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Local and Regional

Shandong University Operatology
Qi Feng

• Local and regional anesthetic techniques
are used to: decrease intraoperative
stimuli, thereby diminishing stress
response to surgical trauma.
• Injected at or near the nerves of the
surgical site, the anesthetic drug temporarily
interrupts sensory nerve impulses during
manipulation of sensitive tissues.

• Regional blocks are useful for more
extensive procedures. Regional anesthesia
may be used, with or without IVCS, when
general anesthesia is contraindicated or
• Nerve blocks, intrathecal blocks,
peridural blocks, and epidural blocks are
examples of regional anesthesia techniques.

the Incas used the coca leaf for local pain relief. • Modern refinements and the development of additional drugs for injection have increased the use of local and regional anesthesia for surgical procedures . More formalized experimentation with cocaine began in 1860.HISTORICAL BACKGROUND • Historically. spinal anesthesia was induced. Local agents procaine (1904) and lidocaine(1948) advanced the use of local anesthesia by many practitioners. Epidural techniques were developed in 1901. • Refinement of other drugs followed and was strongly enhanced by the isolation of epinephrine by John Abel (1857-1938). In 1885. Heinrich Braun (1847-1911) used epinephrine mixed with cocaine for local anesthesia.

• a clear explanation of what to expect are part of the preparatory process. .PREPARATION OF THE PATIENT Include: • careful preoperative assessment. • history taking.

Some drugs are contraindicated for age extremes (i. height. Baseline vital signs. and results of ECG monitoring and any other tests that were performed.. • 2. . laboratory values. and age. pediatric or geriatric patients).preoperative assessment: • Data that should be documented include the following: • 1. blood pressure. Weight. dosage of some drugs is calculated on the basis of body weight in kilograms (mg/kg).e.

• 3. Current medical problem(s) and past history of medical events. Communication ability. • 4. such as insulin for diabetes or hypertensive drugs. Mental status. • 7. • 6. • 5. including a history of substance abuse. . Current medications or drug therapy. Allergy. a patient with hearing impairment or language barrier may be unable to understand verbal instructions during the procedure or to respond appropriately. including emotional state and level of consciousness. or hypersensitivity reactions to previous anesthetics or other drugs.

6 to 8 hours before the surgical procedure is the usual minimum for adults. .Preoperative orders • regarding the time when the patient should cease taking anything by mouth vary with the circumstances. the adult patient is instructed to remain on nothing-by-mouth (NPO) status after midnight. • Many ambulatory surgical patients scheduled for same-day procedures have no premedication and are permitted to walk to the OR. • If possible.

INTRAOPERATIVE PATIENT CARE • The patient must be able to respond cooperatively and to maintain respiration unassisted. and the type and amount of local anesthetic used. • The care the patient will need depends on the type and length of the procedure. . The patient needs careful observation throughout the surgical procedure and for a period afterward for signs and symptoms of delayed reaction or complications. the amount of sedation given.

• The patient should be monitored by qualified personnel and observed for adverse effects of the medication or the procedure. . The patient should be told what to expect and what is expected of him or her.• Psychologic support and reassurance are given before and during the surgical procedure.

. suction. or for adverse reactions.The anesthesia provider is not in attendance for this method. • Supplemental agents should be available for analgesia or anesthesia. • Resuscitative equipment. and oxygen must be at hand before administration of any anesthetic. if necessary. • Qualified personnel should be immediately available to assist in the event of an emergency.LOCAL ANESTHESIA • The surgeon injects the anesthetic drug or applies it topically.

and respiration. blood pressure.Administration of Local Anesthesia • In the absence of an anesthesia provider. • The patient who is under local anesthesia requires observation of physiologic changes in pulse. oxygenation. . a qualified registered nurse is responsible for monitoring the patient's physiologic status and safety during local anesthesia.

including blood pressure. and respirations. are continuously monitored. pulse. • The vital signs.Baseline data • Baseline data obtained during preoperative assessment are compared with intraoperative and postoperative findings. . • Monitoring devices may include an ECG electrocardiograph and pulse oximeter (SpO2). • The total amount of anesthetic and supplementary drugs administered is also recorded in the patient's record.

