Professional Documents
Culture Documents
General principles
• Chemistry.
Esters Amides
-Procaine -Lidocaine
-Chloroprocaine -Mepivacaine
-Tetratcaine -Bupivacaine
-Cocaine -Etidocaine
-Prilocaine
-Ropivacaine
Metabolism
-Hydrolysis by pseudo-
Metabolism
-Liver
cholinesterase enzyme
2
General principles
B.Mechanism of action
1.Local anesthetics block nerve conduction
2. Local anesthetics interact directly with
specific receptors on Na+ channel
3. Physiochemical properties
High lipid solubility
protein binding
pKa
Lower pH of the drug solution
4.Differential blockade of nerve fibers
5. Sequence of clinical anesthesia.
6. Pathophysiologic factors .
3
Clinical uses of local anesthetics
4
Characteristics of local anaesthetic drugs
Maximum dose
5
Local anaesthetic drugs have serious side
effects if given in excess, or inadvertently released
into the circulation. Toxicity is manifested in a
variety of ways ranging from mild excitation to
serious neurological and fatal cardiac sequelae.
6
Symptoms and signs of local anaesthetic toxicity
• Anxiety
• Restlessness
• Nausea
• Tinnitus
• Circumoral tingling
• Tremor
• Tachypnoea
• Clonic convulsions
• Arrhythmias
– ventricular fibrillation
– asystole
7
Recommendations for the safe use of
epinephrine in local anaesthetic solutions
• No hypoxia
• No hypercapnia
• Caution with arrhythmogenic volatile agents,
for example, halothane
• Concentration of ≤1:200,000
• Dose <20 ml of 1:200,000 in 10 minutes
• Total dose <30 ml/hour
8
Requirements before starting regional
anaesthesia
• Informed consent
• Vascular access
• Resuscitation drugs and equipment
• Sterility of anaesthetist
• Sterility of operative site
• No contraindications to procedure
• Correct dosage of local anaesthetic drug
9
Epidural 、 Spinal and Caudal
anaesthesia
10
General considerations
A.Preoperative assessment
B. The area where the block is to be administered
should be examined
C. A history of abnormal bleeding
and a review of the patient's medications
D. Patients should be given a detailed explanation
E. patients should receive appropriate monitoring
and have an intravenous (IV) line in place
11
Segmental level required for surgery
12
Segmental level required for surgery
alive…
-T1-T4: Cardioaccelerator
-T4: Nipple line
-T6: Xyphoid process
-T10: Umbilicus
-S2,3,4: Keep the penis
off the floor…
13
14
Contraindications to peridural anesthesia
A. Absolute
1.Patient refusal.
2.Localized infection at skin puncture site.
3.Generalized sepsis (e.g., septicemia, bacteremia).
4.Coagulopathy.
5.Increased intracranial pressure.
B. Relative
1.Localized infection peripheral to regional technique site.
2.Hypovolemia.
3.Central nervous system disease.
4.Chronic back pain.
15
Section 1 Epidural anesthesia
16
Epidural anesthesia
is achieved by introduction of anesthetics into
the epidural space.
