Neuraxial Anesthesia

Physio
CV:
-SVR falls (block preganglionic fibers in SNS), drop BP
-vasodilation depends on – pt baseline vasomotor tone (high tone in elderly = high SNS
blockade)
-hypotension: >20% fall in SBP baseline, <90.
-tx w/pressors, fluids

Renal:
-dec MAP results in renal perfusion pressure

Indications:
-surgery involved in LE, pelvis, perineum, lower abdomen
-below level of umbilicus
- spinal anesthesia – finite time
-CSE/epidural anesthesia: intermittent, continuous LA delivery or continuous spinal anesthesia

-epidural postop: reliable, potent long lasting analgesia

-can be used intraop, post op – esp in thoracotomy, laparotomy, hip/knee sx, cardiac sx

Contraindications:
-absolute: pt refusal, localized sepsis at site of insertion, allergy to drugs, raised ICP,
coagulopathy
-coagulopathy: acquired or inherited; VWD, hemophilia.
-thrombocytopenia – no minimum level but >75k acceptable if no downward trend.
-acquired: trauma, sepsis, DIC< MTP, uremia, liver disease

-anticoagulation therapy:
-Antiplatelets:
 NSAIDS, ASA – no d/c needed
 Plavix, prasugrel – 7 days
 Ticlodipine – 14d
-warfarin: INR<1.5
-GP IIb/IIIa inhibitors:
 Abxicimab: 48h
 Eptifibatide, tirofiban: 8 hours
-LMWH:
 Lovenox treatment dose: 24 hours
 Lovenox ppx: 12 hours
-UFH subcut
 5000 BID: no d/c needed
  >5000 BID: 6+ hours or normal PTT
-IV Heparin: stop infusion, check PTT after 2 hours

Relative contraindications:
-neurological (spinal stenosis, spinal surgery depending on site/extent, MS, spina bifida)
-cardiac: aortic stenosis, hypoV esp in pts preload dependent

-spinal: sitting or lateral decubitus

-sitting more likely to be a/w hypotension
-midline challenging in lateral decubitus
-spinal cord ends L1/L2 – inject below this.

Monitoring:
-check minute BP
-degree of motor block: 0 – no motor block, 1 – no straight leg raise, 2 – can’t bend knees/legs,
only feet, 3 – complete motor block
-sensory: common by pinprick, cold, touch (motor block largest)

Level of block:
-upper abd – T4
-intestinal, gyn, uro – T6 (sternum)
-vaginal delivery – T10 (umbilicus)
-thigh, legs – L1
-foot, ankle – L2
-perineal, anal sx – Sacral block

-Baricity of LA: ratio of density of LA / density of CSF

-used along with pt positioning and gravity to achieve desired block
-volume/dose/concentration also affects height of block
-patient position, dose of anesthetic, baricity – most important factors
-dose – bigger dose = lasts longer. Duration largely affected by protein bound (bupivicane >
lidocaine protein bound)
-additives: epi, clonidine – vasoconstriction from epi. Clonidine = +1 hour (not FDA approved)
-hyperbaric solns have less duration of block vs isobaric

Epidural:

-test dose to check for intrathecal placement: get sensory/pinprick loss, warmth
-volume and dose of EPIDURAL most important for height of block
-level of injection important factor

Complications:
-neuro: paraplegia, cauda equine, epidural hematoma, TNS
-post dural puncture headache: 1/100. Younger, females, large needle size, more when
pregnant.
-CV: hypoTN, bradycardia, CV collapse
-n/v, pruritus (opiates), shivering (vasodilation), urinary retention