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SPINAL AND EPIDURAL ANESTHESIA

DEPARTMENT OF ANESTHESIA
OSPITAL NG MAYNILA MEDICAL CENTER

GOOD MORNING!!!

EPIDURAL AND SPINAL ANESTHESIA


No absolute indications Clinical situations, patient physiology, surgical procedure: makes central neuraxial block the technique of choice

EPIDURAL AND SPINAL ANESTHESIA


Blunt the stress response to surgery
decrease intraoperative blood loss lower the incidence of postoperative thromboembolic events decrease morbidity and mortality in high-risk surgical patients

extend analgesia into the postoperative period (provide better analgesia than can be achieved with parenteral opioids) provide analgesia to nonsurgical patients

ANATOMY

VERTEBRAE
The spine consists of 33 vertebrae 7 cervical 12 thoracic 5 lumbar 5 fused sacral 4 fused coccygeal

Cervical (except C1), thoracic, and lumbar vertebrae: body anteriorly, two pedicles that project posteriorly from the body, and two laminae that connect the pedicles ----form the vertebral canal, which contains the spinal cord, spinal nerves, and epidural space

Lamina: give rise to the transverse processes (laterally); spinous process (posteriorly) --sites for muscle and ligament attachments Pedicles: contain a superior and inferior vertebral notch through which the spinal nerves exit the vertebral canal

5 sacral vertebrae fused to form the wedge-shaped sacrum (connects


the spine with the iliac wings of the pelvis)

5th sacral vertebra (not fused posteriorly) give rise to a variably shaped opening --- sacral hiatus opening into the sacral canal (caudal termination of the epidural space)
Sacral cornu bony prominences on either side of the hiatus aid in identification of sacral hiatus

Coccyx fused 4 rudimentary coccygeal vertebrae a narrow triangular bone that abuts the sacral hiatus

Tip of the coccyx can often be palpated in the proximal gluteal cleft and by running ones finger cephalad along its smooth surface, the sacral cornu can be identified at the 1st bony prominence encountered

C7 : 1st prominent spinous process

Line drawn between the iliac crests: body of L5 or the 4-5 interspace

T1 : most prominent spinous process T12 : can be identified by palpating the 12th rib and tracing it back to its attachement to T12

encountered while running the hand down the back of the neck

LIGAMENTS
Vertebral bodies are stabilized by 5 ligaments that increase in size between the cervical and lumbar vertebrae

EPIDURAL SPACE
Space that lies between the spinal meninges and the sides of the vertebral canal Boundaries:
Cranially: foramen magnum Caudally: sacrococcygeal ligament covering the sacral hiatus Anteriorly: posterior longitudinal ligament Laterally: vertebral pedicles Posteriorly: ligamentum flavum and vertebral lamina

Not a closed space but communicates with the paravertebral space by way of the intervertebral foramina Shallowest anteriorly where the dura may in some places fuse with the posterior longitudinal ligament Deepest posteriorly

Composed of a series of discontinuous compartments that become continuous when the potential space separating the compartments is opened up by injection of air or liquid

MENINGES
Spinal meninges consist of 3 protective membranes :
Dura mater Arachnoid mater Pia mater

Dura mater Outermost and thickest meningeal tissue Begins at the foramen magnum; ends at approx S2 where it fuses with the filum terminale Inner surface abuts the arachnoid mater

Arachnoid mater Delicate, avascular membrane composed of overlapping layers of flattened cells with connective tissue fibers running between the cellular layers Specialized connections (tight junctions and occluding junctions) account for the fact that it is the physiologic barrier for drugs moving between the epidural space and the spinal cord

Subarachnoid space lies between the arachnoid mater and the pia mater and contains the CSF Spinal CSF is in continuity with the cranial CSF and provides an avenue for drugs in the spinal CSF to reach the brain Spinal nerve roots and rootlets run in the subarachnoid space

Pia mater Adherent to the spinal cord and is composed of a thin layer of connective tissue cells interspersed with collagen Extends to the tip of the spinal cord where it becomes the filum terminale, which anchors the spinal cord to the sacrum Gives rise to the dentate ligaments

TECHNIQUE

NEEDLES

NEEDLES
Spinal Needles Whitacre and Sprotte: pencil-point tip needle hole on the side of the shaft Greene and Quincke: beveled tips with cutting edges

Spinal Needles
* pencil-point needles require more force to insert than the bevel-tip needles but provide better tactile feel; not deflected
* Size: 22-29 gauge larger gauge smaller diameter

