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Dr. Paul Zilberman

Foreword to the reader
This presentation is the result of many years of clinical observation corroborated with
a constant search for a common denominator among many biological variables. It
must be stated from the start that this presentation is not a clinical research and, as
such, it should be regarded only as another clinical tool that could be used in daily
It is the sole responsibility of the reader to adapt the conclusions of this presentation
in her/his current practice. The reader is strongly encouraged, before even
attempting to use the doses presented hereafter, to ask for permission of the
Anesthesia Department of or/and any other legally entitled authority in her/his
However, if the practitioner would wish to clinically validate the figures presented
here, that is conduct a clinical trial, I relieve her/him of any copyright protection
rights. Any supplementary input is welcome.
It is neither the place nor the time to discuss the pros and cons between single dose
LA administration or the continuous one, or the combination of both. This is a topic
largely described in our textbooks.
Hoping my work will bring a small step forward in our field of activity, I would warmly
welcome the reader’s feedback.
Dr.Paul Zilberman

I am impressed by people that know a lot.
I am sad about people who stopped wanting
knowing more.

unknown philosopher

All those numbers and formulas and figures and…and…and…frighten me… .

Why frighten? After all it is all so simple. isn’t it? .


Ufffffffffff. he finally finished! .

If I am not wrong. the theory of relativity sais that… .

Second edition. THE STARTING POINT “For a spinal anesthetic.” James Duke. predictable neural blockade. dense. a small amount of local anesthetic drug is placed directly in the CSF. “Anesthesia secrets”. An epidural anesthetic requires a tenfold increase in the dose of local anesthetic to fill the potential epidural space and penetrate the nerve coverings. Page 358. Question 2 . 2000 Chapter 70. producing a rapid.

The clinician must understand the factors governing spinal and epidural block height and duration to individualize local anesthetic choice and dose for every patient and procedure. PHARMACOLOGY Successful spinal or epidural anesthesia requires a block that is high enough to block sensation at the surgical site and last for the duration of the planned procedure. Barasch. Clinical Anesthesia . recommendations regarding local anesthetic choice and dose must be viewed as approximate guidelines. Because variability between patients is considerable reliable predicting the height and duration of central neuraxial block that will result from a particular local anesthetic dose is difficult. Thus.

Peak spinal block height following 10. isobaric. especially with the hypobaric solution. Note that dose has no influence on block height and there is considerable inter individual variability in peak block height. . and hyperbaric tetracaine solutions injected at the L3-4 with patients in the lateral horizontal position.and 15-mg doses of hypobaric.

It seems all is clear in front of us… .

Absolutely clear… .



Adapt the dose for the specific patient 5. Pray… . LET’S START FROM SOMEWHERE! 1. Downscale for spinal dose 3.that the surgeon is fast enough . 4.that the rest of the OR behaves in a timely fashion . Calculate the mL needed 6. Inject 7. Start from the epidural dose 2. SO.that the calculation is correct .that the patient is behaving “by the book” . Calculate the LA dose in relation to the potency from 1.

Clinical Anesthesiology second edition. But here we still have a problem! “The patient’s height may have some correlation with cephalad spread. At a patient height of 5 feet. with larger volumes approaching 2 mL per segment for taller patients” Morgan. page 238 . the lower end of the dosage range – 1 mL per segment should be used. 1. This dose may vary more with age than height. in a 40 y/o person. THE EPIDURAL DOSE The average dose requirements for blocking an epidural segment is 25 mg Lidocaine.

page 943 And another opinion: “A generally accepted guideline for dosing epidural anesthesia in adults is 1-2 mL per segment to be blocked. THE EPIDURAL DOSE (con’t) Another opinion: “The correlation between patient height or weight and spread of the epidural block is weak and of little clinical significance except perhaps in patients who are extremely tall. = 187. extremely short or morbidly obese” Barasch. = 157.96 cm) Admir Hadzic. Textbook of regional anesthesia and pain management. Clinical Anesthesia. sixth edition.48 cm) or taller patients (> 6ft 2 in. page 245 . 1. Adjust the guideline for shorter patients (< 5ft 2 in.

