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SpinalAnesthesiacontinued
Byadmin04/10/201311:21:00

PharmacodynamicsOfSpinalAnesthesia
The pharmacodynamics of spinal injection of local anesthesia are wideranging. The next section reviews the
cardiovascular, respiratory, and gastrointestinal consequences of spinal anesthesia. This portion of the chapter
focusesonthehepaticandrenaleffectsofspinalanesthesia.
Hepaticbloodflowcorrelatestoarterialbloodflow.Thereisnoautoregulationofhepaticbloodflow,thus,asarterial
blood flow decreases after spinal anesthesia, so does hepatic blood flow.[123] If the anesthesiologist maintains
mean arterial pressure (MAP) after placing a spinal anesthetic, hepatic blood flow will be maintained. Patients with
hepatic disease must be carefully monitored and their blood pressure must be controlled during anesthesia to
maintainhepaticperfusion.Nostudieshaveconclusivelyshownthesuperiorityofregionalorgeneralanesthesiain
patientswithliverdisease.[124128]Inpatientswithliverdiseaseeitherregionalorgeneralanesthesiacanbegiven,
aslongastheMAPiskeptclosetobaseline.

ClinicalPearls
Ifmeanbloodpressureismaintainedafterplacingaspinalanesthetic,neitherhepaticnorrenalbloodflowwilldecrease.
Spinalanesthesiadoesnotalterautoregulationofrenalbloodflow.

Renalbloodflowisautoregulated.ThekidneysremainperfusedwhentheMAPremainsabove50mmHg.Transient
decreasesinrenalbloodflowmayoccurwhenMAPislessthan50mmHg,butevenafterlongdecreasesinMAP,
renal function returns to normal when blood pressure returns to normal. Again, attention to blood pressure is
important after placing a spinal anesthetic, and the MAP should be as close to baseline as possible. Spinal
anesthesia does not affect autoregulation of renal blood flow. It has been shown in sheep that renal perfusion
changedverylittleafterspinalanesthesia.[129132]

CardiovascularEffectsofSpinalAnesthesia
The sympathectomy produced by spinal anesthesia induces hemodynamic changes. The block height determines
the extent of sympathetic blockade, which determines the amount of change in cardiovascular parameters.
However, this relationship cannot be predicted. Hypotension and bradycardia are the most common side effects
seen with sympathetic denervation.[133] Risk factors associated with hypotension include hypovolemia,
preoperativehypertension,highsensoryblockheight,ageolderthan40years,obesity,combinedgeneralandspinal
anesthesia, and addition of phenylephrine to the local anesthetic.[134136] Chronic alcohol consumption, history of
hypertension,elevatedBMI,highlevelofsensoryblockheight,andurgencyofsurgeryallincreasethelikelihoodof
hypotension after spinal anesthesia.[137] Hypotension occurs in about33%of the nonobstetric population.[134]
Figure 7 depicts changes in blood pressure and heart rate after injection of hyperbaric bupivacaine and tetracaine.
[138]

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Figure7:Agraphdepictingchangesinbloodpressureandheartrateafterinjectionofhyperbaricbupivacaineand
tetracaine.Bloodpressureisshownintheuppergraphandheartrateisshowninthelowergraphwiththemean
SD.Time0isthetimebeforespinalanestheticplacementandtime5is5minutesafterspinalanesthetic
placement.ReproducedwithpermissionfromNishiyamaT,KomatsuK,HanaokaK.:Comparisonofhemodynamic
andanestheticeffectsofhyperbaricbupivacaineandtetracaineinspinalanesthesia.JAnesth.,17:219,2003.
Arterial and venodilation both occur in spinal anesthesia and combine to produce hypotension. Arterial vasodilation
is not maximal after spinal blockade, and vascular smooth muscle continues to retain some autonomic tone after
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sympatheticdenervation.Duetoretentionofautonomictone,totalperipheralvascularresistance(TPVR)decreases
only by 15% to 18%, thus MAP decreases by 15% to 18% if cardiac output is not decreased. In patients with
coronaryarterydisease,systemicvascularresistancecanbedecreasedbyupto33%afterspinalanesthesia.[139]
However,afterspinalanesthesia,venodilationwillbemaximal,dependingonthelocationoftheveins.Iftheveins
lie below the right atrium, gravity will cause pooling of the blood peripherally, and if the veins are above, there is
backflowofthebloodintotheheart.Venousreturntotheheart,orpreload,thereforedependsonpatientpositioning
duringspinalanesthesia.[140]

ClinicalPearls
Spinalanesthesiadenervatesthesympatheticchain,whichisthemainmechanismofcardiovascularchanges.
Theblockheightdeterminesthelevelofsympatheticblockade,whichdeterminesthedegreeofchangeincardiovascular
parameters.