Epidural Needles Touhy: curved tip to help control the direction that the catheter moves in the epidural space Hustead: less curved tip Crawford: straight; less suitable for catheter insertion
*sizes: 16-19 gauge

SEDATION
Light sedation before placement of block Successful spinal and epidural anesthesia requires patient participation to: maintain good position evaluate block height indicate paresthesias if needle contacts neural elements properly evaluate an epidural test

Once the block is placed and adequate block height assured, patient can be sedated as deemed appropriate

SPINAL ANESTHESIA
POSITION Patient positioning is critical to successful spinal puncture lateral decubitus sitting position prone jackknife position

POSITION Lateral decubitus patient lies with the operative side down (hyperbaric LA) or with operative side up (hypobaric LA) ---most dense block occurs on the operative side

POSITION

back at the edge of the table patients shoulders and hips positioned perpendicular to the bed knees drawn to the chest; neck flexed; patient instructed to curve the back outward

MIDLINE APPROACH Skin overlying the desired interspace is infiltrated with a small amount of LA (1-2 ml) to a depth of 1-2 inches to prevent pain when inserting the spinal needle Slight cephalad angulation (10-15 degrees)

MIDLINE APPROACH Needle is then advanced


subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space dura mater arachnoid mater

MIDLINE APPROACH

MIDLINE APPROACH Penetration of the dura mater produces a subtle pop


detection of dural penetration
prevent inserting the needle all the way through the subarachnoid space and contacting the vertebral body;

insert spinal needle quickly without having to stop every few mm and remove the stylet to look for CSF at the needle

MIDLINE APPROACH Once the needle tip is believed to be in the subarachnoid space, stylet is removed to see if CSF appears at the needle hub
Small diameter needles (26-29 gauge) requires 5-10 sec or >/= 1 minute

Failure to obtain CSF suggests that the needle orifice is not in the subarachnoid space and must be reinserted

MIDLINE APPROACH Once the needle is correctly inserted into the subarachnoid space, it is fixed in position and the syringe containing LA is attached CSF is gently aspirated to confirm that the needle tip remained in the subarachnoid space and LA slowly injected (</=0.5 ml/s-1)

MIDLINE APPROACH After completing the injection, a small volume of CSF is again aspirated to confirm that the needle tip remained in the subarachnoid space while the LA was deposited This CSF is then reinjected and the needle, syringe, and any introducer removed together as a unit

MIDLINE APPROACH strict attention to patients hemodynamic status with BP and/or HR supported block height should also be assessed early
pin prick temperature sensation
Table may be tilted as appropriate to influence further spread of local anesthetics

PARAMEDIAN APPROACH useful in situations where the patients anatomy does not favor the midline approach
inability to flex the spine heavily calcified interspinous ligaments

Patient in any position; best approach for the patient in the prone jackknife position

PARAMEDIAN APPROACH Identify the spinous process forming the lower border of the desired interspace Needle inserted
~1 cm lateral directed toward middle of the interspace ~45 degrees cephalad medial angulation (~15 degrees) to compensate for the lateral insertion point

PARAMEDIAN APPROACH

Needle inserted ~1 cm lateral, directed toward middle of the interspace ~45 degrees cephalad with just enough medial angulation (~15 degrees) to compensate for the lateral insertion point

PARAMEDIAN APPROACH
1st significant resistance encountered: ligamentum flavum Alternative method:
insert needle perpendicular to the skin in all planes until the lamina is contacted; needle is then walked off the superior edge of the lamina and into the subarachnoid space **Lamina provides a valuable landmark that facilitates correct needle placement

EPIDURAL ANESTHESIA
May be performed at any intervertebral space LA skin wheal is raised to the point of needle insertion Pierce the skin with a >/=18 G hypodermic needle

Epidural needle inserted through the subcutaneous tissue and into the interspinous ligament gritty feel

Needle is advanced slowly until an increase in resistance is felt :

Techniques to identify epidural space:


Loss of resistance technique (fluid/air)
Glass syringe: 2-3 ml saline + 0.1-0.3 ml air bubble

Hanging drop technique

After entering the epidural space, stop advancing the needle


heightens the risk of meningeal puncture wet tap

LA test dose should be administered to help rule out undectected subarachoid or IV needle placement After a negative test dose, desired volume should be administered in small increments

