REGIONAL ANESTHESIA

C. ANCILLARY PROCEDURES AND LABORATORY

OUTLINE EXAMS
I. Case Description ● Laboratory Exams
II. Preoperative Assessment → Mild leukocytosis ranging from 10,000–18,000/mm3
III. Preoperative Assessment specific for Regional Anesthesia predominantly neutrophils. One of the signs of perforated
IV.Premedications appendix
V. Regional Anesthesia → Urinalysis is not diagnostic for appendicitis but it is useful to
VI.Methods of Neuraxial Block rule out the urinary tract infection, pyelonephritis or
A. Review of Spinal Anatomy nephrolithiasis
B. Mechanism of Action → Alvarado score and Appendicitis Inflammatory Response
C. Clinical consideration Score: clinical scoring system that can be used to diagnose
D. Spinal Anesthesia appendicitis.
E. Epidural Anesthesia ● Imaging Studies
F. Caudal Anesthesia → Plain films of the abdomen are rarely but can be used to rule
VII. Method of choice pertinent to the case out other pathology.
VIII. Intraoperative Assessment → Graded compression ultrasonography (ultrasound) is an
A. Fluid Management inexpensive way of diagnosing acute appendicitis with high
B. Intraoperative Complications accuracy.
IX.Post-operative Assessment → High-resolution, helical, computed tomography is the most
X. Post operative complications and ADR accurate imaging study but it is expensive.
XI.Discharge Criteria ● Diagnostic Laparoscopy can serve as both a diagnostic and
therapeutic maneuver for patients with acute abdominal pain
Notes in orange dashed boxes were stressed by Dr. So! and suspected acute appendicitis.

I. CASE DESCRIPTION III. PREOPERATIVE ASSESSMENT SPECIFIC FOR

A 22 year old male student was brought to the emergency room REGIONAL ANESTHESIA
because of abdominal pain in the right lower quadrant
associated with nausea and vomiting. A. GOAL OF PREOPERATIVE ASSESSMENT
He has not taken any meals the whole day, except for sips of ● Reduce the patient’s surgical and anesthetic perioperative
water. He has no childhood diseases or allergies. He was morbidity or mortality
booked for appendectomy. ● Return the patient to desirable functioning as quickly as
How will you anesthetize the patient? possible
● Should appear in the patient’s permanent medical record and
Pertinent Findings: describe pertinent findings like;
(+) Right lower quadrant abdominal pain → Medical history
(+) Nausea → Anesthetic history
(+) Vomiting → Current medications
(+) Anorexia → Physical examination
(-) Childhood diseases and allergies → ASA physical status class
→ Laboratory results
II. PRE-OPERATIVE ASSESSMENT → Interpretation of imaging
A.HISTORY → Electrocardiograms
● A useful rule is never to place appendicitis lower than second → Comment when consultant’s recommendation will not be
in the differential diagnosis of acute abdominal pain in a followed
previously healthy person. ● Preoperative note should briefly describe the following;
● Classic pattern of migratory pain from periumbilical to right → Anesthetic plan
lower quadrant. − Should indicate whether regional or general anesthesia
→ Most reliable symptom. will be used
● Pain usually followed by anorexia and nausea. → Statement regarding informed consent from the patient or
● Vomiting could also be associated symptoms.  guardian
▪ Informed consent discussion indicating the plan,
B. PHYSICAL EXAMINATION alternative plans, advantages and disadvantages
● Temperature and pulse rate might be elevated slightly due to ▪ Indications that there are no interval changes since
ongoing inflammation. preoperative evaluation was performed
● Tenderness often maximal at or near the McBurney’s point.
● Positive direct rebound and indirect rebound tenderness are
both present. (+) Roving’s Sign Preoperative Assessment
● (+) Psoas sign and (+) Dunphy’s sign.
● Relevant anatomy should be examined