17
Anatomy
18
Anatomy
20
Anatomy
21
Anatomy
22
Epidural anesthesia technique
--Preparation
Obtain an epidural anesthesia kit
Check the contents of the kit for the
following items
-Skin local
-Test dose
-16-18g Husted or Touhy needle
-Glass syringe
-Epidural catheter with adapter for
injection
-Various needles for local, “seeker”,
etc. 23
24
Epidural anesthesia technique
Positioning
Sitting vs. lateral decubitis
-Most beginners do better sitting
-ALL patients should be on the monitor before starting
Encourage the patient to extrude their lower back
-Use yourself as an example
- “Push your back out toward me, arched like a mad
cat”
- “pretend you are the world’s largest boiled shrimp”
This will open up the interspace, help ID your landmarks, and
improve your chances
25
26
Paramedian Approach:
Larger Aperture
Better feel
Epidural anesthesia technique
Approach
1.Midline easier
2.Paramedian
when there is narrowing of the
interspace or difficulty in flexion of
the spine
27
Epidural anesthesia
Epidural anesthesia technique
Preparation of the skin is done in a circular motion
from the center out to the periphery
Use all 3 scrub brushes
Place eye drape centered over your target
You can use either the end of your pen or your
fingernail to make an indentation in the back to find
your target more readily
28
Epidural Anesthesia
Epidural anesthesia technique
Skin wheal is accomplished with plain lidocaine
• Be fairly generous
Seeker needle is placed and more local injected on
removal
Some people like to use an 18g needle to break the
skin, followed by the epidural needle into the same
hole
• This is because the epidural needle is not sharp and
significant pressure may be required to break the skin
with it
29
Epidural Anesthesia
Epidural anesthesia technique
The needle is inserted using landmarks and position
identical to that used in spinal anesthesia
Advance the needle and go through the supraspinous
ligament (feels gritty) and seat it in the intraspinous
ligament
Now the needle should not droop when you let go
Remove the stylet at that time and place your glass
syringe tightly onto the hub of the needle
30
Epidural anesthesia
31
Epidural Anesthesia
Epidural anesthesia technique
Loss of resistance technique
• Some people use saline
• Some use air
• Some wet the barrel with saline and use air
• Some use a combination of air and saline
32
Epidural Anesthesia
Epidural anesthesia technique
Loss of resistance technique
• Maintain contact with the skin with your nondominant
hand
• You will notice the resistance increase when you enter
the ligamentum flavum
– This is not always the case in OB
• Continue to advance until air/saline injects with ease
• Injecting saline may help “tent” the dura and make
catheter placement easier
• If fluid rushes back at you when you disconnect the
syringe, it is probably CSF
33
Epidural Technique
(Loss of Resistance Technique)
Hand-position
Note depth
Air or Saline debate
Catheter 3-5 cm in space (should go easily)
34
Air vs Saline LOR Technique
35
Hanging drop technique
Consider for
Cervical
Epidurals (thin
epidural
space)
Prone or
sitting
36
Epidural anesthesia
37
Epidural Anesthesia
Epidural anesthesia technique
• If you think you may have wet tapped the patient, but
are not sure, or if you aspirate fluid from your catheter,
you can test it using glucose test strips
The catheter has a large mark on it to signify the end
of the needle
You advance the catheter 2.5 to 4cm
Hold the catheter as you remove the needle
When the catheter is visible at the skin, grasp it there
and pull the needle the rest of the way off
38
Epidural Anesthesia
Epidural anesthesia technique
Place the catheter injection adapter onto the catheter
• Push the end of the catheter into the adapter and
screw it closed
• Give it a gentle tug to ensure it is seated and clamped
Tape the catheter in the manner. The techniques
vary greatly
39
Epidural Anesthesia
Epidural anesthesia technique
Using sterile technique, draw up your test dose
• Aspirate the catheter to ensure you do not see fluid or
blood
• Inject 3ml of test dose (pt.should be on the monitor)
– If catheter is intravenous, you should notice a 20%
increase in B/P and Heart rate, due to the 15ug
epinephrine
– If the catheter is subarachnoid, you should notice a
sympathectomy and partial sensory/motor block ensure
40
41
Epidural Anesthesia
Epidural anesthesia technique
The rule of thumb is 0.5-1.5ml of local per segment
of block desired
3-5ml of local every 3 minutes until level desired is
reached
Slow dosing decreases the untoward sympathectomy
complications
Baricity is not a factor in the epidural space,
because there is no other fluid normally present
42
Epidural anesthesia
43
Epidural anesthesia
44
Epidural Anesthesia
Epidural anesthesia technique
Place the patient in the position of comfort if laboring
For non labor patients, do not position them for
surgery until you are sure you have an adequate
block
Gravity matters! It will influence the direction and
spread of the block, so consider it’s implications
during your dosing regimen
45
Epidural anesthesia
46
Epidural Anesthesia
Combined spinal/epidural technique
Spinal anesthetic followed by epidural infusion
Combines rapid onset with sustained analgesia
May be used for surgery/post op pain management
May be used for labor/delivery
Access epidural space
Spinal needle fits through the lumen of the epidural
Epidural needle is special – must have “back eye”
47
Epidural anesthesia
Undocumented concern
exists that some of the
epidural injection can
migrate subarachnoid,
causing an increased
level of block
48
Epidural Anesthesia
Immediate complications of epidurals
Sympathetic nervous system disruption
(sympathectomy)
• Severe hypotension (pre-ganglionic sympathetic block)
– Peripheral vasodilation
– Venous pooling
– Reduction in venous return
• High block may result in anesthetizing cardiac
accelerators (T1-T4), with resulting slowed heartrate
called the “Bainbridge Reflex”
49
Epidural Anesthesia
Immediate complications of epidurals
Perioperative hypotension
• Rapid position changes
• Skeletal muscle tone loss
• Decreased venous return
• Reflex surgical stimulation
• Low volume status
• Preoperative medications
• Concurrent medical problems
50
Epidural Anesthesia
52
Epidural Anesthesia
Immediate complications of epidurals
Hypoxia and/or hypercarbia
• High level of block can be insidious
• Remember C3,4,5 keeps the diaphragm alive
• Once your level of blockead has exceeded C3, phrenic
nerve paralysis will ensue
• Perception of intercostal nerves and abdominal
excursion is lost at the level of T2-4
• Intercostal nerves account for 20% of tidal breathing –
some of our patients don’t tolerate that well!