EPIDURAL TEST DOSE


To identify epidural needles or catheters that have entered an epidural vein or the subarachnoid space Failure to perform: IV injection or total spinal block 3 ml of LA + 1:200,000 epinephrine
IV: epinephrine Subarachnoid: motor block ---LA
HR increases 20-40 sec after BP increase of >/=20 mmHg

PHYSIOLOGY

Spinal anesthesia interrupts sensory, motor, and sympathetic nervous system Classic concept:

Conduction blockade through small diameter unmyelinated (sympathetic) fibers before interrupting conduction via large myelinated (sensory & motor) fibers

Block of afferent impulses from the surgical site leads to absence of adrenocortical response to pain

Cardiovascular system Vasodilatation of resistance and capacitance vessels occurs: hypovolaemia, tachycardia, drop in blood pressure exacerbated by blockade of the sympathetic nerve supply to the adrenal glands, preventing the release of catecholamines. Bradycardia: If blockade is as high as T2, sympathetic supply to the heart (T2-T5)

overall result: inadequate perfusion of vital organs measures: restore blood pressure and cardiac output (fluid administration, vasoconstrictors) Sympathetic outflow extends from T1 - L2 (blockade of nerve roots below this level, knee surgery, is less likely to cause significant sympathetic blockade, compared with procedures requiring blockade above the umbilicus)

Respiratory system usually unaffected unless blockade is high enough to affect intercostal muscle nerve supply (thoracic nerve roots) leading to reliance on diaphragmatic breathing alone distress to the patient, as they may feel unable to breathe adequately decreased ability to cough and expel secretions if patients cannot breathe, ventilate (face mask and bag

Gastrointestinal system Blockade of sympathetic outflow (T5-L1), leads to predominance of parasympathetic (vagus and sacral parasympathetic outflow)
leading to active peristalsis and relaxed sphincters, and a small, contracted gut, which enhances surgical access Splenic enlargement (2-3 fold) occurs

If above T5, inhibits sympathetic innervation to the GIT, resulting in unopposed parasympathetic nervous system activity
Contracted intestines and relaxed sphincter; if not on NPO, tendency to develop vomiting

Genitourinary tract urinary retention is a common problem severe drop in blood pressure may affect glomerular filtration in the kidney (if sympathetic blockade extends high enough to cause significant vasodilatation) ureters are contracted and ureterovesical orifice is relaxed

Decreased bleeding may be a reflection of decreased BP Increased blood flow to lower extremities ---- decreased incidence of thromboembolism

BLOCK HEIGHT
SURGICAL PROCEDURE

SUGGESTED BLOCK HEIGHT

TECHNIQUE

Perianal Perirectal
Lower extremity/ Hip TURP Vaginal/ cervical

L1-2
T10

Hyperbaric/sitting pos Hypobaric/jackknife pos


Isobaric

Herniorrhaphy Pelvic procedures Appendectomy Abdominal Cesarean section

T6-8

Hyperbaric/ horizontal

T4-6

Hyperbaric/ horizontal

FACTORS THAT AFFECT SPREAD OF LOCAL ANESTHETIC SOLUTIONS Characteristics of the local anesthetic solution

Baricity: ratio of density (mass/vol) of LA div density of CSF Local anesthetic dose Local anesthetic concentration Volume injected
Age Weight Height Gender Pregnancy Patient position

Patient characteristics

FACTORS THAT AFFECT SPREAD OF LOCAL ANESTHETIC SOLUTIONS Speed of injection Barbotage Direction of needle bevel Addition of vasoconstrictors Technique
Site of injection

Diffusion

LOCAL ANESTHETIC SOLUTION


HYPERBARIC: solution more dense than CSF; >/=1.0015
Add glucose (5-8% dextrose) of increase the density LA solution settles to dependent region

HYPOBARIC: solution less dense than CSF; <0.9990


Add sterile/distilled water; floats up to the nerves innervating surgical site

ISOBARIC: same density; 1.0000


Dilute with CSF or normosaline solution

COMPLICATIONS

Hypotension Postdural puncture headache Hearing loss Total spinal Backache nausea Urinary retention Systemic toxicity Neurologic injury Spinal hematoma

Hypotension
Due to sympathetic nervous system blockade a.Decreased venous return to heart, decreased cardiac output b.Decreased systemic vascular resistance c.Bradycardia due to blockade of cardioaccelerator fibers (T1-3), decreased cardiac output

Hypotension
Treatment: restore venous return to incrase cardiac output Position head-down: autotransfusion Hydration before spinal anesthesia Sympathomimetics