[Type here]
REGIONAL ANESTHESIA
● Evidence of infection near the site of anatomic abnormalities
may contraindicate the planned procedure
● Abbreviated neurological examination is important
→ serves to document whether any neurological deficits may be
present before the block is performed
● Contraindications to spinal anesthesia
→ Patients in shock
− Spinal anesthesia (SA) could cause preganglionic
sympathetic blockade hypotension
→ Patients not yet fully resuscitated
− SA could cause unanticipated cardiac arrest and
bradycardia
→ Infection at the site of spinal needle placement
− SA could introduce the bacteria to the CNS
→ Frank coagulopathy
− SA could cause spinal haematoma formation leading to
compression of the spinal cord and severe neurologic
sequelae
→ Patient refusal
→ Convulsion or raised intracranial pressure due to brain
tumor
− Drainage of the lumbar cerebrospinal fluid (CSF) can
increase the pressure gradient between the spinal,
supratentorial and infratentorial compartments. This
can result in rapid herniation of the brain stem or
occluding hydrocephalus which leads to coma
Notes from Doc So:
For patients with polio, let them sign a written consent that they are
willing to undergo procedure using spinal anesthesia, because
some of them will complain that their other leg got smaller after the
procedure. To prevent lawsuit and other complaints from the
patient, explain well the procedure and other conditions that may
happen if they still prefer spinal anesthesia.
IV. PREMEDICATIONS
A. GOAL OF PREMEDICATION
● Diminish anxiety
→ Ex: benzodiazepine (midazolam)
● Provide relief of preoperative pain or perioperative amnesia
→ Ex: opioids (fentanyl)
● Prophylaxis against postoperative nausea and vomiting
→ Ex: antiemetics, 5HT3 receptor antagonist or 5-
hydroxytyptamine (ondansetron, granisetron)
● Prevention of allergic reactions
→ Ex: antihistamine
● Prevention of aspiration pneumonia
→ Ex: antacids
● Decreasing upper airway secretions
→ Ex: anticholinergics (atropine)
● Today, preoperative sedative-hypnotics or opioids are almost
never administered except for:
→ Intubated patients who have been previously sedated in the
intensive care unit
→ Children 2-10 years old who will experience separation
anxiety may benefit from this
→ Patients who are quite anxious despite preoperative
interview
B. FACTORS TO BE CONSIDERED
● Clinical effects of medications
[Type here]
→ Ex: Benzodiazepine relieve anxiety and provide amnesia
however they have no analgesic activity. On the other hand,
opioids like fentanyl, hydromorphone and morphine could be
used to alleviate pain due to its analgesic effects
→ Opioids can decrease discomfort for patients being
transported to the operating room and during positioning in
the operating table. However, opioids also cause respiratory
depression, orthostatic hypotension and nausea and
vomiting
● Health and emotional status of the patient
● Proposed surgical procedure
● Anesthetic plan
● Duration of surgical procedure
→ Long-acting agents should not be used for short surgical
procedure and for ambulatory patients
C. PREMEDICATION FOR OPEN APPENDECTOMY
● IV fluids in order to correct dehydration that commonly
develops as a result of fever and vomiting in patients with
appendicitis.
● Patient started on antibiotics like;
→ Cefoxitin 1-2 g IV
→ cefotetan 1-2 g IV
→ cefazolin 1-2 g IV + metronidazole 0.5 g IV
● Fentanyl - For painful procedure like regional block or central
venous line that will be performed while the patient is still awake
● IV midazolam 0.07 mg/kg
→ short-acting benzodiazepine that has the benefit of providing
anterograde amnesia and reduce anxiety
→ administration of midazolam before operation is effective in
decreasing the frequency of nausea and vomiting
→ binds to the GABA receptors which increases the frequency
of opening of the associated chloride ion channel.
→ half-life is 2 hours and is the shortest among the
benzodiazepine group because of its increased hepatic
extraction ratio.
→ kidney failure may lead to prolonged sedation in patients
receiving larger doses of midazolam due to the accumulation
of a conjugated metabolite (α-hydroxymidazolam)
● Ondansetron, Granisetron
→ 5-HT3 receptor antagonist-type antiemetic
● Ramosetron
→ higher potency and longer antiemetic action than other 1st
generation 5-HT3 antagonists such as ondansetron
● Clonidine and Dexamethasone can be use as premedication
to prevent nausea and vomiting
Remember:
● Not all patients require preoperative medication because
preoperative anxiety do not harm most patients
● Duration should be noted because effects of some sedatives
may extend into the postoperative period and prolong recovery
time
● Preoperative visit from an anesthesiologist resulted in a greater
