Lecture 11

Instruments for Regional.

Dr. Abdelrahman Alalawneh
Table on content:
➢Spinal & epidural Needles.
➢Nerve Stimulator.
➢BiSpectral Index.
Spinal Anatomy & Landmarks:
Spinal Needle:
Spinal Needle:
• These needles are used to :
1. Inject Local Anaesthetic and Opiates into the Subarachnoid Space.
2. Sample the Cerebral Spinal Fluid (CSF).
3. Intrathecal injections of Antibiotics and Cytotoxic.

• The Subarachnoid Space contains Cerebral Spinal Fluid CSF.

Needle Types:
 Prosperities:
• The needle’s Length varies from 5 to 15 cm; the 10-cm version is most commonly used.
• They have a Transparent Hub in order to identify quickly the flow of CSF.
• A Stylet is used to prevent occluding the lumen during insertion. It also acts to strengthen the
shaft.
• Spinal needles are made in different sizes, from 18 G to 29 G in Diameter.
• The 25-G and smaller needles are used with an Introducer which is usually an 18-G or 19-G needle.

• The Bevel has two designs :

1. Cutting, Traumatic ................................ seen in the Yale and Quincke needles.
2. Noncutting, Atraumatic, Pencil Point ... seen in the Whitacre and Sprotte Needles.

• All Spinal ( intrathecal ) Bolus Doses and Lumbar Puncture Samples are performed using Syringes,
Needles and other devices with Safer Connectors that cannot connect with intravenous Luer
connector.
Post Dural Puncture Headache:
 Post Dural Puncture Headache:
• The incidence is directly proportional to the Gauge of the Needle and the Number of Punctures through the
dura
• It is indirectly proportional to the Age of the patient.
• There is a 30%incidence of dural headache using a 20-Gspinal needle.
• whereas the incidence is reduced to about 1% when a 26-Gneedle is used.
• The Whitacre and Sprotte atraumatic needles separate rather than cut the longitudinal fibers of the dura.
• The defect in the dura has a higher chance of sealing after the removal of the needles.
• The Traumatic bevel needles cut the dural fibers, producing a ragged tear which allows leakage of CSF.
• Dural headache is thought to be caused by the leakage of CSF.

• The Risk of dural headache is Higher during :

1. Pregnancy and Labor.
2. Day-surgery patients.
3. Patients who have experienced a dural headache in the past.
Epidural Needles:
 Epidural Needles:
• Tuohy Needle are used to identify and cannulate the Epidural Space.

• The needle is 10 cm in Length ( the Shaft of 8 cm ).

• A 15-cm version exists for obese patients.

• The needle wall is thinin order to allow a Catheter to be inserted through it.

• The needle is provided with a Stylet Introducer to prevent occlusion of the lumen.

• The Bevel(Huber Point ) is designed to be slightly oblique at 20 degrees to the shaft.

• The commonly used Gauges are either 16 G or 18 G.

Anatomy And
Placement:
 Properties:
• The markings on the needle enable the anesthetist to determine the
distance between the skin and the epidural space.

• The length of the catheter left inside the epidural space can be estimated.
• The shape and design of the Bevel enable the anesthetist to direct the
catheter within the epidural space (either in a cephalic or caudal
direction).

• The bluntness of the bevel also minimizes the risk of accidental dural
puncture.
Safety Features:
• There is a risk of the catheter to be transected by the oblique
Bevel.

• In accidental Dural Puncture, there is a high incidence of

Postdural Headache due to the epidural needle’s large bore (e.g.
16 G or 18 G).

• Epidural Bolus doses are performed using Syringes, Needles and

other devices with Safety Connectors that cannot connect with
intravenous Luer connectors.
Epidural Catheter:
 Epidural Catheter:
• The catheter is a 90-cmTransparent, Malleable tube.

• Made of either Nylon or Teflon.

• The 16-Gversion has an external diameter 1 mm and an internal diameter 0.55 mm.

• The Distal End has two or three side ports with a closed and rounded tip in order to reduce
the risk of vascular or dural puncture.

• The Distal End of the catheter is marked clearly at 5-cm intervals, with additional 1-cm
markings between 5 and 15 cm.

• The Proximal End of the catheter is connected to a Luer lock and a Filter.
 Properties:
• The markings enable the anesthetist to place the desired length of catheter within the epidural
space ( usually 3–5 cm ).

• An Epidural Fixing Device can be used to prevent the catheter falling out.

• It has an Adhesive Flange that secures it to the skin.

• The device does not occlude the catheter and does not increase the resistance to injection.

• Once the catheter has been removed from the patient, it should be inspected for any signs of
breakage.
Epidural Filter:
Epidural Filter:
• The Hydrophilic Filter is a 0.22-μm mesh which acts as a bacterial, viral and
foreign body filter.