Intravenous Conscious Sedation (IVCS) / Moderate Sedation • During procedures performed with the patient under local anesthesia. . mild sedation may be given by IV infusion. • IVCS refers to a mild to moderate depressed level of consciousness that allows the patient to maintain a patent airway independently and to respond appropriately to verbal instructions or physical stimulation.

• A benzodiazepine. . but they also may cause respiratory depression and fluctuations in blood pressure and heart rate and rhythm. • Benzodiazepines provide amnesia with sedation. is most commonly given either alone or in combination with a narcotic and atropine or scopolamine. such as midazolam (Versed) or diazepam (Valium).

. registered nurse should be assigned to monitor the patient's physiologic state.Monitoring the Patient Receiving a Local Anesthetic • In the absence of an anesthesia provider. a qualified.

and/or patient's condition. • depends on the seriousness of the procedure.The extent of monitoring: • determined in consultation with physicians in the department of surgery and anesthesiology where applicable. sedation required. .

SpO2 by pulse oximetry (SaO2) 5. Heart rate and rhythm (Bpm) 3. Skin condition and color 7. Respiratory rate (R) 4. Body temperature (T) 6. Mental status and level of consciousness .Parameters include but are not limited to the following 1. Blood pressure (Bp) 2.

• (Include: maintaining a patent airway. • Changes in the patient's condition are reported to the surgeon immediately. • If an adverse reaction occurs.• Vital signs are taken continually before injection of a drug and at 5-15min intervals after injection.) . starting oxygen therapy when clinically indicated. and administering IV therapy. emergency. measures should be instituted on request as per policy.

Local anesthesia is useful for ambulatory patients having minor procedures. 7. 6.Suitable for patients who recently ingested food or fluids.Use of local anesthetic requires minimal equipment and is economical. The patient can ambulate. 2. 4.Local anesthesia avoids the undesirable effects of general anesthesia.Ideal for procedures in which it is desirable to have the patient awake and cooperative.Considerations of selecting Local Anesthesia • Advantages: 1. 3. 5. eat and resume normal activity.Loss of consciousness does not occur. Minimize the recovery period. .

. Local anesthesia is not practical for all types of procedures. • 4. Some patients prefer to be unconscious and unaware. • 3.Disadvantages • 1. potentially fatal reactions. There are individual variations in response to local anesthetic drugs. Apprehension may be increased by the patient's ability to see and hear. Rapid absorption of the drug into the bloodstream can cause severe. • 2.

apprehension. • 3. Septicemia. • 4. Allergic sensitivity to the local anesthetic drug. excitability or inability to cooperate because of mental state or age. . Local infectious or malignancy at the site of injection. which may be carried to and spread in adjacent tissues by injection.Contraindications • 1. • 2. Extreme nervousness.

. and T6 is near the xiphoid.SPINAL and EPIDURAL ANESTHESIA • Intraspinal injection of an anesthetic drug is a technique of regional anesthesia performed by a person who has been properly trained and has acquired the necessary skill. • Regional anesthesia is delivered to select areas. to affect motor and sensory. nerves as desired. T10 is near the umbilicus. • The patient's dermatome levels can be tested by touch and by asking the patient to move his or her extremities. referred to as dermatomes. Dermatome level T12 is near the iliac crest.

physical condition. and the surgical procedure. intensity. . and level of anesthesia desired. • Choices in Regional Drugs The choice of drug depends on factors such as: the duration. and preference of the patient and surgeon. • Patient factors include the anesthetic history. and blood pressure is essential for early detection of hypotension associated with high spinal anesthesia. the anticipated surgical position of the patient.• Assessment of the patient's level of consciousness. pulse. respirations.

also referred to as an intrathecal block.Spinal Anesthesia • Spinal anesthesia. causes desensitization of spinal ganglia and motor roots. • The agent is injected into the CSF in the subarachnoid space of the meninges (the threelayered covering of the spinal cord) using a lumbar interspace in the vertebral column. .

