Regional Anaesthesia

&
Temperature Control
Aizat
Content
• Definition
• Types
• LA agent
• Specific type
• Temperature control
Definition
• Techniques of abolishing pain using local
anaesthetic agents as opposed to general
anaesthesia.
• Drugs that produce reversible conduction
blockade of impulses along central &
peripheral nerves producing ANS, sensory
blockade and skeletal muscle paralysis in the
area innervated by affected nerve
Types
REGIONAL
ANAESTHESIA
TOPICAL
CENTRAL
NERVE BLOCK
SPINAL
ANAESTHESIA
EPIDURAL
ANAESTHESIA
PERIPHERAL
NERVE BLOCK
PLEXUS BLOCK
SINGLE NERVE
BLOCK
INTRAVENOUS
REGIONAL
(BIER BLOCK)
Aim

• Provide anesthesia for a surgical procedure
• Provide analgesia pre& post-operatively or
during labour and delivery
• Diagnosis or therapy for patients with chronic
pain syndromes


LA agent
• Esters – Procaine, chloropropaine, tetracaine,
amethocaine, cocaine
• Amides – lignocaine, etidocaine, mepivacaine,
bupivacaine,ropivacaine


Mechanism of action
• LA prevent the transmission of
nerve impulse by inhibiting
passage of Na ions through the
ion selective NA channel at the
nerve membrane.
• Reduction in Na conductance
(GNA )
• Slows the rate of depolarisation,
threshold potential not reached
& action potential not
propagated
DRUGS
• Lignocaine (USA – Lidocaine)
• Presentation – Clear aq solution lidocaine HCL
– Plain 0.5%(local infiltration, IVRA ), 1%, 2%(nerve blocks,
extradural anaesthesia)
– with adrenaline 1:200 000
• Use of adrenaline: Vasoconstiction at site of injection ↓ rate of
absorption, ↓ systemic toxicity, ↑ duration of action
– Gel 2% with or without chlorhexidine
• Clinical : onset in 2-20min; duration 60-120min
• Recommended max dose 1-3mg/kg (7mg/kg with adrenaline)
• How to prepare
– Lignocaine conc’n : O.5%: 5mg/ml, 1%: 10mg/ml,
2%:20mg/ml
• E.g: 70kg – 210mg : do not use more than 10ml of 2%
lignocaine
• C/I : Do not use with adrenaline in end arterial supply (fingers,
toes, pinna, penis and nose)
Bupivacaine
• Presentation – clear colourless, aq solution
(bupivacaine hydrochloride )
– Plain (0.25%, 0.5%, 0.75%)
– With 1:200 000 (5µg/ml ) adrenaline
– Heavy 0.5% with 80mg/ml dextrose ( SG 1.026)
• Recommended max dose 2mg/kg (150mg plus up to
50mg 2 hourly subsequently)
• Clinical- onset within 10-20min, duration of action 4-
8hrs. 4X as potent as lidocaine, propensity for
cardiotoxicity
ADVANTAGES
• Conscious patients
– assist in positioning
– early warning of adverse effects
– avoid airway manipulation & complications
• Good quality block in term of motor and sensory
– adequate as per surgical requirement
– surgical / hormonal / psychological stress
• Less post operative complications
– less sedated
– less nausea / vomiting
– reduce atelectasis  pneumonia
– reduce risk of dvt
– early oral intake
DISADVANTAGES
• Patients anxiety
– increased sympathetic tone
– unwanted psychological stress
• Technically difficult procedure
• Co-operation from patients are required
• Abnormal sensation :
– paraesthesia / hyperaesthesia
COMPLICATIONS
• Allergic reaction (rare <1%)
• Local tissue toxicity
– Direct trauma to nerves, vessels and soft tissues
• Haematoma
• Abscess formation
• Anterior spinal artery syndrome (spinal)
• Cauda equina syndrome (spinal)
• Systemic toxicity
– Due to excessive/ IV injection
• Cardiac arrythmias, convulsion, bradycardia
• Methaemoglobinaemia (in prilocaine)

Topical Anesthesia
• Application of local anesthetic to mucous membrane
- cornea, nasal / oral mucosa
• Uses : absorb into dermis and block the nerve end
– awake oral, nasal intubation, superficial surgical procedure
• Advantages :
– technically easy
– minimal equipment
• Disadvantages :
– potential for large doses leading to toxicity