• The Priming Volume is about 0.7 Ml.

• The filter should be changed every 24 hours if the catheter is going to stay in situ
for long periods.

• The syringe has a special Low-Resistance Plunger used to identify the epidural
space by:
• Loss of Resistance to either Air or Saline
Combined Spinal–Epidural Set:
Combined Spinal–Epidural Set:
• It is possible using a 26-GSpinal needle of about 12-cm length.

• With a standard 16-GTuohy needle.

• The Tuohy needle is first positioned in the epidural space.

• Then the Spinal needle is introduced through it into the subarachnoid space.

• A relatively high pressure is required to inject through the spinal needle because
of its small bore.
Nerve Block Needle:
 Nerve Block Needle:
• These needles are used to identify a Nerve Plexus or Peripheral Nerve.
• They are made of Steel with a Luer-Lock Attachment.
• They have short Bevels in order to cause minimal trauma to the nervous
tissue.

• They have Transparent Hubs which allow earlier recognition of

intravascular placement.
• A Side Port for injecting the local anaesthetic solution is found.

• They are connected to a Nerve Stimulator to aid in localizing the nerve

using an Insulated Cable.
• 22-Gsize Needles are optimal for the vast majority of blocks.
Clinical Use:
• The needle should first be introduced through the skin and subcutaneous tissues and
then attached to the lead of the Nerve Stimulator.

• 22 G is optimal with Lengths of 50–150 mm are available.

• The needle is advanced slowly towards the nerve until nerve stimulation is noticed.

• The Current should be 0.2–0.5 mA.

• Contractions with 0.2-0.5 mA mean that the tip of the needle is very close to the nerve.
• Contractions at a current more than 0.5 mA suggest the needle is far from the nerve.
• Contractions at a current less than 0.2 mA may suggest intraneural needle placement.
Nerve Stimulator of Nerve Block:
Nerve Stimulator of Nerve Block:
• This device is designed to produce visible Muscular Contractions at a predetermined current and
voltage once a nerve plexus or peripheral nerve has been located, without touching it.

• It provides a greater accuracy for local anaesthetic deposition.

• Components :
1. on/off Switch
2. Dial selecting the Amplitude of the current
3. Two leads complete the circuit

• The Positive Lead being attached to the skin

• The Negative Lead being attached to the needle
Clinical Use:
• A small constant Current ( 0.25–0.5 mA ) is used to stimulate the nerve fibers
causing the motor fibers to contract.

• The Frequency is set at 1–2 Hz.

• Tetanic stimuli are not used because of the discomfort it causes.

• The Duration of the stimulus should be short ( 50–100 MS ) to generate painless

motor contraction.

• Nerve location can be very accurately defined when low currents are used.
Nerve Stimulator
of Muscle Block:
Nerve Stimulator of Muscle Block:
• These devices are used to monitor transmission across the neuromuscular junction.

• The Depth, Adequate Reversal and type of Neuromuscular Blockade can be established.

• Two surface electrodes (small ECG electrodes) are positioned over the Nerve and
connected via the leads to the Nerve Stimulator.

• A Supramaximal Stimulus is used to stimulate a peripheral nerve.

• This ensures that all the motor fibers of the nerve are depolarized.

• The Duration of the stimulus is less than 0.2–0.3 MS.

Clinical Use:
• Negative Electrode is positioned directly over the most superficial part of nerve
• Positive Electrode is positioned along the proximal course of the nerve to avoid
direct muscle stimulation

• A current of 15–40 mA is used for the Ulnar Nerve.

• Train-of-Four (TOF):
• Used to monitor the Degree of the neuromuscular block.
• The Ratio of the Fourth to the First Twitch is measured.
BiSpectral Index:
BiSpectral Index:
• The BIS monitor is a device used to :
1. Monitor the electrical activity and the level of sedation in the brain
2. Assess the risk of awareness while under sedation or anaesthesia
3. Titration of hypnotics to reduce underdosing and overdosing

• Components :
1. A Forehead Sensor with Four numbered Electrodes and a smart Chip
2. The sensor uses small tines, which part the outer layers of the skin,
and a Hydrogel to make electrical contact
 Clinical Use:
• It uses a Linear, Dimensionless Scale from 0 to 100.

• Value of 100represents an awake EEG.

• Values of Zero represents Complete Electrical Silence ( Cortical Suppression ).
• Values of 65–85are recommended for Sedation.
• Values of 40–60are recommended for General Anaesthesia.

• Hypothermia of less than 33°C results in a decrease in BIS levels as the brain processes slow.

• BIS cannot be used to monitor hypnosis during Ketamine anaesthesia.