weblike layer immediately beneath the dura mater.• The subarachnoid space is located between the pia mater (the innermost membranous layer covering the spinal cord) and the arachnoid (the thin. • Absorption into nerve fibers is rapid. vascular. which is the outermost sheath covering the spinal cord). .

inguinal or lower extremity procedures. . and urologic procedures. surgical obstetrics (cesarean section without effect on the fetus). • requiring relaxation.• Spinal anesthesia is often used for abdominal (mainly lower) or pelvic procedures.

volume. • inclusion of a vasoconstrictor. and coughing or straining. dosage. such as epinephrine.The level of anesthesia • attained depends on various factors. which can inadvertently raise the level. spinal curvature. uterine contractions with labor. site and rate of injection. • such as the patient's position during and immediately after injection. and specific gravity (baricity) of the solution. . CSF pressure. interspace chosen.

the anesthetic is becoming "fixed" (i.e. absorbed by the tissues and unable to travel)..• Spread of the anesthetic is controlled mainly by solution baricity and patient position. • The period immediately after injection is decisive. .

The direction of tilting depends on whether the drug is hyperbaric or hypobaric. or nerve stimulation. the anesthesia provider carefully tests the level of anesthesia by pinprick. to achieve the desired level for the surgical procedure. • Immediately after the anesthetic is injected. lsobaric anesthetics. tilting the bed as necessary. . touch.• Further control is attained by tilting the operating bed at that time.

intensity.• Choice of Agent. The drug used depends on various factors such as the duration. It is prolonged by the addition of a vasoconstrictor. . • Duration of Agent. circulation. the anticipated surgical position of the patient. and the surgical procedure. The variable duration of anesthesia depends on physiologic and metabolic factors. and level of anesthesia desired. Anesthesia diminishes as the agent is absorbed into the systemic.

• The hips and shoulders are vertical to the operating bed to prevent rotation of the spine. . • The knees are flexed onto the abdomen.Spinal Anesthesia Procedure Lateral position: • The patient lies on the side with the back at the edge of the operating bed. and the head is flexed to the chest.

and after spinal anesthesia. The spine is flexed. the arms are crossed and supported on a pillow on an adjustable table. • The BP is checked before. • Attention to asepsis is extremely important. . since hypotension is common. Sterile disposable spinal trays eliminate the need for cleaning and sterilizing of reusable equipment.Sitting position • The patient sits on the side of operating bed with the feet resting on a stool. during. with the chin lowered to the sternum.

• Muscle relaxation and anesthesia are excellent if the procedure is properly executed. The procedure can be performed with IVCS as necessary. because the respiratory system is not irritated. breathing is quiet. • The bowel is contracted. without airway problems. .Advantages • The patient is conscious if desired. • Throat reflexes are maintained.

Disadvantages • Spinal anesthesia produces a circulatory depressant effect: hypotension. a slight elevation of the feet and legs may increase venous return to the heart. • A change in body position may be followed by a sudden drop in blood pressure. . after fixation of the anesthetic. or premedication. • Nausea and emesis may accompany cerebral ischemia. traction on viscera and peritoneum. • The agent cannot be removed after injection.

temporary paresthesias. auditory and ocular disturbances. and loss of spinal fluid with decreased intracranial pressure syndrome are potential complications. . and urinary retention. • Examples include: spinal headache. irritation by the agent. lack of asepsis.Complications • Transient or permanent neurologic sequelae from cord trauma.

. This usually affords prompt relief. • True spinal headache caused by a persistent CSF leak through the needle hole in the dura usually responds to supine bed rest. and systemic analgesia. and ruptured nucleus pulposus. spinal cord lesions. copious oral or IV fluids.• Late complications: include nerve root lesions. • Refractory postspinal headache may be treated by an epidural blood patch: 5 to 10ml of the patient's own blood is administered at the puncture site.

. • Apnea also can be produced by respiratory center ischemia resulting from precipitous hypotension. is thought to be a result of medullary hypoperfusion caused by a sympathetic block. an emergency situation requiring mechanical ventilation until the level of anesthesia has receded. extreme caution is essential to prevent respiratory paralysis ("total spinal"). • Respiratory arrest.• If a high level of anesthesia is reached. although rare.

and IV line must be in readiness before injection. oxygen.• The anesthesia machine. . • Constant vigilance of respiration and circulation is critical. • The blood pressure and heart rate are monitored and maintained at normal levels.

