LOCAL ANESTHETICS AND REGIONAL ANESTHESIA

SMALL GROUP DISCUSSION

1. A 25-year old female underwent emergency appendectomy under subarachnoid

block with unremarkable intraoperative course. After 48 hours, she started to
complain blurring of vision and severe frontal headache which did not respond to
NSAIDs. She was referred back to your service for your evaluation.

a. What are your considerations?

• Post-dural puncture headache (PDPH/Spinal Headache)
o Basis:
§ Patient underwent emergency appendectomy under
subarachnoid block.
§ After 48 hours, she complain of blurring of vision and
severe frontal headache and did not respond to
NSAIDs.

b. Describe spinal headache

• One of the complication of regional anesthesia.
• The onset of headache is usually seen 12-72 hours prior to
injection.
• It is described to be bilateral, frontal, retro-orbital or occipital that
extends into the nape area.
• The hallmark of PDPH is its association with body position. Pain
is aggravated with sitting or standing and pain is relieved by lying
down.
o This is explained from the leaking CSF from the dural defect
causing increased traction on structures that support sthe
brain.
• Treatment:
o Flat on bed
o Application of abdominal binder
o Analgesic administration and infusion of intravenous fluids
and/or oral fluids to promote adequate hydration
o Caffeine
o Epidural blood patch

2. A 47-year old was scheduled for TAHBSO. The anesthesiologist placed an

epidural for anesthesia.
a. What are the advantages of epidural over GETA in this case?
• Advantages of Epidural Anesthesia

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 o Reduced blood loss
o Reduce peri-operative thrombotic events
o Reduced respiratory depression
o Reduced length of stay
o Prolonged post-operative analgesia
o Decrease incidence of post-operative nausea and vomiting
o Epidural analgesia provided greater tramadol-sparing effect
with superior analgesia postoperatively

b. What are the contraindications for Regional Anesthesia?

RELATIVE CONTRAINDICATIONS ABSOLUTE CONTRAINDICATIONS
• Infection • Patient Refusal
• Coagulopathy
• Severe Hypotension
• Increased intracranial
pressure
• Severe Aortic or Mitral
Stenosis

c. The patient suddenly developed tonic-clonic seizures after 15mL of

Levobupivacaine. What could be likely the cause?
• Increasing plasma levels of levobuvicaine can develop tonic-
clonic seizures.
o Muscle twitching heralds the onset of tonic-clonic seizures.
o At higher plasma concentrations, it cancause CNS
depression may be seen in the form of respiratory arrest or
coma.
• Thiopental – can quickly terminate the seizure activity. Ventilatory
and oxygen support should be given.

References:
Bautista, A. O., Dela Cerna, E.D., Ramos, K. M., Gomez, A. C., Chan, S.A., Dela
Cerna, E. M. (2019). Anesthesiology Manual 2nd Edition.

Moraca, R. J., Sheldon, D. G., & Thirlby, R. C. (2003). The role of epidural anesthesia
and analgesia in surgical practice. Annals of surgery, 238(5), 663–673.
https://doi.org/10.1097/01.sla.0000094300.36689.ad

Raghvendra, K. P., Thapa, D., Mitra, S., Ahuja, V., Gombar, S., & Huria, A. (2016).
Postoperative pain relief following hysterectomy: A randomized controlled trial. Journal
of mid-life health, 7(2), 65–68. https://doi.org/10.4103/0976-7800.185327

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