a maximum of 1.6 ml of local anesthetic per segment should be used” Clinical Anesthesia Procedures of the Massachusetts General Hospital. Bruce Scott. “Techniques of Regional Anesthesia”. fourth edition. another opinion: “For the induction of the epidural blockade. THE EPIDURAL DOSE (con’t) And. page 174 . page 220 And. 1. failure to achieve an adequate height will be greatly reduced” D. yet. finally: “The simplest approach to dosage is to plan on injecting rather more than is thought necessary to block nerves to the required level. Thus.

5 mg 3.625 mg/ segment . DOWNSCALE FOR SPINAL DOSE 25 mg : 10 = 2.5 : 4 = 0. 2. CALCULATING THE EQUIPOTENT DOSE Marcaine is 4 times stronger than Lidocaine 2.

Does anybody know the height of this great voice? .

6m.48 cm do it! Supposing the needle is introduced at the L2-L3 level.625 ml . 13 segments. 8.125 mg. If you feel more comfortable with 157.25 : 10 = 8. AND NOW. that is 325mg.6m X 1ml/segment X 13 segments = 13 ml of Lidocaine. Downscaled for spinal : 81. Marcaine equivalent is 325mg : 4 = 81. So: 1. we have to cover till T4.25 mg. HERE WE GO… For short patients we take the limit of 1.125 mg : 5 mg/ml = 1.



the usual woman patient is around 1. And. a 2ml dose should be used per segment. LET’S SEE… By the mentioned theory.7 m in height. unless we have a basket player woman as a patient (and even in this case it is debatable). besides. Sparing you of all the math headache. the final result is : 3.25 ml Marcaine. . That is in theory. No one uses in current practice more than 3 ml.6-1.

WHAT AM I TRYING TO DO… …is to unite all these measurements and calculations under a common denominator. I call it “the progressive dose”. The main point is: 1 ml for 1 m of height And the relative subdivisions .

75 155-160 1.75 175-180 1.55-1.5-7.5-8.55 7.7 8.75-9 . HAVE A LOOK! Height(cm) Milliliters Milligrams 150-155 1.6-1.65-1.65 8-8.7-1.5 170-175 1.8 8.75-8 160-165 1.25 165-170 1.75-1.75 8.6 7.25-8.5-1.


page 90 . 2006 Chapter 3. A POINT OF VUE During the administration of spinal or epidural anesthesia. Physiologic changes that contribute to increased LA distribution during pregnancy include decreases in CSF density. changes in anatomic configuration of the spinal column and CSF volume. Cynthia A. and hormonally mediated enhancement of neuronal sensitivity to LA. pregnant woman typically require lower doses of LA compared to non pregnant woman. Wong “Spinal and Epidural Anesthesia”.


Less concern for the patient that she doesn’t feel the legs . BECAUSE LESS LOCAL ANESTHETIC MEANS: .Less sympathetic block .Less interventions needed from the anesthetist (fluids. ephedrine etc.Less swings () in blood pressure . . .) .Faster recovery from the motor block and as a consequence the earlier neurological assessment should an inadvertent lesion have been produced.Less shivering in the PACU → more comfort for both the patient and the personnel.Less useless motor block in the lower limbs .

YET.block not long enough – slow surgeon. . . SOMETHING CAN GO WRONG .AND. . adhesions. OR dissfunctionalities etc. All depends on the specific policy of every hospital. difficult baby extraction. This method is used today. One of the accepted solutions to prevent all these: CSE.block not high enough – useless suffering .unexpected intra operatory problems. any lost drop can have a great influence on the whole parameters of the block.technical problems: using such “minute” quantities of LA. It can be applied as any continuous method.

I prefer to be an optimist that is sometimes wrong than a pessimist that is always right! .




Questions anyone? .