Becausepreloaddeterminescardiacoutputandpatientpositioningisamajorfactorindeterminingpreload,aslong
asaeuvolemicpatientispositionedwiththelegselevatedabovetheheart,thereshouldbenosignificantchanges
incardiacoutputafterspinalanesthesia.ThereverseTrendelenburgposition,however,leadstolargedecreasesin
preloadandthuslargedecreasesincardiacoutput.[141,142]
Mostpatientsdonotexperienceasignificantchangeinheartrateafterspinalanesthesia,butinyoung(age<50),
healthy (ASA class 1) patients there is a higher risk of bradycardia. Betablocker use also increases the risk of
bradycardia. The incidence of bradycardia in the nonpregnant population is about 13%.[134] The sympathetic
cardiac accelerator fibers emerge from the T1 to T4 spinal segments, and blockade of these fibers is proposed as
the cause of bradycardia. Decreased venous return may also cause bradycardia, due to a fall in filling pressures.
This triggers the intracardiac stretch receptors to lower the heart rate. Even though both of these mechanisms are
proposed to cause bradycardia, other as yet undetermined factors may contribute to the bradycardia seen with
spinal anesthesia.[143] Even though bradycardia is usually well tolerated, asystole and second and thirddegree
heart block can occur, so it is wise to be vigilant when monitoring a patient after spinal anesthesia and treat
promptlyandaggressively.[144]Hypotensionoccursinabout33%ofthenonobstetricpopulation.[134]

TreatmentofHypotensionAfterSpinalAnesthesia
To effectively treat hypotension, the cause of the hypotension must be corrected. Decreased cardiac output and
venousreturnmustbetreated,andabolusofcrystalloidisoftenusedtoenhancevenousvolume.Thepracticeof
prehydrationwith500to1500mLofcrystalloidhasbeenshowntodecreasehypotensioninsomestudies,butnotin
others.[145147]Noreliablemethodtopreventhypotensionafterspinalblockadeexists.Treatmentofhypotension,
however, remains essential so that the myocardium and brain remain perfused. If a patient is asymptomatic,
decreases in blood pressure up to 33% need not be treated. Careful monitoring of blood pressure as well as
supplemental oxygen should be implemented when performing spinal anesthesia. Fluid bolus should be carefully
monitored as excess fluid may cause patients to go into congestive heart failure, pulmonary edema, or both, and
also may necessitate bladder catheterization after surgery. Bladder catheterization can lead to its own set of
problems,includingurinarytractinfections.
Ifpharmacologictreatmentofhypotensionisindicated,vasopressorsremainthemainstayoftreatment.Combined
andadrenergicagonistsmaybebetterthanpureagonistsfortreatingbloodpressuredepression,andephedrine
is currently the drug of choice.[148,149] Cardiac output and peripheral vascular resistance are increased by
ephedrine, which restores blood pressure. However, physiologic treatment of hypotension centers on restoration of
preload. The most effective and simple way to achieve this is by positioning the patient in the Trendelenburg, or
headdown,position.[150]Thispositionshouldnotexceed20degreesbecauseextremeTrendelenburgcanleadtoa
decrease in cerebral perfusion and blood flow due to increases in jugular venous pressure. If the level of spinal
anesthesiaisnotfixed,theTrendelenburgpositioncanalterthelevelofspinalanesthesiaandcauseahighlevelof
spinalanesthesiainpatientsreceivinghyperbariclocalanestheticsolutions.[151]Thiscanbeminimizedbyraising
theupperpartofthebodywithapillowundertheshoulderswhilekeepingthelowerpartofthebodyelevatedabove
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heartlevel.Figure8showsanalgorithmforthetreatmentofhypotensionafterspinalanesthesia.

Figure8:Treatmentofhypotensionafterspinalanesthesia.CVA=cardiovascularaccident,CNS=centralnervous
system,BP=bloodpressure,HR=heartrate,bpm=beatsperminute.