Local/Field Anesthesia
• Application of local subcutaneously to anesthetise
distal nerve endings
• Uses:
– Suturing, minor superficial surgery, line placement, more
extensive surgery with sedation
• Advantages:
– minimal equipment, technically easy, rapid onset
• Disadvantages:
– potential for toxicity if large field

Forehead block
2 nerves from superior orbital margin
Supraorbital n: 2.5cm from midline
Supratrochlear n: upper medial corner of orbit

Insert needle from eyebrow midline direct
laterally
Auricular block
Nerve: auriculotemporal, greater auricular and lesser
occipital
Peripheral Nerve Block
• Injecting local anesthetic near the course of a named
nerve
• Uses:
– Surgical procedures in the distribution of the blocked
nerve
• Advantages:
– relatively small dose of local anesthetic to cover large area;
rapid onset
• Disadvantages:
– technical complexity, neuropathy

Wrist block
Median nerve : lies superficially between palmaris longus and FCR
Ulnar nerve : lies between FCU and ulnar artery
Radial nerve: over radial styloid up to extensor surface
Digital nerve block
Web space approach. 2 dorsal & 2 palmar. NEVER use adrenaline
Ankle block
Saphenous nerve: ant and just above medial malleolus
Superficial peroneal nerve: above the ankle joint from anterior border of tibia to lateral
malleolus
Deep peroneal n: above ankle joint between tibialis ant tendon and ext hallucis longus
Sural n: Lateral to achilles tendon to lateral malleolus
Tibia n: Medial to achilles tendon to lateral PTA (by palpation)

Femoral block
Femoral nerve : Lateral to artery under inguinal ligament
Plexus Blockade
• Injection of local anesthetic
adjacent to a plexus,e.g
cervical, brachial or lumbar
plexus
• Uses :
– surgical anesthesia or post-
operative analgesia in the
distribution of the plexus
• Advantages:
– large area of anesthesia with
relatively large dose of agent
• Disadvantages:
– technically complex, potential
for toxicity and neuropathy

Biers block (IVRA)
• Indication : M&R of forearm #
• Drugs: 10ml of 1% lignocaine
– Dosage :0.4ml/kg(2mg/kg), onset 3mins
• Technique
– V/S monitoring & IV branula on both
hands
– Torniquet affevted limb: 50-100mmhg
above SBP
– Elevate hand above heart beofre
torniquet
– Confirm dissappearnace of radial pulse
before injecting LA
– Don’t deflate cuff within <20mins, may
cause high concn to circulation
Spinal vs Epidural
SPINAL

EPIDURAL
site of
administration :
subarachnoid space –
CSF (+)
extra dural space --
loss of resistance
technically : easier
Spinal needle
LOR
more difficult
Tuohy needle
CSF fluid
failure rate : low high
Spinal vs Epidural
SPINAL EPIDURAL
onset : Fast Slow
duration : ± 2 to 2.5 hours
( ± flexible)
flexible
level : lumbar ; sacral cervical to caudal
volume of LA : small
1.0 to 3.0 mls
large
5.0 to 30 mls
Temperature control
• Hypothalamus is the body thermostat
• Normal core temp: 37°C (if taken internally)
– 36.8° ± 0.4°C (98.2° ± 0.7°F) in oral,axilla&rectal
• Ideal site : Pulmonary artery (gold standard)
– Using thermistor cathether
– Blood mix from skin to viscera

Thermoregulation
Drugs influence in thermoregulation
• Neuromuscular blocking agent : Scoline
– Malignant hyperthermia – initiated by uncontrolled
release of Ca ions leading to incr muscle metabolism
– Cx features : muscle spasm, rigidity, contracture, metabolic
acidosis
– Tx : Rapid cooling, O2, correct met H+, IV dantrolene
• Opioids : Morphine, Fentanyl
– Promote heat loss by vasodilatation
– Impair hypothalamic thermoregulation resulting reduce
sympathetic outflow
– Tx: Warm IV fluids, warmer, blanket
• Usually occurs in GA, however, may occur in RA esp in
spinal/epidural (Volatile anaesthetic agent, propofol)
Take home message
• LA produce reversible conduction blockage by
inhibiting passage of Na ions through the ion
selective NA channel at the nerve membrane.
• Lignocaine 1-3mg/kg, 2% = 20mg/ml
• Serious systemic effect are cardiac arrythmias
and convulsion
• Identify anatomy first before giving LA
• Hypothalamus controls the body temp