• Injection is made into this space surrounding the dura mater. The epidural space lies between the dura mater. and the walls of the vertebral column. • The spread of anesthetic and duration of action are influenced by the concentration and volume of solution injected (total drug mass) and the rate of injection. • Anesthesia is prolonged while the drug is absorbed from CSF into the bloodstream. and extradural are used synonymously. the outermost sheath covering the spinal cord.Epidural Anesthesia • The terms epidural. peridural. The drug diffuses slowly through the dura mater into CSF. .

and gravity have little influence on anesthetic distribution.• In contrast to spinal anesthesia. baricity. patient position.000 is usually added to retard absorption. . • The high incidence of systemic reactions is attributed to absorption of the agent from the highly vascular peridural area and the relatively large mass of anesthetic injected. • Epinephrine 1:200.

vaginal. . • It is used commonly for postoperative pain management and in obstetrics during labor and delivery or during and after cesarean section. anorectal. • The management and sequelae of epidural anesthesia are similar to those of spinal anesthesia. abdominal. urologic.Approaches used for epidural anesthesia and analgesia • including: thoracic. and caudal approaches. lumbar. or perineal procedures. • An epidural approach may be used for lower extremity.

• Vital signs should be monitored at regular intervals. or blood pressure should be reported immediately to the anesthesiologist. pulse. respirations. . and any deviation of level of consciousness.

• A patient may come to the OR for placement of an epidural catheter or pump device for ongoing pain management. an implanted epidural catheter with infusion port or reservoir and pump. or an implantable infusion device.Epidural narcotic analgesia • may provide sustained postoperative relief or control of pain in patients with intractable or prolonged pain. . • This may be administered by a percutaneous indwelling epidural catheter.

. stopcocks. requiring additional needles. and a plastic catheter in the setup. • Insertion of a catheter allows repeated injections for continuous intraoperative and postoperative epidural anesthesia. Equipment is similar to that for a spinal block.Thoracic and Lumbar Approaches • The thoracic and lumbar approaches are peridural blocks.

desensitizing nerves emerging from the dural sac. sacrum horizontal. • The patient position for injection is prone with the hips flexed. and heels turned outward to expose the injection site.Caudal Approach • The caudal approach is an epidural sacral block. Epidural injection is through the caudal canal. .

atherosclerosis. • The left lateral position is used in the pregnant patient.• The sacral area is prepared and draped. . and advanced age. with care taken to protect the genitalia from irritating solution. • The spread of agents in epidural anesthesia is enhanced in pregnancy.

. • Epidural anesthesia has a decreased incidence of hypotension.Advantages Compared with spinal anesthesia. and potential for neurologic complications. • Although a higher failure rate is reported. headache.

it is time-consuming (i. • a larger amount of agent injected continuous technique may slow the first stage of labor.e. there is a greater area of potential infection from anaerobic organisms with the caudal approach. . a longer time is required for complete anesthesia).. • it is unpredictable.Disadvantages • It is a more difficult technique.

• The patient may suffer hypoxia. backache. and transient or permanent paralysis are possible complications. blood vessel puncture and hematoma.Complications • IV injection. accidenta dural puncture and total spinal anesthesia. . respiratory arrest. profound hypotention. and/or cardiac arrest.


to a serous surface.Topical Application • The anesthetic is applied directly to a mucous membrane. for insertion of airways before induction or during light general anesthesia. or into an open wound. • It is also used in the urethral meatus for cystoscopy. . or for therapeutic and diagnostic procedures such as laryngoscopy or bronchoscopy. • A topical agent is often applied to the respiratory passages to eliminate laryngeal reflexes and cough.

• Also.Preanesthetic anticholinergics • Atropine: are important before topical application within the respiratory tract. a dry throat is necessary to prevent aspiration until the anesthetic effect has disappeared and throat reflexes have returned. .

