SURGERY II 2.

04
REGIONAL ANAESTHESIA
August 1, 2019 | Dr. Martija (Part 1) & Dr. Salazar (Part 2)
Transcriber/s: Group 2A
Subtranshead notes: Doc’s lecture was back and forth when discussing the spinal and Needs only a small dose of the local anesthetic, ~4-5 cc or 20 mg
epidural anesthesia. I took the liberty to place the corresponding part under one that can block the spinal cord up to T4-T6
heading, i.e. all that relates to spinal is under one section of spinal anesthesia, and all
that is under the epidural is in one section as well. Doc did not elaborate much on the Only for lumbar surgeries due to the danger of injuring the
anatomy part in fact he just skipped it altogether, that’s why it’s at the last part. Tbh, I spinal cord
feel like the summary of Dr. Salazar is more enlightening, hehe. So if gipit sa oras, When you introduce the local anesthetic in the subarachnoid
summary na yan.
space, it is absorbed by the spinal cord and the initial response
NEURAXIAL ANESTHESIA of the body is sympathetic block followed by sensory block
In short for spinal, regional, epidural, and caudal anesthesia then motor block, vice versa when recovery starts.
Deals with introducing the local anesthetic in to the spinal cord o Sympathetic block is manifested by hypotension, peripheral
to block or to anesthetize the spinal cord, thereby causing vasodilation, because if you block the sympathetic part, the
analgesia and anesthesia from the level of the block down. parasympathetic part predominates which causes the
o Example: Introduction of the anesthetic into the T4 vasodilation and hypotension.
interspace will block from level T4 and down. o The reason why sypathetic nerves are blocked first, followed
Main purpose: provide the surgeon an adequate, relaxed picture by sensory and motor, respectively, is due to the size of the
nerves. From the smallest to the biggest nerve size.
OBJECTIVES
General: to define neuraxial anesthesia
Specific:
1. To identify its indications and contraindications
2. To analyze the anatomy, technique, pharmacology, and
physiology
3. To recognize complications because not all procedures are
complication free (if you don’t recognize these, cardiac
arrest, paralysis, or death may occur)

INTRODUCTION
Subarachnoid or intrathecal anesthesia Figure 1. Have the patient lie on either the left or right side. In this
o Commonly referred to as spinal anesthesia case, the patient is in right lateral decubitus position. Remember to
o Subarachnoid = injection in the subarachnoid space do the antiseptic technique.First, introduce the local anesthesia in
o Intrathecal = inside the dura the skin/subcutaneous before puncturing use spinal needle gauge
Neuraxial includes both spinal and epidural injection 26 (may also be 23, 25, or 27)
Subarachnoid injection using a local anesthetic
o Rapidly produce dense surgical anesthesia ADVANTAGES
o Almost always done in the lumbar region Cheap, easy to do
Always explain to the patient the meaning of whatever you are Patient compliance is good
going to do to them Excellent relaxation of the muscles
When you do a spinal anesthesia, NEVER tap (inject) wherever
the spinal cord is. Spinal cord in ADULT ends in T12-L1, for COMPLICATIONS OF SPINAL/DURAL TRAUMA
PEDIATRICS L2-L3. Spinabifida
Caudal Anesthesia (Kiddie caudal) is usually used in pediatric Paralysis (temporary/permanent)
patients, difficult in adult patients. Arachnoiditis
Hematoma
SUBARACHNOID/SPINAL ANESTHESIA Spinal stenosis
• Provides excellent operating conditions for lower abdominal,
pelvic and lower extremity surgery CRITICAL COMPLICATIONS IN THE CVS
• Single injection only
Hypotension (severe, mild, irreversible) especially on patients
• Last 2-3 hours (i.e., Bupivacaine 0.5% ~2 hours for
with hypovolemia
appendectomy, cesarean section, hernia, etc.)
Severe Bradycardia (reversible/irreversible) in patients with
o How can doctors do surgery for more than 2 hours with
intractable cardiac disease or impending arrhythmias
spinal anesthesia?
Put a catheter directed towards the epidural area, then
EPIDURAL ANESTHESIA
introduce local anesthetics in the epidural area. This
Epidural anaesthesia may be intermittent or continuous
becomes a combination of spinal & epidural anesthesia.