Postdural puncture headache

Frontal/occipital Worsened by sitting, improved by supine position Due to decreased CSF pressure and resulting tension on meningeal vessels and nerves as a result of leakage of CSF through the dural hole Diplopia due to traction on abducens nerve Treatment: bed rest, analgesics
Hydration (>/= 3L/day) to increase CSF production Epidural patch (10-20 ml) to seal dura Caffeine-sodium benzoate (by vasoconstriction)

Hearing loss

High Spinal
Undesired excessive level of sensory and motor anesthesia associated with difficulty of breathing or apnea --arterial hypoxemia or hypercarbia Apnea reflects ischemic paralysis of medullary ventilatory centers due to profound hypotension and associated with decreased cerebral blood flow

High Spinal
Treatment: support breathing and circulation
a. Positive pressure ventilation with face mask b. IVF and sympathomimetics c. Head down to increase venous return (head up will jeopardize cerebral blood flow -- medullary ischemia d. Intubation of trachea in those at risk for aspiration

Total spinal
rare complication profound hypotension apnea unconsciousness dilated pupils as a result of the action of local anesthetic on the brainstem

Management
Airway secure, administer 100% oxygen Breathing - ventilate by facemask, intubate Circulation - treat with iv fluids and vasopressor Continue to ventilate until the block wears off (2 - 4 hours) As the block recedes the patient will begin recovering consciousness followed by breathing and then movement of the arms and finally legs. Consider some sedation (diazepam 5 - 10mg i/v) when the patient begins to recover consciousness but is still intubated and requiring ventilation

Backache
May be related to position required for surgery More likely due to ligamentous strain when in an uncomfortable position

Nausea
May be due to hypotension --- cerebral ischemia; tx sympathomimetics May be due to predominance of parasympathetic nervous system activity; tx atropine 0.4 mg IV

Urinary Retention
Because spinal anesthesia interferes with innervation of the bladder Administration of large amounts of fluid --- bladder distention requiring catheter drainage

Systemic toxicity

Neurologic injury
Very rare due to small dose of LA employed In the absence of hematoma or abscess, treatment is symptomatic

Spinal hematoma
Rare; present with numbness or LE weakness Risk factor: coagulation defects

Inadvertent high epidural block


due to an excessively large dose of local anesthetic hypotension, nausea, sensory loss or paresthesia of high thoracic or even cervical nerve roots (arms), or difficulty breathing most severe cases may require induction of GA with securing of the airway, while treating hypotension

If patient has a clear airway and is breathing adequately: reassurance and any hypotension immediately treated Difficulty in talking (small tidal volumes due to phrenic block) and drowsiness are signs that the block is becoming excessively high and should be managed as an emergency

Local anesthetic toxicity


excessive dose of local anaesthetic moderate dose of LA, injected directly into a blood vessel epidural catheter is inadvertently advanced into one of the many epidural veins. It is therefore vital to aspirate from the epidural catheter prior to injecting local anaesthetic

symptoms: light-headedness, tinnitus, circumoral tingling or numbness and a feeling of anxiety or "impending doom", followed by confusion, tremor, convulsions, coma and CPR arrest early recognition: discontinue further administration of local anesthetic drugs treatment: supportive, sedative/anticonvulsants, cardiopulmonary resuscitation if required

CONTRAINDICATIONS

Patient refusal: only absolute contraindication Conditions that increase the apparent risk of central neuraxial block

- Hypovolemia or shock increase the risk of hypotension - Increased ICP increases the risk of brain herniation when CSF is lost through the needle, or if a further increase in ICP follows injection of large volumes of solution into the epidural or subarachnoid spaces - Coagulopathy or thrombocytopenia increase the risk of epidural hematoma - Sepsis increases the risk of meningitis - Infection at the puncture site increases the risk of meningitis

Pre-existing neurologic disease (multiple sclerosis) : considered CI


No evidence to suggest that spinal or epidural anesthesia alters the course of any preexisting neurologic disease Recommendations to avoid RA stem largely from a medicolegal concern that the anesthetic may be incorrectly blamed for any subsequent worsening of the patients preexisting condition

SPINAL OR EPIDURAL ANESTHESIA?


Spinal Anesthesia
Less time to perform Produces more rapid onset of better quality sensorimotor block Less pain during surgery

SPINAL OR EPIDURAL ANESTHESIA?


Epidural Anesthesia
Lower risk of PDPH Less hypotension if epinephrine is not added to the LA Ability to prolong or extend the block via an indwelling catheter Option of using an epidural catheter to provide postoperative analgesia

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