TheBezoldJarischReflex
The BezoldJarisch reflex (BJR) has been implicated as a cause of bradycardia, hypotension, and cardiovascular
collapse after central neuraxial anesthesia, and in particular spinal anesthesia.[152,153] The BJR is a cardio
inhibitoryreflexandconsistsofthetriadofsymptoms,bradycardia,hypotension,andcardiovascularcollapse,seen
after intravenous injection of Veratrumalkaloids in animals.[154] The BJR is usually not a dominant reflex and the
associationwithspinalanesthesiaisprobablyweak.[154,155]Bloodpressureregulationismultimodalandcomplex,
and while the BJR likely plays a role in this regulation, the dominant reflex in regulation of blood pressure is the
baroreceptor reflex. The BJR is also not a vasovagal reflex, although BJR has been blamed for bradycardia after
spinalanesthesia,especiallyafterhemorrhage.[156]Nostudieshaveyetdefinedthisrelationship.Withthedearthof
dataavailable,moreresearchmustbedonebeforetheBJRisnamedasthecauseofbradycardia,hypotension,and
circulatorycollapseafterspinalanesthesia.

RespiratoryEffectsofSpinalAnesthesia
In patients with normal lung physiology, spinal anesthesia has very little effect on pulmonary function.[157] Lung
volumes, resting minute ventilation, dead space, arterial blood gas tensions, and shunt fraction show minimal
changeafterspinalanesthesia.Themainrespiratoryeffectofspinalanesthesiaoccursduringhighspinalblockade
when active exhalation is affected due to paralysis of abdominal and intercostal muscles. During high spinal
blockade, expiratory reserve volume, peak expiratory flow, and maximum minute ventilation are reduced. Patients
withobstructivepulmonarydiseasethatrelyonaccessorymuscleuseforadequateventilationshouldbemonitored
carefully after spinal blockade. Patients with normal pulmonary function and a high spinal block may complain of
dyspnea,butiftheyareabletospeakclearlyinanormalvoice,ventilationisusuallynormal.Thedyspneaisusually
due to the inability to feel the chest wall move during respiration, and simple assurance is usually effective in
allayingthepatient'sdistress.
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ClinicalPearls
Arterialbloodgasmeasurementsdonotchangeduringhighspinalanesthesiainpatientswhoarespontaneously
breathingroomair.
Sinceahighspinalusuallydoesnotaffectthecervicalarea,sparingofthephrenicnerveandnormaldiaphragmatic
functionoccurs,andinspirationisminimallyaffected.

Arterial blood gas measurements do not change during high spinal anesthesia in patients who are spontaneously
breathing room air. The main effect of high spinal anesthesia is on expiration, as the muscles of exhalation are
impaired. Since a high spinal usually does not affect the cervical area, sparing of the phrenic nerve and normal
diaphragmaticfunctionoccurs,andinspirationisminimallyaffected.AlthoughSteinbrookandcolleaguesfoundthat
spinal anesthesia was not associated with significant changes in vital capacity, maximal inspiratory pressure, or
resting endtidal PCO2, an increased ventilatory responsiveness to CO2 with bupivacaine spinal anesthesia was
seen.[158]

GastrointestinalEffectsofSpinalAnesthesia
The sympathetic innervation to the abdominal organs arises from T6 to L2. Due to sympathetic blockade and
unopposed parasympathetic activity after spinal blockade, secretions increase, sphincters relax, and the bowel
becomesconstricted.

ClinicalPearls
Increasedvagalactivityaftersympatheticblockcausesincreasedperistalsisofthegastrointestinaltract,whichleadsto
nausea.
Atropineisusefulfortreatingnauseaafterhighspinalblockade.

Nausea and vomiting occur after spinal anesthesia approximately 20% of the time, and risk factors include blocks
higher than T5, hypotension, opioid administration, and a history of motion sickness.[134] Increased vagal activity
after sympathetic block causes increased peristalsis of the gastrointestinal tract, which leads to nausea.
Accordingly,atropineisusefulfortreatingnauseaafterhighspinalblockade.[149]

TheUseOfSpinalAnesthesiaInObstetrics
In1901,Kreisdescribedthefirstspinalanestheticforvaginaldelivery.[159]Spinalanesthesiaforlaboranddelivery
has progressed greatly since that time. When contemplating induction of anesthesia in the pregnant patient, many
factorsplayarole.Theanesthesiologistmustperformacompletepreanestheticevaluation,includingpastmedical
and surgical history, past reactions to anesthesia, any difficulties during the pregnancy, maternal airway and back
anatomy,andfetalassessment.Inaddition,theanesthesiologistmustobtaininformedconsentforbothregionaland
generalanesthesia.Beforeperformingaspinalanestheticonthelaborfloor,resuscitativeequipmentandemergency
medicationmustbereadilyavailable.Althoughmanyargumentsaremadeagainstgeneralanesthesiainthepregnant
woman due to increased risk of aspiration and difficult intubation, the anesthesiologistmust be prepared to induce
generalanesthesiainthefaceofafailedortotalspinalanesthetic.