Usually combined in general anesthesia
Surgeries can then last as long as 10-12 hours.
You can also thread your catheters in the subarachnoid Used to prolong spinal anesthesia
space but you have to be very aseptic to avoid direct Thoracic epidural anesthesia/segmental block for upper
introduction of infection. abdominal/intrathoracic surgery
Spinal anesthesia may be single shot or continuous Bigger space to cover, presence of a barrier (dura) between the
Introducing the local anesthetic directly into the subarachnoid epidural space and the spinal cord hence, requires larger doses
space of local anesthetic

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 Takes more time to produce block History of blood dyscrasias and stroke in the past 6 months
Local anesthetic can be injected repeatedly through the catheter On medication with anticoagulants (Ex: Heparin, etc.)
and can be prolonged to match duration of surgery, and can be
used to introduce analgesics/narcotics post-operatively LEVEL/SPREAD OF BLOCK
Can be safely performed in the lumbar, thoracic and even Determined by:
cervical regions o Dose of anesthetic: low dose, low level of blockade, and vice
Thoracic epidural anesthesia is a useful adjunct to general versa
anesthesia for upper abdominal and thoracic surgeries o Pressure of introduction: with an increase in pressure, there
Epidural injection of medications can also provide analgesia is an increase in blockade
The flexibility of continuous epidural block makes it excellent for o Hyperbaric anesthetic: an anesthetic that is heavier than the
labor pain relief CSF
When introducing the catheter in the thoracic epidural, be Patient variability
careful when puncturing using the needle not to hit the artery of o Older patients- faster spread of local anesthetics
Adamkiewicz, this supplies the anterior portion of the spinal o Pregnant patient- more extensive block
cord. When this is hit, the patient will be paralyzed which may o Drug dose is directly proportional to level of block not
be permanent, due to hypoperfusion of the spinal cord plus the duration
hematoma produced by the bleeding. o Site of injection has major impact on spread of block, higher
site, higher spread; lower site, only those below are affected
TECHNIQUE Onset and Duration
Patient preparation o Sensory block within 5-10 min.
o Equipment o Full extent block within 20-30 min.
o Positioning *Test dose is very important (especially in epidural) – to make sure
o Skin preparation that the catheter is placed correctly; if a catheter is placed
o Needles intravascularly and you give high dose local anesthetic, patient
o Approach may have seizures, undergo cardiac arrest, or die
Combined Spinal-Epidural
o How do you make a choice which technique to use? Talk to CEREBROSPINAL FLUID
your surgeon (how long the surgery will take, what incisions, Examine it grossly
etc.) so you can plan your technique. Check if the CSF is bloody, turbid, or abnormal
o This can affect the effectivity of the anesthetic
PHARMACOLOGY o If it’s bloody, expect a delay in the onset of the anesthetic.
Sub-arachnoid anesthesia
o Factors for Spread and Duration: PHYSIOLOGY
Density and Dose (most important factors) CNS CARDIOVASCULAR
Density (ratio of mass of a substance to its volume) Intrathecal local anesthetics: Intrathecal injection:
Baricity (ratio of 2 densities) Reduce somatosensory evoked More extensive sympathetic
Hyperbaric local anesthetic potentials block
o Greater density compared to CSF
Neuraxial block: Venodilation= lower cardiac
o will flow to dependent areas due to gravity
-Potentiates effects of output and hypotension
Isobaric local anesthetic
sedatives *With variable heart rate
o Initial spread; by bulk displacement - decrease MAC for inhaled
o CSF movements: cardiac pulsation or gross patient movment agents
o Long duration
Large motor nerve more Thoracic level (T1-T4) can
resistant to local anesthetic produce sympathetic block