53
Epidural Anesthesia
54
Epidural Anesthesia
Total spinal/epidural
Can lead to acute pulmonary collapse
Treated symptomatically
Intubation required
Will loose consciousness
Will be severely hypotensive, requiring vasopressor
infusion
Unopposed parasympathetic system leads to
bradycardia and vomiting
55
Epidural Anesthesia
Immediate complications of epidurals
Nausea and/or vomiting
• Parasympathetically mediated
• Always rule out neurological hypoxia as the first cause
• Factors that increase neurological hypoxia:
– ETOH (ethyl alcohol )
– Obesity
– Prone position
– Apprehension
– High level of blockade
56
Epidural Anesthesia
Immediate complications of epidurals
Intravascular injection
• You can never over test dose a catheter
• You should re-test dose if it has been 4 hours since
placement or last bolus
• IV lidocaine leads to neurologic symptoms, such as
ringing in the ears, metallic taste in mouth, numbness
and/or tingling around the mouth
• Epinephrine 15ug should be enough to cause
hypertension, palpitations, anxiety, tachycardia
57
Epidural Anesthesia
Immediate complications of epidurals
Intravascular injection
• ALWAYS aspirate your catheter before you inject…
EVERY time
• Positive blood aspiration requires immediate removal
and/or replacement of catheter
• Positive CSF aspiration is problematic- use blood
glucose strip to test if unsure, or CSF will precipitate
when mixed with thiopental (not as accurate)
58
Epidural Anesthesia
Immediate complications of epidurals
Subarachnoid injection
• Immediate change in sensorium
• Anxiety
• Dyspnea
• Immediate intubation and vasopressor support are
crucial to survival
• Discontinue the catheter
• Call for help!
59
Epidural Anesthesia
Delayed complications of epidurals
Post dural puncture headache (PDPH)
• Can occur after either obvious or occult dural puncture
• CSF leaks chronically out of the hole in the dura
• Decreased amount of available CSF in Subarachnoid
space
• Medulla and brainstem sag into foramen magnum
• Resulting stretching of the meninges and pulling on the
tentorium cause the headache
60
Epidural Anesthesia
Delayed complications of epidurals
Post dural puncture headache (PDPH)
• Headaches most common in parturients, as they
already have a decreased CSF production and
engorged epidural veins
• The proposed causes are related to
– Needle type and size
– Direction of the bevel
– Number of punctures
– Patient position
61
Epidural Anesthesia
63
Epidural Anesthesia
Delayed complications of epidurals
Post dural puncture headache (PDPH)
• Conservative treatment is always attempted first
– Bed rest
– Vigorous hydration (if tolerated)
– Use of sedatives and opioids
– Abdominal binder for ambulation
– Caffeine and niacin
64
Epidural Anesthesia
Delayed complications of epidurals
Post dural puncture headache (PDPH)
• Definitive treatment is epidural blood patch
– Epidural space is accessed using sterile technique
– 30cc of blood drawn from dependent antecubital of
patient
– Blood is slowly injected into epidural needle until the
patient complains of pressure in the back
– Pt. Placed supine flat in bed for 2 hours
– Severe backache (you artificially induced one heck of a
bruise!) almost always follows (tx with ice, analgesics)
65
Epidural Anesthesia
Delayed complications of epidurals
Low back pain
• Many patients will complain of backache after epidural
removed
• Traumatic procedure with large needle
• Consider if patient positioning during surgery could
have exacerbated symptoms
• Were there multiple attempts/punctures?