ClinicalPearls
Pregnantwomenrequirelesslocalanesthetictoachievethesamelevelofanesthesiaasnonpregnantwomen.
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AT4levelblockisusuallyrequiredforacesareansectionduetotractionontheperitoneumanduterineexteriorization.

Spinal anesthesia is useful in both elective and emergent cesarean sections. Noncutting, pencilpoint spinal
needlesareusedforspinalobstetricanesthesia,whichhasresultedinadecreasedincidenceofPDPH.Mostofthe
time, spinal obstetric anesthesia is administered as a single injection, and the rapid onset and dense neural block
areofbenefit.Becauseofthesympatheticblockade,hypotensionmayresult,soitisprudenttomonitortheblood
pressureverycarefullyandfrequently.Theanesthesiologistshouldtreathypotensionimmediatelywithmedications
orfluidadministration,orboth.
Pregnantwomenrequirelesslocalanesthetictoachievethesamelevelofanesthesiaasnonpregnantwomen.This
observation is likely due to both hormonal and mechanical factors. Procaine, tetracaine, lidocaine, bupivacaine,
ropivacaine, and levobupivacaine have all been used for obstetric anesthesia, but the preferred local anesthetic is
bupivacaine. Dosing is generally done either with a fixed amount of local anesthetic or changing the amount
accordingtotheheightandweightofthepatient.Ifhyperbaricbupivacaineisused,12mgisgenerallygiven,witha
decreaseddoseforshortpatientsandanincreaseddoseifthespinalisgiveninthesittingposition.Fentanyl1020
mcg is usually added to enhance the quality of the block. Prior to placement of a spinal anesthetic, the pregnant
patientshouldreceive30mLof0.3Msodiumcitrateorallytodecreasethestomachacidity,andabolusofRinger's
lactate1520mL/kg.Metoclopramidetoimprovegastricemptyingcanalsobegivenpriortothespinal.
Afterthespinalanestheticisgiven,thepatientshouldbeinthesupinepositionwithleftuterinedisplacement.Fetal
heart rate should be monitored by Doppler or fetal scalp electrocardiogram (ECG). Blood pressure and heart rate
should be monitored every minute for at least 10 min, and immediate treatment should be given for decreases in
blood pressure. A T4 level block is usually required for a cesarean section due to traction on the peritoneum and
uterineexteriorization.Somepatientscomplainofdyspneaduetoabdominalandintercostalmotorblockade,butif
the patient is able to speak clearly, assurance and possible gentle bag and maskassisted ventilation is usually
enoughtocalmthepatientuntildelivery.Oncethefetusisdelivered,theuterusnolongercausesupwardpressure
onthediaphragm,andthepatientisabletobreathemoreeasily.

FactorsAffectingLevelOfSpinalBlockade
Manyfactorshavebeensuggestedaspossibledeterminantsofspinalblockadelevel.[50]Thefourmaincategories
of factors are (1) characteristics of the local anesthetic solution, (2) patient characteristics, (3) technique of spinal
blockade,and(4)diffusion.Characteristicsoflocalanestheticsolutionincludebaricity,localanestheticdose,local
anesthetic concentration, and volume injected. Patient characteristics include age, weight, height, gender, intra
abdominal pressure, anatomy of the spinal column, spinal fluid characteristics, and patient position.[160]
Techniques of spinal blockade include site of injection, speed of injection, direction of needle bevel, force of
injection,andadditionofvasoconstrictors(seeTable1).

ClinicalPearls
Thethreemostimportantfactorsindetermininglevelofspinalblockade:
Baricityofthelocalanestheticsolution
Positionofthepatientduringandjustafterinjection
Doseoftheanestheticinjected

Althoughallthesefactorshavebeenpostulatedasaffectingspinalspreadofanesthetic,notmanyhavebeenshown
tochangethedistributionofblockadewhenallotherfactorsthataffectblockadearekeptconstant.Siteofinjection,
age,positionofthepatientduringandafterinjection,dosageandvolumeofanestheticsolutioninjected,baricityof
local anesthetic, anatomy of the spine, direction of the needle during injection, volume of CSF, and increased
intraabdominalpressurecanallinfluencethespreadofspinalblockade.
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SiteofInjection
Thesiteofinjectionoflocalanestheticsforspinalanesthesiacandeterminethelevelofblockade.Insomestudies,
isobaric spinal 0.5% bupivacaine produces sensory blockade that is reduced by two dermatomes per interspace
wheninjectionatL23,L34,andL45interspacesarecompared.[161,162]

ClinicalPearls
Siteofinjectionandbaricityappeartobecorrelatedindeterminingthelevelofspinalblockade.

