usually benign and self-limiting. A clinically significant spinal hematoma can occur following spinal
or epidural anesthesia, particularly in the presence of abnormal coagulation or bleeding disorder.

 Infection:

 Meningitis
 Epidural abscess
Agents used for spinal anesthesia:

 All agents must be preservative free

A. Short Acting:

* Procaine 10%
-Is the oldest that still used for spinal anesthesia
-Has a rapid onset 3—5 minutes

-Short duration of action approximately 60 m when used with adrenaline


-Has a high frequency of nausea and vomiting, and a high frequency of failed block
-Low frequency of transient neurological symptoms TNS
- Dose: 75 mg for lower limb surgery and 125 mg for lower abdominal surgery and
200 mg for upper abdominal surgery
* Lidocaine: 5%
- Has a rapid onset 3—5 m
- Duration of action 60----75 without adrenaline and up to 90 with adrenaline
- Limitations to its use are transient neurological symptoms
- Dose: 25 – 50 mg for lower limbs, 50 – 75 mg for lower abdominal and 75 – 100 mg for upper abdomen

* Mepivacaine: 2%
- Has a lower incidence of TNS
- Slightly longer than lidocaine
- Dose 30 - 60 mg
- Now is not approved in USA for spinal anesthesia
B- Long-Acting agents:

* Bupivacaine: is a long acting with slow onset, produce a profound motor block.
- Present in concentrations 0.5% and 0.75% hyperbaric
- Dose:
- 4 – 10 mg for lower limbs, 10 – 12 mg for lower abdomen and 10 – 15 mg for upper abdominal surgery
- Plain solution has a duration 90 – 120 mg and that with adrenaline 100 – 150 mg
* Ropivacaine: 0.2 - 1 % solution
- Less toxic to cardiovascular system
- Double dose of bupivacaine to produce the same block
- Dose: 8 – 12 mg for lower extremities, 12 – 16 mg for lower abdomen and 15 – 20 mg for upper
abdominal surgery
- Duration: 90 – 120 m

* Tetracaine 0.5% or 1%
- Are the longest acting.
- Plain solution lasts 2 – 3 h, and that with vasoconstrictors up to 5 hours
- Dose:
- 4 – 8 mg for lower limbs, 10 – 12 mg for lower abdomen and 10 – 15 mg for upper abdominal

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