Simple Local Infiltration • The agent is injected intracutaneously and subcutaneouslv into tissues at and around the incisional site to block peripheral sensory nerve stimuli at their origin. . • It is used before suturing superficial lacerations or excising minor lesions.

deeper area is anesthetized than with simple infiltration. • A wider. . • The injection is at a distance from the surgical site.Regional Injection • The agent is injected into or around a specific nerve or group of nerves to depress the entire sensory nervous system of a limited. localized area of the body.

. • Blocks may be used preoperatively. and/or sympathetic transmission.Nerve Block • Nerve blocks are performed to interrupt sensory. intraoperatively. and postoperatively to prevent pain of the procedure. or therapeutically to relieve chronic pain. motor. • Diagnostically to ascertain the cause of pain.

e. such as drain placement. Intercostal block for relatively superficial intraabdominal procedures. such as a penile block for circumcision in adults. Blocks in other specific areas. . c. Paravertebral block of the cervical plexus for procedures in the area between the jaw and the clavicle. f. Median. d. Hand and digital block for fingers. radial.Some examples of blocks follows • 1. Branchial plexus or axillary block for arm procedures. b. Surgical blocks a. or ulnar nerve block for the elbow or wrist.

Diagnostic or therapeutic blocks • a. Celiac block for relief of abdominal pain of pancreatic origin. Paravertebral lumbar block to increase circulation in the lower extremities. • c. or hand. arm. Sympathetic nerve ganglion block. neck. Stellate ganglion block to increase circulation in peripheral vascular disease in the head. .2. • b. • d.

75% Lidocaine Xytocaine Topical 2% to 4% 1/2 to 2 200 mg Infiltration 0.75% Epidural 1% 6 to 10 AMINO ESTERS Chloroprocaine Nerve block 2% 1/4 to 1/2 1000 mg Cocaine Topical 4% or 10% 72 200 mg or 4 mg/kg Procaine Novocain Infiltration 0.5% to 1% 1/2 to 2 500 mg Ropivacaine Naropin nerve block 0.5% 1/4 to 1/2 1000 mg Tetracaine Cetacaine Topical 2% 2 to 4 20 mg -------------------------------------------------------------------------------------------------- .Local and Regional Anesthetic Agents ---------------------------------------------------------------------------------------------------------Concentration Duration(hr) Maximum Dosage AMINO AMIDES Bupivacaine Marcaine Local infiltration 0.25% to 0.5% 500 mg Peripheral nerves 1% to 2% Mepivacaine Carbocaine Infiltration 0.50% 2 to 3 400mg Surgical epidural 0.

• Serious complications. are usually permanent.COMPLICATIONS OF LOCAL AND REGIONAL ANESTHESIA • Minor or transient complications of local and regional anesthesia are common. and effects unrelated to the anesthetic drug. although rare. systemic effects. . • Complications of local and regional anesthesia may be summarized briefly as: local effects.

• Avoidance of repetitive injection that promotes trauma.Local Effects • Tissue trauma. and infection. • Avoidance of local anesthetics with vasoconstrictors in sites with smaller vascular structures (digits. edema. sterile technique. penis). tissue necrosis. and infection can be minimized by the use of proper drugs and equipment. hematoma. . drug sensitivity. ischemia.

or respiratory. seizure. (e.g. neurologic.Systemic Effects • Systemic effects are primarily cardiovascular. hypotension.. . respiratory depression).

but it is less frequent than reactions from overdosage of pharmacologic agents. dermatitis.Predisposing Factors for Hypersensitivity • True hypersensitivity that produces an allergic response can occur. mediated by antigenantibody reaction. urticaria (skin wheals). • 1. . laryngeal edema. and possibly cardiovascular collapse. True allergy. itching. can cause anaphylaxis.

. The IV route is the most dangerous route of injection. and tissues of the head.• 2. and paravertebral region. Hazardous sites involve vascular areas of tracheo-bronchial mucosa. neck. Overdosage: An excessive amount of drug may enter the bloodstream if the injection exceeds maximum dose or is absorbed too rapidly.

• Signs and Symptoms of Systemic Reactions .