However, no difference in block height exists when hyperbaric bupivacaine or dibucaine is injected as a spinal
anestheticindifferentinterspaces.[163165]

Age
Somestudieshavereportedchangesinblockheightafterspinalanesthesiaintheelderlypatientascomparedwith
the young patient, but other studies have reported no difference in block height.[166169] These studies were
performedwithbothisobaricandhyperbaric0.5%bupivacaine.

ClinicalPearls
Baricityplaysamajorroleindeterminingblockheightafterspinalanesthesiainolderpopulations.

Isobaricbupivacaineappearstoincreaseblockheight,andhyperbaricbupivacainedoesnotappeartochangeblock
height with increasing age. If there is a correlation between increasing age and spinal anesthesia height, it is not
strong enough by itself to be a reliable predictor in the clinical setting.[170,171] Just as with site of injection, it
appearsthatbaricityplaysamajorroleindeterminingblockheightafterspinalanesthesiainolderpopulationsand
ageisnotanindependentfactor.

Position
Positioning of the patient is very important for determining level of blockade after hyperbaric and hypobaric spinal
anesthesia, but not for isobaric solutions. Sitting, Trendelenburg, and prone jackknife positions can greatly change
the spread of the local anesthetic due to effect of gravity.[172174] Gravity and baricity are interrelated when
positionisinvolvedindeterminingspinalblockheight.

ClinicalPearls
Positioningofthepatientisveryimportantfordetermininglevelofblockadeafterhyperbaricandhypobaricspinal
anesthesia,butnotforisobaricsolutions.

The combination of baricity of the local anesthetic solution and patient positioning determines spinal block height
level.[175] Thesitting position in combination with a hyperbaric solution can produce analgesia in the perineum.
Trendelenburg positioning will also affect spread of hyperbaric and hypobaric local anesthetics due to the effect of
gravity.[151,176] Prone jackknife positioning is used for rectal, perineal, and lumbar procedures with a hypobaric
localanesthetic.[59,177]Thispreventsrostralspreadofthespinalblockadeafterinjection.

SpeedofInjection
Speed of injection has been reported to affect spinal block height, but the data available in the literature are
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conflicting.178

ClinicalPearls
Eventhoughspinalblockheightdoesnotchangewithspeedofinjection,useasmooth,slowinjectionwhengivinga
spinalanesthetic.

Instudiesusingisobaricbupivacaine,thereisnodifferenceinspinalblockheightwithdifferentspeedsofinjection.
[179181]Eventhoughspinalblockheightdoesnotchangewithspeedofinjection,asmooth,slowinjectionshould
beusedwhengivingaspinalanesthetic.Ifaforcefulinjectionisgivenandthesyringeisnotconnectedtightlytothe
spinalneedle,thelocalanestheticmightbeaerosolizedandlosttotheatmosphere.

Volume,Concentration,&DoseofLocalAnesthetic
It is difficult to maintain volume, concentration, or dose of local anesthetic constant without changing any of the
other variables, thus it is difficult to produce highquality studies that investigate these variables singly. Axelsson
andassociatesshowedthatvolumeoflocalanestheticcanaffectspinalblockheightanddurationwhenequivalent
dosesareused.[182]

ClinicalPearls
Whenperformingaspinalanesthetic,becognizantofnotonlythedoseoflocalanesthetic,butalsothevolumeand
concentrationsoasnottooverdoseorunderdosethepatient.

Peng and coworkers showed that concentration of local anesthetic is directly related to dose when determining
effective anesthesia.[183] However, dose of local anesthetic plays the greatest role in determining spinal block
duration, as neither volume nor concentration of isobaric bupivacaine or tetracaine alter spinal block duration when
thedoseisheldconstant.[184,185]Studieshaverepeatedlyshownthatspinalblockdurationislongerwhenhigher
doses of local anesthetic are given.[54,61,182,186,187] When performing a spinal anesthetic, be cognizant of not
only the dose of local anesthetic, but also the volume and concentration so as not to overdose or underdose the
patient.
The use of hyperbaric solutions minimizes the importance of dose and volume except when doses of hyperbaric
bupivacaine equal to or less than 10 mg are used. In those cases, there is less cephalad spread and a shorter
durationofaction.[173]Adoseofhyperbaricbupivacainebetween10and20mgresultsinsimilarblockheight.[163]
Whenusinghyperbaricsolutions,itisimportanttonotethatpatientpositioningandbaricityarethemostinfluential
factorsonblockheight,exceptwhenlowdosesofhyperbaricbupivacaineareused.