Pregnant patient: block
Epidural anesthesia:
Higher levels of sensory block compared to non-pregnant
Sensory nerve intermediate Gradual decrease in
Female and pregnancy: sensitivity sympathetic block
Increase motor block
Preganglionic symphatetic
Old age: (smallest) more sensitive to LA
Slower onset and longer duration
Analgesia extends more Vasopressors reverse
Increased intra abdominal and epidural space pressure: segments than anesthesia hypotension (neuraxial block)
Enhance sensory spread by decreasing lumbar CSF volume
Ephedrine:
Raise BP by raising stroke
INDICATIONS volume and cardiac output
No absolute contraindications
Its use is determined by a combination of preferences of patient, Phenylephrine:
surgeon, and anesthesiologist Increases systemic vascular
resistance and decreases
CONTRAINDICATIONS cardiac output
Patient refusal Norepinephrine:
Coagulopathy/Hemodynamic instability Maintains heart rate and
Infection on site of injection (abscess, ulcers) cardiac output

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 HYPOTENSION Hearing loss
The most common side effect of local anesthetics o Can occur after subarachnoid anesthesia
Can be prevented by: o More common in elderly
o Pre-loading: before you induce the patient, you give high o Due to effects of decreased CSF pressure on inner ear
volume (at least 500 cc) of isotonic IV fluid in anticipation to function
the vasodilation Total spinal anesthesia/ total subarachnoid block
o Give vasopressors: most commonly given is Ephedrine; o Inadvertent puncture of the dura
Norepinephrine or Phenylephrine can also be given o Patient just lies flat, not breathing, not responding, when
unrecognized, patient may undergo cardiac arrest
BEZOLD-JARISCH REFLEX o Respiratory compromise and cardiac arrest
Reflex mediated by 5HT-3 serotonin receptors located in the o ACLS
vagus nerve and ventricular myocardium o Treated by supportive measures, i.e. intubation, caridac
Systemic hypotension activates these receptors causing efferent support
vagal signaling producing bradycardia, reduced cardiac output Systemic toxicity
and worsened hypotension o Absorption from the epidural space or unrecognized
intravascular injection
RESPIRATORY SYSTEM o Symptoms: tinnitus, metallic taste, seizures, cardiac arrest
Subarachnoid and epidural have little effect on pulmonary Neurologic Injury
function o Catastrophic complication of neuraxial block
High spinal block can affect the accessory muscles of respiration o Due to direct trauma, mass effect and physiologic damage
can cause dyspnea, apnea ,or hypopnea Hypoperfusion
Well-sedated patients cannot complain about difficulty in o Spinal cord ischemia due to direct needle trauma to spinal
breathing, in a few minutes, patient may go into hypoxemia and cord vasculature, prolonged hypoperfusion and spinal
cardiac arrest stenosis
Chemical Injury
GASTROINTESTINAL SYSTEM o Adhesive arachnoiditis
Neuraxial-induced sympathetic block leads to unopposed vagal o Transient neurologic symptoms
stimulation of the GIT o Cauda equine syndrome: direct chemical injury to nerve
o Increase secretions roots
o Sphincters relax and bowel constricts o Inadvertent introduction of drugs

TEMPERATURE HOMEOSTASIS ANATOMY (NOT ELABORATED)

Hypothermia occurs routinely Spine is composed of 33 vertebrae:
Neuraxial anesthesia inhibits central thermoregulatory control o 7 cervical
Block of peripheral sympathetic and motor nerves prevents o 12 thoracic
vasoconstriction and shivering o 5 lumbar
o 5 fused sacral
COMPLICATIONS o 4 fused coccygeal
Backache
o Accidental dural puncture may cause persistent backache FROM 2019 lecture: Regional differences in vertebral
until 6 weeks postpartum structures are important to central blockade particularly
Headache with regards to the angle of needle insertion & the choice of
o Common complication of both intentional and unintentional median or paramedian approach.
