6th Year Medical School

Regional Anesthesia and

Post-Operative Pain
 Objectives
1. What options of regional anesthesia offered to
the patient.
2. Anatomy of neuro-axial approach.
3. What are the contraindications to the neuro-axial
technique.
4. What are the commonly used local anesthesia
agents and their complications.
5. Common complications of Regional anesthesia.
6. Basic approaches to acute post-surgical pain
7. Advanced Approaches to acute post-surgical pain
Types of Anesthesia

General Anesthesia
Neuroaxial anesthesia
Brachial Plexus
Local anesthesia
 What options of regional anesthesia offered to
the patient.

Regional + GA
Options of regional Anesthesia offered to the
patient.

GA + Local
 What options of regional anesthesia offered to
the patient.

Regional + Neuraxial
Vertebral Column Anatomy
Anatomy of neuro-axial approach.
Epidural Vs Spinal

Spinal Approach
 Contraindications to the Neuroaxial
technique
Absolute contraindications to spinal anesthesia:
Patient refusal
Sepsis at the site of injection
Hypovolemia
Coagulopathy
Indeterminate neurologic disease
Increased intracranial pressure
Relative contraindications:
Infection distinct from the site of injection
Unknown duration of surgery (spinal)
Commonly Used Local Anesthesics
how do we use them:
Commonly Used Local Anesthesics
more examples:
Anesthetic Agents
Lidocane
Type: Amide
Onset: Fast
Duration: Medium/short
Uses: wound infiltrate, Regional
anesthetic.
Max Dose: 3mg/Kg (6mg/kg if with
epineph)
 Bupivacane
Type: Amide
Onset: Medium
Duration: Long
Max dose : 2mg/kg
Used in Regional
Anesthesia and local
infiltrate
 Numbness of the tongue
Light headedness
Seizures
Unconsciousness
Arrhythmias
Hypotension
Cardiovascular collapse
 What would you Do???
Call For Help
ABC to Treat Symptoms (treat seizures)
Arrest ACLS protocol
20% Intralipid
1.5 mg/kg initial bolus
0.25 mg/kg/min infusion for 30-60 minutes
Bolus may be repeated 1-2 times for
persistent asystole
 Neuroaxial Anestheics
Complications
1) Headache
2) Urinary Retention (foleys needed)
3) Hypotension
4) Bradycardia
5) Total Spinal
6) Incomplete block
7) Infection
8) Hematoma ( 1: 200 000)*
9) Nerve injury (1: 13 000) *
10) Cardiac Arrest during Spinal (1:1500 case) *
Approaches to the acute post-surgical
pain management.

1. Basic: by ward doctors:

Example: NSIADS , Paracetamol, , Narcotics.
2. Advanced: By Acute pain team:
1. Patient Controled Analgesia (PCA)
2. Neuroaxial (spinal , Epidural)
3. Regional: Brachial plexus , Popliteal
,femoral .etc
B:Look at the patient and see if
plan is working!!
 NSAIDS (Examples):
Celecoxib : 200mg P.O BID (Max 400/Day)
Ketorolac : 30 mg iv q6 (Max 120mg /day)
Diclofenac sodium 75mg im/po BID
(Max 150mh/day)
Ibuprofen 200-400mg TID.
 Narcotics (basic)
Morphine, administered iv by a nurse:
Post surgery order:
2mg iv. as required-Pain-. Max 4mg in 1h.
Onset of action: 3mins
Peak: 15 mins
Avoid in renal failure.
Antiemetic (zofran/primpram)
 Narcotic (Advanced)
By Acute pain service only:
Morphine PCA (Example):
Bolus 1mg
Lock out time :8mins
Maximum dose lock-out: 12mg / hr
 References
NYSORA : www.nysora.com
Miller: 7th edition