ChoiceOfLocalAnesthetic
The choice of local anesthetic determines the duration of the spinal blockade. The shortest acting local anesthetic
for spinal use is preservativefree 2chloroprocaine.[188] Procaine is the next shortest acting local anesthetic,
followed by lidocaine. The longacting local anesthetics include bupivacaine, ropivacaine, and tetracaine. Even
thoughchloroprocaineisnotcurrentlyapprovedbytheFDAforthespecificindicationofintrathecaluse,resultsfrom
recent clinical trials have shown preservativefree 2chloroprocaine to be safe, shortacting, and acceptable for
outpatient surgery, with some episodes of flulike symptoms and low back pain associated with the addition of
epinephrine.[88] Chronic neurologic deficits have been reported in rabbits when sodium bisulfite is injected into the
lumbar subarachnoid space, but when preservativefree 2chloroprocaine was injected, no permanent neurologic
sequelae were noted.[189] Onset time is very fast, and the duration is around 60 min for surgical anesthesia. The
doserangesfrom20to60mg,with40mgasausualdose.
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Procaine,commonlyknownasNovocain,isashortactingesterlocalanesthetic.Procainehasanonsettimeof3to
5 min and a duration time of 50 to 60 min. However, there is a 14% incidence of block failure associated with
procaine10%.[190]Adoseof50to100mgissuggestedforperinealandlowerextremitysurgery.Concernsabout
the neurotoxicity of procaine have limited its use, but there appears to be less risk of TNS and transient radicular
irritation(TRI).[191193]Procainecanbeusedonlyforshortcases.

ClinicalPearls
Theshortestactinglocalanestheticforspinaluseispreservativefree2chloroprocaine.
Procaineisthenextshortestactinglocalanesthetic,followedbylidocaine.
Thelongactinglocalanestheticsincludebupivacaine,ropivacaine,andtetracaine.

Lidocaine,anamidelocalanesthetic,alsoprovidesanonsettimeof3to5minwithadurationtimeof60to90min.
As described previously, there is a strong association between lidocaine and TNS, which limits the usefulness of
lidocaine.[6567]Forperinealsurgeryandsaddleblockanesthesia,adoseof25to50mgisgiven.Lidocaineisalso
usedforshortoperatingroomcases.
Tetracaine, another ester local anesthetic, provides anesthesia within 3 to 6 min and lasts 210 to 240 min. The
durationofanesthesiaismuchlongerthanwiththeotheresteranestheticsandalsomuchlongerthanwithlidocaine.
The suggested dose is 5 mg for perineal and lower extremity surgery. Tetracaine is used for intermediate to long
lastingcases.
Bupivacaine,anotheramidelocalanesthetic,hasanonsettimeof5to8minwithadurationtimeof210to240min,
whichissimilartotetracaine.Thesuggesteddoseis810mgforperinealandlowerextremitysurgeryand1520mg
for abdominal surgery. Bupivacaine is one of the most widely used local anesthetics for spinal anesthesia and
providesadequateanesthesiaandanalgesiaforintermediatetolongdurationoperatingroomcases.

Number&FrequencyofLocalAnestheticInjections
Inthemajorityofcases,asingleshotinjectionoflocalanestheticisgivenwhenaspinalanestheticisperformed.At
times, a continuous spinal anesthetic is utilized with an infusion pump continuously providing medication though a
spinalcatheterorbygivingbolusesthroughaspinalcatheter.

ClinicalPearls
IfthespinalblockadelevelislowerthanT10,halftheinitialdoseoflocalanestheticshouldbegiventhroughthecatheter.

Procaine,commonlyknownasNovocain,isashortactingesterlocalanesthetic.Procainehasanonsettimeof3to
5 min and a duration time of 50 to 60 min. However, there is a 14% incidence of block failure associated with
procaine10%.[190]Adoseof50to100mgissuggestedforperinealandlowerextremitysurgery.Concernsabout
the neurotoxicity of procaine have limited its use, but there appears to be less risk of TNS and transient radicular
irritation(TRI).[191193]Procainecanbeusedonlyforshortcases.

