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DEPARTMENT OF ANESTHESIA
OSPITAL NG MAYNILA MEDICAL CENTER
GOOD MORNING!!!
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
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
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
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
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
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
TECHNIQUE
Perianal Perirectal
Lower extremity/ Hip TURP Vaginal/ cervical
L1-2
T10
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
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
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
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
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