reduction in patient anxiety than preoperative sedative drugs
● Premedication should be given purposefully, not as a
mindless routine
V. REGIONAL ANESTHESIA
● Regional anesthesia is the use of local anesthetics to provide
nerve blocks to a wide area of the body such as the arm, leg
or the entire lower extremities.
REGIONAL ANESTHESIA
→ It can be divided into Peripheral and Central
A. PERIPHERAL NERVE BLOCK
● Local anesthetic can be injected peripherally, near a large
nerve or plexus, to provide anesthesia to a larger region of the
body.
● Examples include:
→ Blockade of brachial plexus for surgery of the arm or hand
→ Blockade of the femoral and sciatic nerves for surgery of
the lower extremity,
→ Ankle block for surgery of the foot or toes,
→ Intercostal block for analgesia of the thorax
postoperatively,
→ Blockade of the cervical plexus, which is ideal for carotid
endarterectomy
B. CENTRAL NERVE BLOCK
● AKA Neuraxial Blockade
● The injection of local anesthetic centrally near the spinal
cord which provides anesthesia to a large area of the body
depending:
→ On the site of injection on the spinal cord
→ Patient positioning
→ Anesthetic used
→ More factors that affect the level of neural blockade.
● Neuraxial anesthesia may be used simultaneously with general
anesthesia or afterward for postoperative analgesia.
VI. METHODS OF NEURAXIAL BLOCK
A. REVIEW OF SPINAL ANATOMY
Figure 1. Meninges and Spaces
● The spinal canal, composed of vertically stacked bony
vertebrae, contains the spinal cord with its coverings (the
meninges), fatty tissue, and a venous plexus.
● The meninges are all contiguous with their cranial
counterparts and are composed of three layers:
→ Pia mater – innermost
→ Arachnoid mater
→ Dura mater - outermost
● Between these layers are spaces:
→ Subarachnoid Space - Between the pia and arachnoid
mater wherein Cerebrospinal fluid (CSF) is contained
→ Subdural Space – a poorly demarcated potential space
between the dura and arachnoid membrane.
[Type here]
→ Epidural space - a better defined potential space within the
spinal canal that is bounded by the dura and the
ligamentum flavum.
Figure 2. Spinal cord
● Each spinal nerve begins as an anterior and a posterior
nerve root arising from the spinal cord and uniting at the
intervertebral foramina, to form a single spinal nerve from C1
to S5.
→ The anterior nerve root carries the efferent motor and
sympathetic outflow
→ The posterior nerve root receives somatic and visceral
sensation.
● The spinal cord normally extends from the foramen magnum
and tapers off at the level of L1 in adults and to the level of L3
in children as conus medullaris.
→ Lower nerve roots course some distance before exiting the
intervertebral foramina. These lower spinal nerves form the
cauda equina.
→ Performing a lumbar (subarachnoid) puncture below L1 in an
adult (L3 in a child) usually avoids potential needle trauma to
the cord and damage to the cauda equina is unlikely, as
these nerve roots float in the dural sac below L1 and tend to
be pushed away rather than pierced by an advancing needle
B. MECHANISM OF ACTION
● Nerve Root
→ Believed to be the principal site of action for neuraxial
blockade.
● Spinal Anesthesia
→ Local anesthetic is injected into CSF in the subarachnoid
space.
→ Direct injection of local anesthetic into CSF for spinal
anesthesia allows a relatively small dose and volume of
local anesthetic to achieve dense sensory and motor
blockade.
● Epidural and Caudal Anesthesia
→ Local anesthetic is injected into the epidural space.
→ The same local anesthetic concentration is achieved within
nerve roots only with much larger volumes and quantities of
 REGIONAL ANESTHESIA
local anesthetic molecules during epidural and caudal
anesthesia.
→ Level of injection site for epidural anesthesia must generally
be close to the nerve roots that must be anesthetized.
● Blockade of neural transmission in:
→ Posterior nerve root fibers
▪ interrupts somatic and visceral sensation
→ Anterior nerve root fibers
▪ prevents efferent motor and autonomic outflow
● Local anesthetics may also have actions on structures within
the spinal cord during epidural and spinal anesthesia.
1. SOMATIC BLOCKADE
● Neuraxial blocks can provide excellent operating conditions by:
Interrupting the afferent transmission of painful stimuli and efferent
impulses responsible for skeletal muscle tone.
● Sensory blockade interrupts both somatic and visceral
painful stimuli.
● Effect of local anesthetics on nerve fibers varies according to:
→ size, length and characteristics of the nerve fiber
→ type and concentration of the local anesthetic
● Spinal nerve roots contain varying mixtures of these fiber types.
→ Smaller and myelinated fibers are generally more easily