EquipmentForSpinalAnesthesia
In the past, most institutions had reusable trays for spinal anesthesia. These trays required preparation by
anesthesiologistsoranesthesiapersonneltoensurethatbacterialandchemicalcontaminationwouldnotoccur.The
contents of the trays did not differ from those currently available commercially, but strict attention to sterility must
bemaintainedtoensurepatientsafetywhileusingthetrays.
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ClinicalPearls
Resuscitationequipmentmustbeavailablewhenperformingaspinalanesthetic.

Currently,commerciallyprepared,disposablespinaltraysareavailableandareinusebymostinstitutions.Mostof
these trays contain the same items: a paper towel, fenestrated drape, gauze sponges, prep solution well and
sponges, medicine well, ampules of lidocaine 1% and epinephrine, standard or pencilpoint needles, introducers,
syringesandneedles,afilterstraw,povidoneiodinesolutionpacket,needleblockfoamwithholder,andanampule
of local anesthetic for spinal injection. These trays are portable, sterile, and easy to use. Familiarity with the
contents of the spinal tray is essential to placing a spinal anesthetic quickly. Figure 9 shows the contents of
standard,commerciallypreparedspinalanesthetictray.

Figure9:Thecontentsofstandard,commerciallypreparedspinalanesthesiatray.
Resuscitationequipmentmustbeavailablewheneveraspinalanestheticisperformed.Thisincludesmedicationfor
sedationandinductionofgeneralanesthesia(propofol,fentanyl,midazolam,succinylcholine),medicationforsupport
of cardiac function (ephedrine, epinephrine, atropine), an oropharyngeal airway, a laryngoscope with blade, an
endotracheal tube with stylet and cuff syringe, tape for securing the endotracheal tube, a tongue depressor, a
Yankauersuctiontube,anoxygensource,andanAmbubagandfacemask.Thepatientmustbemonitoredduring
theplacementofthespinalanestheticwithapulseoximeter,bloodpressurecuff,andECG.Alloftheseprecautions
arenecessarytoprovidethesafestenvironmentforperformingaspinalanesthetic.

Needles
Needles of different diameters and shapes have been developed for spinal anesthesia. The ones currently used
haveaclosefitting,removablestylet,whichpreventsskinandadiposetissuefrompluggingtheneedleandpossibly
enteringthesubarachnoidspace.Figure10showsthedifferenttypesofneedlesusedalongwiththetypeofpointat
theendoftheneedle.

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Figure10:Thedifferenttypesofneedlesusedforspinalanesthesiaalongwiththetypeofpointattheendofeach
typeofneedle.
The pencilpoint needles (Sprotte and Whitacre) have a rounded, noncutting bevel with a solid tip. The opening is
locatedonthesideoftheneedle24mmproximaltothetipoftheneedle.Theneedleswithcuttingbevelsinclude
theQuinckeandPitkinneedles.TheQuinckeneedlehasasharppointwithamediumlengthcuttingneedle,andthe
Pitkin has a sharp point and short bevel with cutting edges. Finally, the Greene spinal needle has a rounded point
and rounded noncutting bevel. If a continuous spinal catheter is to be placed, a Tuohy needle can be used to find
thesubarachnoidspacebeforeplacementofthecatheter.
Pencilpointneedlesprovideabettertactilesensationofthelayersofligamentencounteredbutrequiremoreforceto
insertthanbeveltipneedles.Thebeveloftheneedleshouldbedirectedlongitudinallytodecreasetheincidenceof
PDPH.[195]

ClinicalPearls
Pencilpointneedlesprovideabettertactilesensationofthelayersofligamentencounteredbutrequiremoreforceto
insertthanbeveltipneedles.
ThebeveloftheneedleshouldbedirectedlongitudinallytodecreasetheincidenceofPDPH.

Larger gauge needles and needles with rounded, noncutting bevels also decrease the incidence of PDPH, but are
moreeasilydeflectedthansmallergaugeneedles.
Introducershavebeendesignedtoassistwiththeplacementofspinalneedlesintothesubarachnoidspacedueto
thedifficultyindirectingneedlesofsmallborethroughthetissues.Introducersalsoservetopreventcontamination
of the CSF with small pieces of epidermis, which could lead to the formation of dermoid spinal cord tumors. The
introducer is placed into the interspinous ligament in the intended direction of the spinal needle, and the spinal
needleisthenplacedthroughtheintroducer.