• Prolonged labor?
66
Epidural Anesthesia
Delayed complications of epidurals
Urinary retention
• Common in labor
• Most places place foley after epidural in place
• Sympathetic blockade allows for parasympathetic
override
• Bladder distention may occur with fluid bolus
• Full bladder can impede fetal decent
• Narcotics can exacerbate urinary retention
• Allow attempt to void, if possible
67
Epidural Anesthesia
Delayed complications of epidurals
Infection
• Septic meningitis
• Aseptic meningitis
• Adhesive arachnoiditis
Intraneural injection
Injection of wrong medications
Undiagnosed neurological disease
68
Epidural Anesthesia
Technical difficulties in epidurals
Broken needles
• Most common cause is “burying the needle”
Broken or sheared catheters
• NEVER pull a catheter back through the insertion needle
• ALWAYS chart that the tip of the catheter was intact when
you removed it
• Visually inspect all catheters before inserting them
Glass from broken vials in the epidural space
• Break away from the tray and use a 4X4
• Use filter needles
• Do not core the bottom of the vial when drawing from it
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
Section 2 Spinal anesthesia
86
Spinal anesthesia
involves the administration of local anesthetic into
the subarachnoid space.
87
Anatomy
90
Physiology
4.Visceral effects
Bladder.
Intestine.
5. Renal blood flow is maintained, except
91
Technique
1.Spinal needle.
92
Technique
2.Patient position.
a.lateral position .
b.sitting position
c.prone position
93
Technique
3.Procedure
a.The L2-3, L3-4, or L4-5 interspaces are commonly
used for spinal anesthesia.
b. Disinfect a large area of skin with an appropriate
antiseptic solution.
c. Check the stylet for correct fit within the needle.
d. Raise a skin wheal with 1% lidocaine and a 25-gauge
needle at the spinal puncture site.
94
Technique
e. Approaches
1.Midline.
2.Paramedian.
3.Needle placement.
4.Remove the stylet
5.Administration of anesthetic.
95
Technique
96
Determinants of level of spinal blockade
1.Drug dose.
2. Drug volume.
3. Turbulence of CSF.
4. Baricity of local anesthetic solution.
5. Increased intraabdominal pressure.
6. Spinal curvatures.
97
Complications
1.Hypotension
2. Bradycardia
3. Paresthesias.
4. Bloody tap.
5. Dyspnea
6. Apnea
7. Nausea and vomiting
8. Postdural puncture headache
9. Backache.
10. Urinary retention.
11. Neurologic impairment
12. Infection
98
Summary
99
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
100
Section 3 Caudal anesthesia
(Learn by yourself)
101
References(video)
http://v.blog.sohu.com/u/vw/318279
http://v.blog.sohu.com/u/vw/289724
http://v.blog.sohu.com/u/vw/877237
http://v.blog.sohu.com/u/vw/1627820
102
Peripheral nerves
are classified according to size and function
104
Neural blockade of peripheral nerves
usually progresses in the following order:
105
Pathophysiologic factors
a. A decrease in cardiac output
reduces the volume of distribution and plasma clearance
of local anesthetics, increasing plasma concentration and
the potential for toxicity.
b. Severe hepatic disease may prolong the duration
of action of amino amides.
c.Renal disease has minimal effect.
d. Patients with reduced cholinesterase activity
(newborns and pregnant patients) and patients with atypical
cholinesterase may have an increased potential for toxicity.
e.Fetal acidosis may result in greater transplacental transfer
and trapping of local anesthetics from mother to her fetus and
thus may have an increased potential for fetal toxicity.
106
Spine Landmarks/Positions
(Fetal, Sitting, Prone)
107
Sitting Position
Advantages:
Ease of placement
Disadvantages:
Vasovagal
Onset w/ hypo or
hyperbaric
Sedation
108
Landmarks
L1 End of cord
S2 End of dura
109
110
Reverse Trendelenburg Position
111
steep Trendelenburg position
112
113
114
115
116
117