History

Ambroise Par (1510-1590) squeezing limb

Benjamin Bell (1749-1806) nerve
compression
Dominique J. Larrey (1766-1842) cold
environments
Benjamin Ward Richardson (1828-1896)
ether spray

Topical Anesthesia

Cocaine (Erythroxylon coca)

Inca
Bernabe Cobo (1582-1657),
toothache (1544)
Albert Niemann (1834-1861)
isolated the and gave the
name cocaine
Vasili von Anrep (1852-1918)
first to remark on its local
anesthetic properties
Sigmund Freud (1856-1939)
cocaine for substitute for
opioids
Carl Koller (1858-1944)
producing local anesthesia for
operations on the eye.

Regional Anesthesia
New applications for cocaine.
November 1884 subcutaneous injection
December 1884, William Halsted and
Richard Hall, blocks of the sensory nerves
of the face and arm.
Spinal anesthesia (1885) Leonard Corning
a substitute for etherization in genitourinary or other branches of surgery.

August Bier and Theodor Tuffier, described a spinal anesthesia

Heinrich Quincke described technique of lumbar puncture.
Prof. August Bier, Dr. Hildebrandt perform a lumbar puncture,
A strong blow with an iron hammer against the tibia was not
felt as pain. Strong pressure and pulling on a testicle were not
painful.
Clinical effect and complication from spinal anesthesia

 1944 Edward Tuohy, Tuohy needle

1949, Martinez Curbelo perform the first
continuous epidural anesthetic.
Caudal anesthesia.
Jean Athanase Sicard, relief of back pain.
Fernand Cathelin, alternative to spinal anesthesia

Achille M. Dogliotti the loss-of-resistance

technique.

Regional
Anesthesia

Central
Neuraxial

Spinal

Epidural

Peripheral

Caudal

PNB

Physiologic Effect of Spinal &

Epidural Anesthesia

Cardiovascular
Blockade of Sympathetic Preganglionic Neurons
Predominant action is venodilation
Reduces:

Venous return
Stroke volume
Cardiac output
Blood pressure

T1-T4 Blockade
Causes unopposed vagal stimulation
Bradycardia
Associated with decrease venous return &
cardioaccelerator fibers blockade

Hypotension
Treatment
Primary treatment
Increase the cardiac preload
Large IV fluid bolus as preloading 10-20 ml/kg

Secondary treatment
Pharmacologic
Ephedrine VS Phenylephrine

Respiratory
Healthy patients
Appropriate spinal blockade has little effect on
ventilation

High spinal
Decrease functional residual capacity (FRC)
Paralysis of abdominal muscles
Intercostal muscle paralysis interferes with
coughing and clearing secretions
Apnea is due to hypoperfusion of respiratory
center

Gastrointestinal
Result of sympathetic blockade
Unopposed parasympathetic activity
Secretions increase, sphincters relax, and
the bowel becomes constricted
Nausea, associated with:
Blocks higher than T5
Hypotension
Opioid premedication
History of motion sickness

Endocrine-Metabolic
Inhibit many of the endocrine-metabolic
changes associated with the stress response.
lower abdominal > lower extremity > upper
abdominal and thoracic procedures

Spinal Cord
Spinal Cord
Adult
Begins: Foramen Magnum
Ends: L1

Newborn
Begins: Foramen Magnum
Ends: L3

Terminal End: Conus Medullaris

Filum Terminale: Anchors in sacral region
Cauda Equina: Nerve group of lower dural sac

Spinal Anesthesia
Indications
Operation of lower extremities
Lower abdominal surgery
Some upper abdominal surgery

 Preparation & Monitoring

As in GA

Patient Positioning for spinal anesthesia

Lateral decubitus
Sitting
Prone (hypobaric technique)

Drugs
Local Anesthetic
Hyperbaric Local anesthetic
Isobaric Local anesthetic
Hipobaric Local anesthetic

Adjuct

Epinephrine
Opioids
NaHCO2
Prostigmine
Clonidine

 Assessment of Sensory Blockade

Alcohol swab
Most sensitive initial indicator to assess loss of
temperature

Pin prick
Most accurate assessment of overall sensory block

Spinal Anesthesia Levels

Spinal Anesthesia Levels (You must know dermatomes)

