SURG ANES: REGIONAL ANESTHESIA

Dr. Serrano Ligaments:

Anterior longitudinal ligament
HISTORICAL BACKGROUND Posterior longitudinal ligament
Ligamentum flavum
1851- CHARLES PRAVAZ, French orthopedic Interspinous ligament
surgeon invented hypodermic needle syringe Supraspinous ligament

1852- ALEXANDER WOOD, introduced hypodermic
syringe and needle
1884- KARL KOLLER, (Vienna, Austria) introduced
topical cocaine anesthetics for ophthalmology
The curvatures of the vertebral column:
Primary thoracic and sacral kyphosis
Secondary cervical and lumbar lordosis
Lowest point : T5 concavity
Highest point: L3 lordosis

1885- WILLIAM HALSTED, Father of Regional

Anesthetics; 1st injection of cocaine around the SENSORY LEVEL OF SKIN ANALGESIA
nerve tracts
T4 Nipple line Upper Full dosage
1885- JAMES CORNING, accidentally introduced abdominal gastrectomy,
cocaine intrathetically- 1st performed neuroaxial operation cholecystectomy
blockade (epidural) T6 Xiphoid Lower Caesarian
abdominal section,
1889- AUGUST BIER (Germany), true spinal operation appendectomy
anesthesia in animals and man T10 umbilicus bladder
T12 Lower LE Lesser dosage
1895- FERDINAND CATHELIN, first used epidural extremities operation
anesthesia in sacral region
PREOPERATIVE EVALUATION (SPINAL OR EPIDURAL
1939- ACHILLE MARIO DOGLIOTTI, popularized ANESTHESIA)
epidural anesthesia
PHYSICAL EXAMINATION:
TYPES OF REGIONAL ANESTHESIA
Examination of the thoracic and lumbar
CENTRAL NERVE BLOCKS spine and the skin near the site of the
Spinal intradural, intrathecal, needle insertion
subarachnoid block
Anatomical abnormalities such as scoliosis
Epidural extradural
or limited flexion of the spine causes a
Caudal
more difficult anesthesia
PERIPHERAL NERVE BLOCKS
Infection at proposed puncture site
precludes anesthesia
ANATOMIC AND PHYSIOLOGIC CONSIDERATIONS
Documentation of pre-existing
The vertebral column consists of 33 vertebrae:
neurological deficits
7 cervical
12 thoracic CONTRAINDICATIONS OF SPINAL OR EPIDURAL
5 lumbar ANESTHESIA
5 fused sacral ABSOLUTE C/I:
4 fused coccygeal Lack of patient consent
Infection at the site of needle insertion
The spinal cord ends at the 2nd Lumbar vertebra Severe coagulopathy or bleeding -> fear of
(L2) hematoma
The spinal dura ends at the 2nd sacral vertebra
Hypovolemia
(S2)
 Increased ICP
RELATIVE C/I:
Sepsis
Pre-existing neurologic disease
Herniation of an intervertebral disk or
previous back surgery
Back pain
Children
Mild bleeding point
TECHNIQUES (SPINAL AND EPIDURAL):
PREPATION:
Vasopressor to treat hypotension
Supplemenktal O2 via nasal cannula or
face mask to treat respiratory depression
due to sedatives or anesthetics
Administration of narcotics and sedatives
can make patient more comfortable during
placement of the needle but usually
patient should remain sufficiently awake
to report paresthesia during the procedure
Precautions to avoid infections:
Aseptic technique
Skin preparation with bactericidal
solution
Sterile drape and gloves
Careful check sterilization indicator
POSITIONING TECHNIQUES:
Sitting position may faint and require
assistance
Lateral decubitus most comfortable
Prone position difficult since muscles are
not relaxed; CSF will not appear,
paramedian approach is required
Appropriate landmarks are identified; palpable for
the spinous process
Appropriate landmarks:
TUFFIERS LINE a line drawn
between highest points of both
iliac crest is perpendicular to the
body of L4 or the L4-L5 interspace.
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SPINAL ANESTHESIA
Subarachnoid block; subdural block
Positioning for lumbar puncture is
determined by:
Patient comfort
Surgical site
Density of the local anesthetic
solution
**lumbar area is flexed to spread the
spinous processes and enlarge the
interlaminar spaces
Spinal puncture can be done safely at
the interspace between:
L2 and L3
L3 and L4
L4 and L5
Termination of the spinal cord:
Adults: L1
Infants: L2 to L3
Midline approach is more common
SPINAL ANESTHESIA APPROACHES:
PARAMEDIAN APPROACH
o for elderly patients with
calcified ligaments or patients
who are difficult to position
because of limited lumbar
flexion
o The needle is inserted 1 cm
lateral to the spinous process
and directed toward the middle
of the interspace.