PositionOfThePatient
Properpositioningofthepatientforspinalanesthesiaisessentialforafast,successfulblock.Manyfactorscome
intoplayforpositioningofthepatient.Beforebeginningtheprocedure,boththepatientandanesthesiologistshould
becomfortable.Thisincludesaproperleveloftheoperatingroomtable,adequateblanketsorcoversforthepatient,
a functioning intravenous line, standard American Society of Anesthesiologists (ASA) monitors, administration of
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100%oxygen,andsedationforthepatient.

ClinicalPearls
Thepatientshouldreceivesomesedation,butnottoomuch,inordertobecomfortableduringtheprocedure.
Thepatientshouldbeabletocooperatebefore,during,andafteradministrationofthespinalanesthetic.

Atrainedassistantshouldbeavailabletohelpoptimizepatientposition.Thepatientshouldreceivesomesedation,
but not too much, in order to be comfortable during the procedure. The patient should be able to cooperate before,
during, and after administration of the spinal anesthetic. There are three main positions for administering a spinal
anesthetic:thelateraldecubitus,sitting,andproneposition.

LateralDecubitusPosition
Themostcommonlyusedpositionforplacingaspinalanestheticisthelateraldecubitusposition.Idealpositioning
consists of having the back of the patient parallel to the edge of the bed closest to the anesthesiologist, knees
flexedtotheabdomen,andneckflexed.Figure11showsapatientinthelateraldecubitusposition.

ClinicalPearls
Themostcommonlyusedpositionforplacingaspinalanestheticisthelateraldecubitusposition.
Idealpositioningconsistsofhavingthebackofthepatientparalleltotheedgeofthebedclosesttotheanesthesiologist,
kneesflexedtotheabdomen,andneckflexed.

Itisessentialtohaveanassistanttohelpholdandencouragethepatienttostayinthisposition.Dependingonthe
operativesiteandoperativeposition,ahypo,iso,orhyperbaricsolutionoflocalanestheticcanbeinjected.

Figure11:Apatientinthelateraldecubitusposition.

SittingPosition&"SaddleBlock"
Strictlyspeaking,thesittingpositionisbestutilizedforlowlumbarorsacralanesthesiaandininstanceswhenthe
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patient is obese and there is difficulty in finding the midline in the lateral position. In practice, however, many
anesthesiologists prefer the sitting position in all patient who can be positioned for the ease of identification of the
landmarks. Using a stool for a footrest and a pillow for the patient to hold can be valuable in this position. The
patientshouldhavetheneckflexedandpushoutthelowerbacktoopenupthelumbarvertebralspace.Figure12
depictsapatientinthesittingpositionandtheL45interspaceismarked.

Figure12:ApatientinthesittingpositionwiththeL4/L5interspacemarked.

ClinicalPearls
Thesittingpositionisutilizedforlowlumbarorsacralanesthesiaandininstanceswhenthepatientisobeseandthereis
difficultyinfindingthemidlineinthelateralposition.
Whenperformingasaddleblock,thepatientshouldremaininthesittingpositionforatleast5minafterahyperbaric
spinalanestheticisplacedtoallowthespinaltosettleintothatregion.

Whenperformingasaddleblock,thepatientshouldremaininthesittingpositionforatleast5minafterahyperbaric
spinalanestheticisplacedtoallowthespinaltosettleintothatregion.Ifahigherlevelofblockadeisnecessary,the
patientshouldbeplacedsupineimmediatelyafterspinalplacementandthetableadjustedaccordingly.

PronePosition
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Thepronepositionisutilizedforspinalanesthesiaifthepatientneedstobeinthispositionforthesurgery,suchas
forrectal,perineal,orlumbarprocedures.Ahypobaricorisobaricsolutionoflocalanestheticispreferredintheprone
jackknifepositionfortheseprocedures.

ClinicalPearls
Thepronepositionisutilizedforspinalanesthesiaifthepatientneedstobeinthispositionforthesurgery,suchasfor
rectal,perineal,orlumbarprocedures.

This allows the anesthetic to spread in the caudal direction and avoid rostral spread and the risk of high spinal
anesthesia.Careshouldtobetakentokeepthepatientinthesamepositionforatleast15minafterinjectionprior
tomovingsothatthelocalanestheticsolutionwillnotmigratetoalevelthatitwasnotintendedtobe.
Another, less elegant solution is to inject a hyperbaric solution of local anesthetic with the patient in the sitting
position and await until the spinal anesthesia setsin, which is typically 1520 min after injection. The patient is
then positioned in the prone position with vigilant monitoring, including frequent verbal communication with the
patient.

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