Dermatome

Application

C4 (clavicle)

Chest surgery

T4-T5 (nipples)

Upper abdominal surgery

T6-T8 (xiphoid)

Intestinal surgery, appendectomy, gynecologic

pelvic surgery, and ureter and renal pelvic surgery

T8 (lower border of
ribcage

Abdominal surgery

T10 (umbilicus)

Transurethral resection, obstetric vaginal delivery,

and hip surgery

L1 (inguinal ligament)

Transurethral resection, if no bladder distension,

thigh surgery, lower limb amputation

L2-L3 (knee and below)

Foot surgery

S2-S5 (perineal)

Perineal surgery, hemorrhoidectomy, anal dilation

Spinal Anesthesia
Contraindications
Absolute

Refusal
Infection
Coagulopathy
Severe hypovolemia
Increased intracranial pressure
Severe aortic or mitral stenosis

Relative
Post-Stroke

Spinal Anesthesia
Complications
Failed block
Back pain (most common)
Hematoma
Nerve Injury

Regional Anesthesia in the

Anticoagulated Patient
Basic Labs:
Platelet counts > 50,000 (minimum), prefer >
100,000
Prothrombin time (PT) & Partial thrombin time
(PTT)
Note that PT & PTT require approx. 60-80% loss of
coagulation activity before becoming abnormal

Thrombin time
Hemoglobin & Hematocrit
Bleeding time

Regional Anesthesia in the

Anticoagulated Patient
Heparin: Reverse with FFP or Protamine
IV discontinue 4 hours prior to block
SQ can block one hour prior to dose
Do not D/C cath until 4 hours after heparin D/Cd &
obtain normal lab values

Low Molecular Weight Heparin: No Reversal

Stop 10 days prior to surgery
Post op D/C cath 2 hours prior or 10 hours after first
dose

Coumadin: Reverse with Vit K or FFP

Stop 7 days prior to surgery
Check PT/INR

Regional Anesthesia in the

Anticoagulated Patient
Plavix: No Reversal
Stop 5-10 days prior to surgery

NSAIDS: No Reversal
May be safe for regional block
Ideal to stop 5 days prior to surgery

ASA: No Reversal
Stop 7-10 days prior to surgery

 Spinal headache (PDPH)

More common in women ages 13-40

Larger cutting edge needle size, increase severity
Onset typically occurs first or second day post-op
Treatment:

Bed rest
Fluids
Caffeine
Blood patch

Epidural Anesthesia

Epidural Space
Space that surrounds the spinal meninges
Potential space

Ligamentum Flavum
Binds epidural space posteriorly

Widest at level L2 (5-6mm)

Narrowest at Level C5 (1-1.5mm)

Epidural Anesthesia
Test dose: 1.5% Lido with Epi 1:200,000
Tachycardia (increase >30bpm over resting
HR)
High blood pressure
Light headedness
Metallic taste in mouth
Tinitus
Perioral numbness

Epidural Anesthesia
Complications
Penetration of a blood vessel
Hypotension (nausea & vomiting)
Headache
Back pain
Intravascular catheterization
Wet tap
Infection

Caudal Anesthesia
Anatomy
Sacrum
Triangular bone
5 fused sacral
vertebrae

Needle Insertion
Sacrococcygeal
membrane
No subcutaneous
bulge or crepitous at
site of injection after 23ml

Caudal Anesthesia
Post Operative Problems
Pain at injection site is most common
Slight risk of neurological complications
Risk of infection

Dosages
Thoracolumbar 1 ml/kg
Lumbosacral 0.5 ml/kg

Peripheral Nerve Block

Disadvantage
INJECTION!!!!!!!!!!!!!
BLIND Technique!!!!!!! Low successful rate!!
If nerve stimulation, - USG
Time consuming!!!!!
Local Anesthetic toxicity!!!!!

Advantage
Less GA drugs side effect
Patent airway
Post operative pain control

Upper Extremity Block

Intravenous Regional Anesthesia (Bier Block)
Brachial Plexus Blockade
Interscalene block
Supraclavicular block
Infraclavicular block