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Spinal anaesthesia

Dr S R Nafeesa Banu
Spinal anaesthesia-
defn
1. Also called spinal block or
subarachnoid block
2. A form of regional
anaesthesia involving
injection of local
anaesthetic into the SA
space through a fine needle
objectives
Describe anatomy of spinal canal
Identify anatomic landmarks for proper
placement of a spinal needle
Define appropriate steps for placement of
spinal, epidural, or caudal needle
Distinguish level of anesthesia after
administration of regional
State factors affecting level and duration
of spinal vs. epidural block
Explain potential complications and
corresponding treatments associated with
administration of regional anesthetics
Basic Anatomy
BLOOD SUPPLY TO SPINAL
CORD
Indications
Orthopaedic surgery on
pelvis femur tibia and ankle
Vascular surgery- lower limb
Hernia- inguinal ,epigastric
Perineum-haemorrhoid,
fissure, fistula
Urology- TURP,
Abdomen- Abd and vaginal
hysterectomy, Caesarian
contraindications
local infection , sepsis at
puncture site
Bleeding disorders ,
thrombocytopaenia,
anticoagulation
SOL brain
Spinal anomaly-spina bifida,
Hypovolaemia
Lack of consent from patient
-Procedure-Spinal
Needle
Spinal Anaesthesia
Holding for Spinal
Sitting Position
Structure
s Pierced
Local Anesthetics-
Classn
Esters Amides
Procaine Lidocaine
Chloroprocaine Mepivacaine
Tetratcaine Bupivacaine
Cocaine Etidocaine
Prilocaine
Ropivacaine

Metabolism
Metabolism
Hydrolysis by psuedo-
cholinesterase enzyme Liver
Drug for Spinal
Anaesthesia
Lignocaine 5% with
Bupivacaine Glucose
0.5% with
Hyperbaric Glucose
Stay in the
lowest area as
per gravity Does not mix up
with CSF
Metabolism & Toxicity
Toxicity
Determined by blood concentration of
local anesthetics
Metabolism
Ester locals are metabolized by
plasma psuedocholinesterase
Amide locals are metabolized by the
liver
Mechanism of Action
Un-ionized local
anesthetic
defuses into
nerve axon & the
ionized form
binds the
receptors of the
Na channel in the
inactivated state
Lignocaine
Dose 3mg /kg

7mg/kg with adrenaline

Prolong action/reduces the toxicity


Lignocane Toxicity
Tingling sensation around mouth
Drowsiness
Hypotension
Fits
Treatment
Dizepam/Thiopentone
Muscle relaxant
Bupivacaine
Longacting 4-6 hours
Deferential blockers
-Sensory more than Motor
-Dose- 1-1.5 mg/kg
-Cardiac Toxic
-No Tachyphylaxis- Repeat drug
Factors Influence The Level Of
Anaesthesia
The level of
Injection
The volume of
drug
Tilt of Table
Speed of
Injection
Reason For the Patho
physiological Changes

Blockade of the
Sympathetic Systems
Cardiovascular Changes
Hypotension Sympathetic
Blockade
Tachycardia Marys
law/Mayos
Reflex
Bradycardia
Bainbridge
Reflex
Complications
On Table

Delayed
Hypotension
Treatment
Best way to treat is physiologic not
pharmacologic
Primary Treatment
Increase the cardiac preload
Large IV fluid bolus within 30 minutes prior to
spinal placement, minimum 1 liter of
crystalloids
Secondary Treatment
Pharmacologic
Ephedrine is more effective than
Phenylephrine
Cardiovascular Effects
Blockade of Sympathetic
Preganglionic Neurons
Send signals to both arteries and
veins
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
Decreased venous return to right atrium
causes decreased stretch receptor
response
Respiratory System
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
On Table Complication
Hypotension Mx.
IV Isotonic
Fluids
Vasopressors
Oxygen by
mask
Atropine-
Bradycardia
Pregnancy & Spinal
Aortocaval Mx.
Occlusion Pre loading
with IV Fluids
Left lateral
Position
Vasopressors
Oxygen therapy
How to prevent Delayed
Complication

Use Thin Spinal needles

Sterile Precaution
complications
Failed block
Back pain (most common)
Spinal head ache
More common in women ages 13-40
Larger needle size increase severity
Onset typically occurs first or second day
post-op
Infection
Advantages of spinal

anaesthesia
Full and complete anaesthesia
Prolonged block: Pain free postoperatively
Alternative to GA for certain poor risk patients
esp.:
- Difficult airway
- Respiratory disease
Contracted bowel,full stomach
Good muscle relaxation
Suitable for certain surgical procedures:
-
Epidural Space
Ligamentum Flavum
Binds epidural space posteriorly
Widest at Level L2 (5-6mm)
Space that surrounds the spinal
meninges Potential space
Narrowest at Level C5 (1-1.5mm)
Epidural Anatomy
Safest point of entry
is midline lumbar
Spread of epidural
anesthesia parallels
spinal anesthesia
Nerve rootlets
Nerve roots
Spinal cord
Epidural Anesthesia
Order of Blockade
B fibers
C & A delta fibers
Pain
Temperature
Proprioception
A gamma fibers
A beta fibers
A alpha fibers
Epidural Anesthesia
Distances from Skin to Epidural
Space
Average adult: 4-6cm
Obese adult: up to 8cm
Thin adult: 3cm
Assessment of Sensory Blockade
Alcohol swab
Most sensitive initial indicator to assess
loss of temperature
Pin prick
Most accurate assessment of overall
sensory block
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
Ring in ears
Facial numbness
Note: if beta blocked will only see increase in
BP not HR
Bolus Dose: Preferred Local of Choice
10 milliliters for labor pain
20-30 milliliters for C-section
Epidural Anesthesia
Complications
Penetration of a blood vessel
Hypotension (nausea & vomiting)
Head ache
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 2-3ml
Caudal Anesthesia
Post Operative Problems
Pain at injection site is most common
Slight risk of neurological
complications
Risk of infection
Dosages
S5-L2: 15-20ml
S5-T10: 25ml