LUMBOSACRAL (TAYLOR) APPROACH
o A paramedian approach
directed toward the L5-S1
interspace, the largest in the
vertebral column
o Can be used when other
approaches are not successful
or cannot be performed
o The needle is inserted 1cm
medial and inferior to the
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 posterior superior iliac spine,
then angled cephalad 45-55
degrees.
STRUCTURES TRAVERSED BY THE NEEDLE IN
SPINAL ANESTHESIA:
Skin and subcutaneous tissue
Supraspinous ligament
Interspinous ligament
Ligamentum flavum (popping sound)
Epidural space
Spinal dura
SPINAL NEEDLES:
Choice depends on:
Patients age
Anesthesiologists ability
Cost
TYPES OF SPINAL NEEDLES:
Quinke-Bobcock needle
o Standard, sharp beveled needle
o Gauge 20-29 ->g22 and g25
needles are used most
frequently (g29 used today)
o More likely to produce a dural
leak and subsequent headache
in young patients
Pitkin needle
o Short, sharp
o 20G or 22G needle made up of
relatively flexible rustproof
steel with a (spinal arrest) to
mark the depth of insertion
o The tip of the needle has a
short, sharp bevel grounge off
to a taper of 45 degrees,
resulting in a rounded, blunted
bevel heel.
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o There was a matching, beveled
stylet.
Whitacre
o First closed-ended, lateral
orifice, pencil-point needle with
a tapered tip
o Rounded, no cutting edges ->
need more force to insert
o More expensive, like to cause
headache
Tuohy
o Epidural type of needle
o Hollow hypodermic needle, very
slightly curved at the end, suitable
for inserting epidural catheters.
o For continuous epidural anesthesia
o Blunt and curved end
o Gauges 6 to 18 -> bigger in size
PHYSIOLOGIC EFFECTS:
SOMATIC BLOCKADE
Sensory and motor
Pain prevention and muscle
relaxation
Onset of action not uniform
VISCERAL BLOCKADE
Hypotension due to interruption
of sympathetic nerve impulses ->
dec. TPR and CO
Bradycardia due to blockage of
cardiac accelerator fibers
(sympathetic)
Note: sympathetic block may be two segments
higher than the sensory block which in turn may
extend higher than the motor blockade.
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 o Morphine (most common)
o Improve the quality of the
sensorimotor blockade and
provide post-operative analgesia
o Side effects:
DRUGS USED FOR SPINAL ANESTHESIA: Pruritus
n/v
SATISFACTORY SPINAL ANESTHESIA REQUIRES resp. depression
THAT: urinary retention
The block extends to the dermatomes
needed for the operation OPIODS USED IN SPINAL AND EPIDURAL
Anesthesia last longer than the procedure ANESTHESIA
Anesthesia is profound enough to block
all sensory modalities EPIDURAL SPINAL
DOSE DURATION DOSE DURATION
MORPHINE 1-5 mg 5-24 hrs 0.1-0.2 8-24 hrs
LOCAL ANESTHETICS MOST FREQUENTLY USED:
mg
Tetracaine (Pontocaine) FENTANYL 25-100 1-2 hrs 25-50 1-2 hrs
Bupivacaine (sensorcaine) ug ug
Lidocaine (Xylocaine) for brief SULFENTANIL 10-5 ug 2-3 hrs 5-10 ug 2-3 hrs
procedures
CONDUCTION OF SPINAL ANESTHESIA
DOSAGE AND ACTIONS Distribution of block is measure by
peripheral tests:
Preparation Dosage Duration Duration w/ o Loss of cold perception correlates
w/o epinephrine with level of sympathetic block
epinephrine o Pinprick or finger scratch
Tetracaine 1% 14-20 mg 90 min 120-150
dry crystal min
correlates with level of sensory
Lidocaine 5% in 75-100 mg 60 min 60-90 min block
75% glucose o Tests for motor function; by
Bupivacaine Not asking the patient to:
Hyperbaric 12-20 mg 120-150 min effective Plantar flex the toes 9S1-
isobaric 12-25 mg 120-150 min with
epinephrine S2)
Dorsiflex the foot (L4-L5)
DRUGS USED FOR SPINAL ANESTHESIA: Raise the knees (L2-L3)
VASOCONSTRICTORS Tense the rectus muscles
o the duration of blockade can be by lifting the head (T6-T7)
increased 1 to 2 hours by adding
vasoconstrictors to the solution DIFFERENCES BETWEEN SPINAL AND EPIDURAL
injected into the CSF ANESTHESIA
o epinephrine (0.1 to 0.2 mg) or
phenylepinephrine (1. to 4.0 mg) SPINAL EPIDURAL
o actions: LOCATION Below the Cervical to
constrict the blood vessels spinal cord sacral
decrease vascular volume Small (2-4cc) Large (15-20
adsorption and cc)
subsequent elimination of onset Faster (3-7 Slower (15-20
the anesthestic. min), ave: 5 min)
min
OPIODS relaxation excellent fair

