REGIONAL

ANESTHESIA

Kezza Marie D. Marba

Anesthesia Clerk
Spinal Column

 33 Vertebrae
◦ 7 Cervical
◦ 12 Thoracic
◦ 5 Lumbar
◦ 5 Sacral
◦ 4 Coccygeal
Spinal Cord
– Adult
• Begins: Foramen Magnum
• Ends: L1
– Newborn
• Begins: Foramen Magnum
• Ends: L3
– Terminal End: Conus
Medullaris
– Filum Terminale:
Anchors in sacral region
– Cauda Equina: Nerve
group of lower dural sac
Epidural Space

• Space that surrounds the spinal meninges

contains nerve roots, fat, lymphatic and
blood vessels, areolar tissue
 Subarachnoid Space

• Lies between the pia mater and the arachnoid

and extends from S2 to the cerebral ventricles.
Layers Traversed by the Spinal Needle

• Skin
• Subcutaneous tissue
• Supraspinous ligament
• Interspinous ligament
• Ligamentum flavum
• Epidural space
• Dura
• Subarachnoid space
PHYSIOLOGIC CHANGES

• Sympathetic block with peripheral

vasodilation
• and skin temperature elevation
• Loss of pain and temperature sensation
• Loss of proprioception
• Loss of touch and pressure
• Motor paralysis
Sequence of Neural Blockade

• Smaller C fibers are blocked more easily than

the larger sensory fibers, which are blocked
more easily than motor fibers

• Autonomic blockade extends above the level

of sensory blockade by 2 segments, while the
motor blockade is 2 segments below the
sensory blockade
 Regional Anesthesia

• Also known as “the nerve block”

• It is a form of anesthesia in which there
is a loss of sensation in a region of
the body produced by application of
an anesthetic agent to all the nerves
supplying that region
 Spinal Anesthesia

• It is accomplished by injecting local

anesthetic solution into the cerebrospinal
fluid (CSF) contained within the
subarachnoid (intrathecal) space at the
level below L2, where the spinal cord
ends, anesthesia of the lower body part
below the umbilicus is achieved.
 Epidural Anesthesia

- It is achieved by injecting local anesthetic solution into

the epidural space that lies between ligamentum
flavum and the dura mater, exterior to the spinal fluid.

• Technique:
• Loss of resistance technique to identify the epidural
space.
• 0.5% Bupivacaine (mainly) or lidocaine (2.0%) is usually
used to produce epidural anaesthesia.
 Advantages

• SPINAL ANESTHESIA • EPIDURAL ANESTHESIA

1. takes less time to perform

1. a lower risk for post-dural puncture
2. produces a more rapid headache,
onset of better quality 2. Less systemic hypotension if
sensory and motor epinephrine is not added to the local
anesthesia anesthetic solution
3. associated with less pain 3. ability to prolong or extend the
during surgery anesthesia through an indwelling
epidural Catheter
4. option of using the epidural catheter

to provide postoperative analgesia .

 INDICATIONS:

• SPINAL • EPIDURAL
ANESTHESIA ANESTHESIA

-generally used for surgical -often used as the primary

procedures involving the anesthetic for surgeries
lower abdominal area, involving the abdomen or
perineum, and lower lower extremities.
extremities.
-effective and widely used for
the control of labor pain.
ABSOLUTE CONTRAINDICATIONS TO
NEURAXIAL ANESTHETIC TECHNIQUES

• Infection at the site of injection

• Patient refusal
• Coagulopathy or other bleeding
diathesis
• Severe hypovolemia
• Increased intracranial pressure
• Severe aortic & mitral stenosis
RELATIVE CONTRAINDICATIONS TO
NEURAXIAL ANESTHETIC TECHNIQUES

• Sepsis
• Uncooperative patient
• Pre-existing neurologic deficits
• Stenotic valvular heart lesions
• Severe spinal deformity
SPINAL ANESTHESIA

• The technique of administering spinal

anesthesia can be described as the:

• “4 P’s”:
1. Preparation
2. Position
3. Projection
4. Puncture
SPINAL ANESTHESIA TECHNIQUE
1. PREPARATION:
- Preparation of equipment/ medications is the first step.
• Discuss the options for anesthesia.
-risk and benefits
• Choose an appropriate local anesthetic
• Choose the appropriate spinal needle
2. Positioning

- essential for a successful block

- three positions used for the
administration of spinal anesthesia:
lateral decubitus
sitting
prone
22
SPINAL KIT
• Sterile towels
• Sterile gloves
• Sterile spinal needle
• Sterile filter needle to draw up medications
• Sterile 5ml syringe for spinal solution
• Sterile 2ml syringe with a small gauge needle to
localize skin prior initiation of the spinal
anesthetic.