dural puncture using a large needle
o Risk of post dural puncture headache correlates with needle
The vertebral canal contains the spinal cord, CSF, meninges,
tip design, size and bevel orientation
spinal nerves and epidural space
o PDPH develops 24-72 hours after dural puncture
S5 is not fused posteriorly – sacral hiatus
Postdural Puncture Headache (PDPH)
o Most caudal point of the epidural space
o Frontal and occipital pain made worse by standing and
o Sacral hiatus is open in children
relieved by lying flat
o Severe types may cause neck, shoulder or back pain, not Commonly identified landmarks:
relieved by lying down, symptoms of visual disturbances, o C7 spinous process
vertigo and cranial nerve palsies o 12th rib
o Rarely: cortical vein thrombosis and subdural hepatoma o Iliac crests
o Treatment: Tuffier line- line between the iliac crests to identify L4-L5
Bed rest interspace
Hydration Anterior and posterior longitudinal ligaments- link the ventral
Analgesics (NSAIDS) surfaces of vertebral bodies
Caffeine Supraspinous and interspinous ligaments, ligamentum flavum-
Epidural blood patch (20ml blood volume injection) connect the vertebrae
Supraspinous ligament continues as ligamentum nuchae
Anterior and posterior longitudinal ligaments – link the ventral
Autologous epidural blood patch is done to create some sort of surfaces of vertebral bodies
hematoma/thrombus to avoid leaking of CSF Supraspinous and interspinous ligaments, ligamentum flavum-
connect the vertebrae
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Supraspinous ligament continues as ligamentum nuchae
o Lies within the vertebral canal but outside the dural sac SUMMARY
o Extends from the foramen magnum to sacral hiatus Everything below this is from Dr. Salazar. She did not have a
o Cervical level has no epidural fat powerpoint so everything is from the recording. Just to reiterate the
o Boundaries of epidural space important portions of the lecture and the parts where we will be
Anterior – Posterior longitudinal ligament getting the questions for the exam.
Posterior – lamina and ligamentum flavum
Lateral – extends to the pedicles (communicates with Basically, there are two types of regional anesthesia under
paravertebral space) neuraxial- that’s spinal and epidural.
So what’s the difference?
Supraspinous ligament thins in the lumbar region to allow o Physiologically, the main difference is when you do a spinal,
greater flexion of the spine (SNAP) you mix your local anesthetic with the CSF so the effect will
Intraspinous ligament contains fat-filled cavities that creat “false be faster; the onset will be speedier than the epidural. So
loss of resistance” during epidural attempts (MUSHY) there’s pronounced hypotension and bradycardia that you
Ligamentum flavum- made mostly of elastin (GRITTY) will observe.
Epidural space o Meanwhile, with your epidural anesthesia, you use an
epidural catheter, you insert that into the epidural space and
Epidural veins – mostly in the anterior epidural space then you let the drug pass through the catheter. Because the
Meninges epidural cath is in the epidural space, it is not really in direct
o Surround and protect the spinal cord, CSF and nerve roots contact with your CSF, the spread of the block will depend
until they exit the foramina on the transfer or seepage of the local anesthetics to the
o Meningeal layers: nerve sheath and nerves that you have to block. SO the block
Dura is gradual compared to spinal anesthesia.
thickest, outermost layer For the indications and contraindications, there’s really no
Consists mostly of collagen fibers absolute technique to use so you have to talk to your surgeon,
Subdural space your patients. Because, for instance, there are patients for
potential space between dura and arachnoid appendectomy, the incision level is below umbilicus, so you
Continuation of spinal meninges from the foramen don’t need to have a higher block or general anesthesia for that
magnum to S2 and fuses with filum terminale but sometimes patients are too scared because ‘yung kapitbahay
Arachnoid had appendectomy last time na paralyzed na ngayon. So it’s your
Lies within the dura job as the anesthesiologist to convince them that it could
Low permeability - keep CSF in subarachnoid space happen but since appendectomy is a very simple procedure and
Herniates through the dura and forms arachnoid you don’t need super complicated techniques for you not to feel
granulations provide an exit for the materials leaving anything during the surgery. Just try to explain the advantages of
the CNS) using a regional over a general anesthesia.
Pia If you use GA, you will be giving a lot more medications, you will
Innermost be dealing with the airway which sometimes is very deceiving.
Consists of cells that coat spinal cord and nerve roots Some patients have long neck but once you give them muscle
Cerebrospinal fluid – main carrier of anasthetic relaxants, and you visualize the glottis opening, you can’t see it
o Aqueous solution anymore. So it’s safer to do regional anesthesia for procedures
o Consists of 99% water not requiring complete relaxation of the whole body.
o Minor components: protein, glucose, electrolytes, The epidural technique is very useful for pregnant patients
neurotransmitters because sometimes you don’t need to give complete anesthetic.