• The cardiovascular system seems more resistant than the CNS to toxic effects of local anesthetics. .• CNS stimulation or depression may be followed by depression and cardiovascular collapse.

pale or cyanotic. bounding pulse. tremors. syncope. moist skin.Stimulation: Talkativeness.• 1. tachycardia. restlessness. disorientation. apprehension. coma . thready pulse or bradycardia. muscular twitching. hypotension. hyperactive reflexes. convulsions 2. decreased hearing ability. rapid. stupor. incoherence. Depression: Drowsiness. flushed face. hyperpyrexia. excitation.

hypotension. unarousable sleep. Other signs and symptoms: Nausea. dizziness.• 3. airway obstruction. vomiting. IVCS may include: slurred speech. rashes. combativeness. bronchospasm). urticaria. angioneurotic edema (wheeze. sudden severe headache. • 4. severe local tissue reaction. extreme pulse rate or blood pressure change. . agitation. hypoventilation. laryngeal edema. blurred vision. precordial pain. and apnea.

Treatment must be promptly. • Therapy is generally supportive. the specifics dictated by clinical manifestations. • Administration of the agent thought to produce the reaction is stopped immediately at the first indication of reaction. .Treatment of Adverse Reactions • Treatment of an adverse reaction is aimed at preventing respiratory and cardiac arrest.

• Tracheal intubation may be indicated.• Treatment consists of the following: • 1. .Maintaining oxygenation of vital organs and tissues with ventilation by manual or mechanical assistance to give 100% oxygen with positive pressure.

IV fluid therapy is begun. Antagonist drug. b. Ephedrine and other vasoconstrictors such as phenylephrine or mephentermine. . • The patient is supine with the legs elevated.Reversing myocardial depression and peripheral vasodilation. Steroids. Isoproterenol (Isuprel). f. d. • Drugs include: a.2. and a vasoconstrictor drug may be given IV or IM for hypotension or a weak pulse. Epinephrine. c. e. Antihistamines.

aspiration.An emergency cart with emergency resuscitative drugs and a defibrillator should be immediately available. Diazepam in 5mg doses or a short-acting barbiturate is given IV to inhibit cortical irritation.Stopping muscle tremors or convulsions if they are present. since they constitute a hazard for further hypoxia. or bodily injury.• 3. . • 4.

The following equipment:
• Oxygen and positive pressure breathing
device (e.g., Ambu bag and mask)
• Oral and nasopharyngeal airways and
endotracheal tubes in an assortment of sizes
• Cardiac and oxygen saturation monitoring
• Suction

Toxic Reaction
• symptoms vary depending on the drug.
• SUBIECTIVE: Dizziness, somnolence
paresthesia, nausea, visual/speech problems
• OBJECTIVE: Decreased breathing rate and
depth, muscle twitches, tremors, slurred speech
seizures, vomiting unconsciousness, coma

• VASOVAGAL: Dysrhythmia, bradycardia,
vasodilation, hypotension, myocardial
depression, Cardiac arrest
• TREATHENT: Supportive, airway
management; intravenous (IV) line;
Trendelenburg position; muscular contractions
are treated with diazepam (Valium)

urticaria. vasodilation. wheals • VASOVAGAL: Coughing. IV fluids. hypovolemia. pruritus.Allergic Reaction • SUBIECTIVE: Sense of uneasiness. and steroids as needed . Cardiac arrest • TREATHENT: Especially with amino ester type: airway management. bronchospasm. wheezing. sneezing. epinephrine. diphenhydramine. hypotension. paresthesia • OBJECTIVE: Erythema. agitation. Cardiovascular collapse.

trauma from retractors. . or an improperly applied cast. it may be from a cause unrelated to the anesthetic drug. resulting in ischemia or pressure on peripheral nerves. such as faulty positioning. such as pain or neuritis. a tourniquet inflated for an inordinately long period. • Less common causes involve bleeding around the nerve or reaction to epinephrine. • Alternatively. may occurs in the postoperative period may be related to a preexisting condition such as multiple sclerosis.Unrelated Effects • A nerve deficit.

End .