Antiseptic for the skin (such as betadine, methyl

alcohol)
Sterile gauze for skin cleansing
Single use preservative free local anesthetic
ampoule.
SPINAL ANESTHESIA TECHNIQUE

• patient should be positioned to take

advantage of the baricity of the spinal local
anesthetic.

Projection and puncture

• Palpate the ASIS (Ant Superior Iliac
Spine). The line that corresponds to
your Right and Left ASIS
• Wash hands, put sterile gloves
MIDLINE APPROACH

1. Identify the top of the iliac crest.

. ANATOMICAL LANDMARK:
ANTERIOR SUPERIOR ILIAC SPINE
• 2. Palpation in the
midline should help to
identify the
interspinous ligament.
The extent of the space
is noted by palpating the
cephalad and caudad
spine. The midline is
noted by moving your
fingers from medial to
lateral.
3. Wash hands, put on sterile gloves, use
sterile technique.

4.Prepare the back with an antiseptic. Start at the

area of intended injection and move out. This is
done three times.

5. Place a skin wheal of local anesthetic at the

intended spinous interspace.
 SPINAL ANESTHESIA TECHNIQUE

• control the needle carefully. Be prepare for

unanticipated movement of the patient.

• as the ligamentum flavum and dura are traversed,

a change in resistance is noted. some will describe
this as a “pop”; however this may be due to
decrease in pressure or a loss of resistance.
SPINAL ANESTHESIA TECHNIQUE

• Once in a subarachnoid space remove the stylet and

CSF should appear (clear and free flowing). If CSF
does not appear, rotate the needle 90 degrees until it
appears.
• Once CSF returns, steady the needle with the
dorsum of the non dominant hand against the
patients back.
• Inject anesthetic agent after you aspirate. After
injection aspirate 0.2ml of CSF to confirm the needle
remains intact.
LEVEL AND DURATION OF
ANESTHESIA

FACTORS THAT AFFECT DISTRIBUTION OF

ANESTHETIC SOLUTION IN CSF

(1) the baricity of the solution,

(2) the contour of the spinal canal
(3) the position of the patient in the first few minutes
after injection of local anesthetic solution into the
subarachnoid space.
CHOICE OF LOCAL
ANESTHETICS

• LIDOCAINE (FOR SHORT-DURATION SPINAL

ANESTHESIA)

- For decades, lidocaine was the most commonly

used short-acting local anesthetic for spinal
anesthesia.
- It has a duration of action of 60 to 90 minutes, and it
producesexcellent sensory anesthesia and a fairly
profound motor block.
CHOICE OF LOCAL
ANESTHETICS

• LONG-DURATION SPINAL ANESTHESIA

Bupivacaine and Tetracaine are the local
anesthetics most frequently used for long-
duration spinal anesthesia. Although
Ropivacaine has been used as a spinal
anesthetic.
SENSORY LEVEL ANESTHESIA FOR SURGICAL
PROCEDURES
 Complications

• SPINAL ANESTHESIA • EPIDURAL ANESTHESIA

• NEUROLOGIC
COMPLICATIONS
• Dural puncture - 1% of
• HYPOTENSION epidural injections
• BRADYCARDIA AND
ASYSTOLE • Catheter complications
• POST–DURAL
PUNCTURE HEADACHE
• Inability to insert the
• NAUSEA catheter
• HYPOVENTILATION • Catheter inserted into an
• URINARY RETENTION
• BACKACHE
epidural vein
• Catheters can break off or
become knotted within the
• epidural space
THE END!