o Volume: 100-160ml you just need to block the sensory for labor. So they can still feel
o Produced and absorbed in the parenchymal capillaries of the the contractions but the pain is no longer there. When there are
brain and spinal cord contractions, you can ask the patient to bear down, and they can
Spinal cord move their legs. Epidural is very safe and makes the labor very
o At birth – L3 relaxed. After that, you pull out the epidural catheter and just
o Adult – L1 give them oral medications. Unlike for CS, when you do a spinal,
o 31 pairs of spinal nerves since nagalaw ang uterus, na-touch ang intestines, so the patient
o In short, in pediatric its longer in adults its shorter will not be fed right away, they will be put on NPO (nothing per
Nerve roots orem) for 2 days. Nakakagutom. Unlike if you do an epidural, as
o Arise from individual spinal cord segments soon as the epidural catheter is removed, tulog ka nang konti,
o Each posterior sensory nerve root innervates a specific pagkagising mo kain ka na ng lechon. That’s for the indications.
dermatome For the contraindications, the first absolute contraindication is
o Sympathetic nervous system system arises from patient refusal.
intermediolateral grey matter of TI-L2 o Another one is coagulopathy and hypovolemic shock. When
Grey matter we see patients in the ER, usually they are trauma patients,
o contains cell bodies of preganglionic sympathetic neurons like vehicular accidents, pagdating nila sa ER they have liver
o Dural sac level of T12-S1 injuries that you can’t visualize. But as soon as the patient is
o Dural sac volume: 34 ml referred to an anesthesiologist and is mentioned to be
hypotensive, do not do spinal anymore because it will just
aggravate the hypotension. So just hydrate the patient and
do a GA.

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o For coagulopathy, there are patients with hematologic
problems. When I was a resident, there was a patient
referred to us. Initially, she was for epidural only because
she’s going into labor so the consultant inserted an epidural
catheter. But then during the active portion of the labor, the
progression of labor did not push through, so we had to do a
CS. This patient was believed to not have a coagulopathic
problem, so we did a CS. After the baby came out, the uterus
was repaired but began to bleed, and the bleeding did not
stop, to the point that the IV insertion and the catheter
insertion was bleeding already. Only then did we know that
she was having a coagulopathic event and we did not know
what it is. So we had to stop surgery, we had to pack
everything, and close it very fast. We did transfusion and
fluid management, and then we sent out blood samples to
UST. Patient was found out to be hemophiliac. So we did
everything we can, we provided everything she needs, but
she died. So when you interview your patients with regional
anesthesia, you have to be very careful in extracting this
information. The simplest question would be, “Pag
nasusugatan kaba, mabilis lang matanggal yung dugo?” Kasi
that simple information can give you an idea that you have
to be cautious.
Before you do a regional, you have to know the volume status of
the patient. If trauma, know levels of injury. For pregnant
patients, know if there are coagulopathic disorders.
For managing complications, before you do an operation or
surgery, the surgeon and the anesthesiologist have to talk to the
relatives and the patients, and explain everything. Explain the
need for this technique, what would be the indications,
contraindications, even the complications. Don’t hide anything
from them, tell them everything that can happen to them, so
that whenever an adverse event happens during the surgery or
after the anesthetic, at least you were able to explain that to the
patient so it’s kind of expected. If you conceal something and it REFERENCES
happens to the patient, you are more prone to legal problems. 1. Recordings
With the anesthetics used, the medications, it’s basic for 2. Lecture PPT
epidural and RA to use one type of drug- local anesthetics. Your TRANSCRIBERS
choice of drug will depend on the kind of the procedure, if it’s 1. TRANS GROUP: 2A
long or if it’s just a short one; if you need a lower block or a 2. SUBTRANSHEAD: MAR
higher block. 3. EDITOR:
For the combined spinal epidural, we do that for gynecologic 4. TRANS HEAD: KJLA
patients. For those who are for hysterectomy, because the
epidural anesthesia will take effect after 30 minutes so you can’t
ask your surgeon to wait for 30 minutes. Your anesthesia has to
work right away. What are you going to do? You insert the
epidural catheter but don’t give the drug yet; insert the spinal
and put the drug. The spinal will work in five minutes and the
patients can have preps and undergo surgery. If the surgery gets
prolonged, give the epidural after 1.5 hours. The combination
will give a faster onset and a longer duration.
Also, if you combine GA and epidural, your epidural will lower
the concentration of the gas that you will be needing for the
procedure so mas tipid siya. And lesser tachycardia and
hypertension during surgery.

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