 Regional Anesthesia part 1

 Spinal Anesthesia

 Bassim Mohammed Jabbar

 MSc ansthesia & intensive care unit
Objectives
◦ Describe anatomy of spinal canal
◦ Identify anatomic landmarks for proper placement of a spinal needle
◦ Define appropriate steps for placement of spinal, epidural.
◦ 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
Spinal Anatomy

33 Vertebrae
◦ 7 Cervical
◦ 12 Thoracic
◦ 5 Lumbar
◦ 5 Sacral
◦ 4 Coccygeal
High Points: C5 & L5
Low Points: T5 & S2
 Spinal Meninges

Dura Mater
◦ Outer most layer
◦ Fibrous
Arachnoid
◦ Middle layer
◦ Non-vascular
Pia
◦ Inner most layer
◦ Highly vascular
Sub Arachnoid Space
◦ Lies between the arachnoid and
pia
Spinal Anesthesia AND EPIDURAL

 Indications & Advantages

 Full stomach
 Anatomic distortions of upper airway
 TURP surgery
 Obstetrical surgery (T4 Level)
 Decreased post-operative pain
 Continuous infusion
Relative:
Use your best judgment
Contra-indication
Spinal Pharmacology

 Factors Effecting Distribution

 Site of injection
 Shape of spinal column
 Patient height
 Angulation of needle
 Volume of CSF
 Characteristics of local anesthetic

 Density
 Specific gravity
 Baracity
 Dose
 Volume
 Patient position (during & after)
•Lidocaine (5%): Onset of action occurs in 3 to 5 minutes with a duration of
anesthesia that lasts for 1 to 1.5 hours
•Bupivacaine (0.75%): One of the most widely used local anesthetics; onset of action is within
5 to 8 minutes, with a duration of anesthesia that lasts from 90 to 150 minutes
Spinal Pharmacology

 Anesthesia level is determined by patient position

 Uptake of local anesthetic occurs by diffusion

 Elimination determines duration of block

 Lipid solubility decreases vascular absorption
 Vasoconstriction can decrease rate of elimination
 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
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
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 hypo perfusion of respiratory center
Spinal Technique

Preparation & Monitoring

◦ ECG
◦ NBP
◦ Pulse Oximeter
Patient Positioning
◦ Lateral decubitous
◦ Sitting
◦ Prone
Spinal Technique

 Midline Approach
1. Skin
2. Subcutaneous tissue
3. Supraspinous ligament
4. Interspinous ligament
5. Ligamentum flavum
6. Epidural space
7. Dura mater
8. Arachnoid mater
 Paramedian or Lateral Approach
 Same as midline excluding supraspinous & interspinous
ligaments
Spinal Anesthesia Levels
Spinal head ache
 More common in women ages 13-40
 Larger needle size increase severity
 Onset typically occurs first or second day post-op
 Treatment:
 Bed rest (remain lying flat in bed as this relieves pain)
 Fluids (drink freely or IV fluid to maintain hydration)
 Simple analgesia such as paracetamol, or aspirin or
codeine may be helpful.
 Caffeine containing drink
 Blood patch
Blood Patch

 Increase pressure of CSF by placing blood in

epidural space
 May do no more than two
 95% success with first patch
 Second patch may be done 24 hours after first
Failed injection
‫اذا اردت ا‪O‬لنجاح فعليك ان تبعد ال‪O‬فاشلين من طريقك‬
‫‪.‬واال ستنال مصيرهم‬
‫‪ ….‬مجرد ن‪OO‬صيحة‪….‬‬
‫‪Thank you for you meticulous attention‬‬