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Epidural Anesthesia
Preparation of the Patient:
1. informed consent
Anatomic Considerations
2. pre-operative evaluation
3. laboratory analysis
1. It is circular space extending from the
4. pre-medication
foramen magnum and ends at the spinal hiatus.
2. The sacral hiatus is widest at L2.
3. Contents of epidural space:
musccle and fat
nerve roots
EPIDURAL ANESTHESIA
venous plexus
lymphatic vessels
Choice of local anethetic determined
by:
4. Borders:
the duration of surgical procedure
dorsally- ligamentum flavum
required intensity of motor blockade
ventrally- dura mater of spinalis
Almost all Amide local anesthetics are used
Exception: Chloroprocaine fastest onset of
Level selected:
action but shortest duration of action
lumbar- for midline and paramedian approach
Bupivacaine (Sensorcaine) most
most frequent used
commonly used LA in OB patients (0.25%, 0.125%)
thorasic- for midline and paramedian approach
Surgical cases Bupivacaine (0.5%) for
cevical
more profound or dense anesthesia
Structure traversed by midline approach:
Epinephrine (5ug/ml)- added to determine
skin and subcutaneous
IV injection
supraspinous ligament
interspinous ligament
ligamentum flavum
epidural space
Indications for Epidural Anesthesia
poor risk patient
Technique
cardiac disease
pulmonary disease
METHODS OF IDENTIFICATION
metabolic disturbance
loss of resistance method- most common
when spinal and general anesthesia are
hanging drop method
contraindicated
a drop of saline solution is placed in the
obstructive analgesia
open needle hub
post-operative pain relief
then the needle is inserted mm by mm
the saline solution is sucked inside the
Physiologic Changes After Successful Epidural
space due to negative pressure
Anesthesia
Strategies for introduction of anesthetic agent:
hypotension
tachycardia
1. test dose: local anethesia 3-5 cc with
bradycardia- blockage above T4 disrupts
epinephrine injected directlly into the
cardiac fibers
epidural needle facilitates placement
ventilatory changes- phrenic nerve (L3-L5)
of catheter cause increase in HR by
20% if test dose is injected IV
2. incremental dosing is an important safety
Complications
precaution- 20-25 cc in the maximum dose.

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 similar to those spinal anesthesia obstetric procedure
additional risks: pediatric patients
local anesthetic toxixity
unwanted dural puncture with a large bore needle Contraindications:
headache extremely obese patients
infection at the site of needle insertion

Advantages of Epidural Anesthesia Over Spinal
Anesthesia
no post-operative headache- absence of
dural puncture
less hypotension
fewer psychological objections on the part
of the patient
can be used for post-operative pain relief-
long term analgesia or anesthesia
Procedure:
lateral, prone or jack-knife position
sterile skin preparation and draping
identify sacral cornua
skin & underlyng ligaments and infiltrated
with local anesthesia
needle inserted at 45 degree angle to the
sacrum between the two cornua

CAUDAL ANESTHESIA

a special form of epidural anesthesia with

access through the sacral hiatus
more useful in pediatric patients
landmaks are easier to identify and anesthetic
spread is more consistent

Anatomic Considerrations:
SACRUM
-formed by the fusion of the 5 sacral vertebrae, the
caudal space is an extension of the epidural space
SACRAL HIATUS
-formed by failure of the laminae of the 4th and
5th sacrral vertebrae to fuse
-converted by the SACROCOCCYGEAL
LIGAMENT formed from:
-supraspinous ligament
-interspinous ligament
-ligamentum flavum

Structure Traverse:
skin
sacrococcygeal ligament
sacral hiatus
sacral canal

Indications:
surgical operation of ano-rectal area

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