blocked than larger and unmyelinated ones.
● Differential Blockade
→ Clinical phenomenon that nerve fibers with different functions
have different sensitivities to local anesthetic blockade.
→ Explained by:
▪ size and character of the fiber types
▪ the fact that the concentration of local anesthetic
decreases with increasing distance from the level of
injection
→ Sympathetic nerve fibers are blocked by the lowest
concentration of local anesthetic followed by sensory nerve
fibers responsible for pain and touch and finally motor
nerve fibers.
→ This relative sensitivity of certain nerve fibers is displayed by
a spatial separation (sympathetic block will be approximately
2-4 dermatomes beyond motor block, the pain/touch will be
2-3 dermatomes beyond motor block).
→ Presumed etiology is as the local anesthetic gets further from
the injection site, it is present in lower concentration and
sympathetic nerve fibers do not require the same
concentration to be blocked as do motor nerve fibers.
2. AUTONOMIC BLOCKADE
● Sympathetic Blockade
→ Produced by interruption of efferent autonomic transmission
at the spinal nerve roots during neuraxial blocks.
● 2 outflows from the spinal cord:
→ Sympathetic outflow
▪ “Thoracolumbar”
▪ Sympathetic preganglionic nerve fibers (small, myelinated
B fibers) exit the spinal cord with the spinal nerves from
T1–L2 and may course many levels up or down the
sympathetic chain before synapsing with a postganglionic
cell in a sympathetic ganglion.
→ Parasympathetic outflow
▪ “Craniosacral”
▪ Parasympathetic preganglionic fibers exit the spinal cord
with the cranial and sacral nerves.
● Neuraxial anesthesia DOES NOT block the ` nerve.
[Type here]
● Physiological responses of neuraxial blockade result from
decreased sympathetic tone and/or unopposed
parasympathetic tone.
3. SYSTEMIC MANIFESTATIONS
Cardiovascular Manifestations
● Neuraxial blocks produce variable decreases in blood
pressure that may be accompanied by a decrease in heart
rate.
→ These effects are proportional to the dermatomal level and
extent of sympathectomy.
● Vasomotor tone
→ Primarily determined by sympathetic fibers arising from T5-
L1, innervating arterial and venous smooth muscle.
→ Blocking these nerves causes:
▪ Vasodilation of the venous capacitance vessels
▪ Pooling of blood in the viscera and lower extremities
▪ Decreasing the effective circulating blood volume and
venous return to the heart.
● Arterial vasodilation may also decrease systemic vascular
resistance.
● Effects may be minimized by compensatory vasoconstriction
above the level of the block, particularly when the extent of
sensory anesthesia is limited to the lower thoracic dermatomes.
● In a high sympathetic block:
→ Does not only prevents compensatory vasoconstriction,
→ Also blocks the sympathetic cardiac accelerator fibers that
arise at T1–T4.
● Profound hypotension may result from:
→ arterial dilation and venous pooling combined with
bradycardia
→ possibly milder degrees of decreased contractility
● Effects are exaggerated if venous pooling is further augmented
by a head-up position or the weight of a gravid uterus.
● Unopposed vagal tone may explain the sudden cardiac arrest
sometimes seen with spinal anesthesia.
● Deleterious cardiovascular effects should be anticipated
and steps undertaken to minimize the degree of
hypotension.
● Volume loading with 10–20 mL/kg of intravenous fluid in a
healthy patient before initiation of the block has been shown
repeatedly to fail to prevent hypotension.
● Left uterine displacement in the third trimester of pregnancy
helps to minimize physical obstruction to venous return.
(AORTOCAVAL SYNDROME)
● Despite these efforts, hypotension may still occur and should be
treated promptly.
● Autotransfusion
→ may be accomplished by placing the patient in a head-down
position
● A bolus of intravenous fluid (5–10 mL/kg)
→ May be helpful in patients who have adequate cardiac and
renal function to be able to “handle” the fluid load after the
block wears off.
● In cases of excessive or symptomatic bradycardia, treatment is
done by giving Atropine
● In cases of hypotension, treatment is done by giving
vasopressors
REGIONAL ANESTHESIA
● Direct alpha-adrenergic agonists (e.g. phenylephrine) produce
arteriolar constriction and increase reflexive bradycardia 🡪
increased systemic vascular resistance

● Ephedrine
→ “mixed” agent because it has both direct and indirect beta-
adrenergic effects
→ Increases heart rate and contractility
→ Produces vasoconstriction
● Epinephrine
→ 2 mcg boluses were found to be effective in treating
anesthesia-induced hypotension
→ However, if there is profound hypotension and/or bradycardia
persists, vasopressor infusions are used

[Type here]