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Central neuroaxial blockade

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Central neuroaxial blockade

  1. 1. Neuraxial Anesthesia Neuraxial anesthesia is a type of regional anesthesia that involves injection of anesthetic medication in the fatty tissue that surround the nerve roots as they exist the spine (also known as an epidural) or into the cerebrospinal fluid which surrounds the spinal cord (also known as a spinal). This numbs the patient from the abdomen to the toes and often eliminates the need for general anesthesia.
  2. 2. HISTORY 1885 - J. Leonard Corning – first spinal anesthetic was administered accidentally The needle was made of gold 1898 - August Bier - first planned spinal anesthesia for surgery In 1921, Spanish military surgeon Fidel Pagés (1886– 1923) developed the modern technique of lumbar epidural anesthesia Robert Andrew Hingson (1913–1996), working at the United States Marine Hospital in New York, developed the technique of continuous caudal anesthesia.
  3. 3. Advantages over Regional Anaesthesia over GA Safe, reliable technique in patients at risk of apnoea, bradycardia, desaturation, cardiac or respiratory complications after GA Good alternative for day care surgeries Minimal risk of postoperative respiratory depression Limited stress response to surgery Cost effective
  4. 4. VERTEBRA  33 Vertebrae ◦ 7 Cervical ◦ 12 Thoracic ◦ 5 Lumbar ◦ 5 Sacral ◦ 4 Coccygeal
  5. 5. 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
  6. 6. Sagittal Section Through Lumber Vertebrae Supraspinous Ligament (Outer most layer) Intraspinous Ligament (Middle layer) Ligamentum Flavum (Inner most layer)
  7. 7. CONTRAINDICATIONS Absolute Patient Refusal Infection At The Site Of Injection Coagulopathy And Other Bleeding Disorders Severe Hypovolemia Increased Intracranial Pressure Severe Aortic Stenosis Severe Mitral Stenosis
  8. 8. CONTRAINDICATIONS Relative Sepsis Uncoperative Patient Preexisting Neurological Deficits Severe Spinal Deformity Controversial Prior Surgery At The Site Of Injection Complicated Surgery Prolonged Operation Major Blood Loss
  12. 12. Midline Approach Skin Subcutaneous tissue Supraspinous ligament Interspinous ligament Ligamentum flavum Epidural space Dura mater Arachnoid mater Paramedian or Lateral Approach Same as midline excluding supraspinous & interspinous ligaments Anatomic Approach
  13. 13. Spinal Needle Types Quincke Whitacre Sprotee
  14. 14. Selection of equipments Selection of block needles and catheters: Block procedure Recommended device Spinal anaesthesia Spinal needle (24-25 gauge; 30, 50 or 100 mm long, Quincke bevel, stylet) Caudal anaesthesia Short (25-30 mm) and short beveled (45-degree) needle with stylet Epidural anaesthesia Tuohy needle (22, 20, and 19/18 gauge); LOR syringe and medium epidural catheter PNB Insulated 21-23 gauge short beveled needles
  16. 16. Spinal Anesthesia Levels
  18. 18. Complications of Spinal Anaesthesia Hypotension Bradycardia Cardiac Arrest Total Spinal Anesthesia Neurological Complecations – Cauda Equina Syndrome Post Dural Puncture Headache Infection
  19. 19. Backache Inflammatory reaction due to tissue trauma May result in back spasms Short lived, analgesics, ice May last a few weeks Back ache may be a sign of serious complications such as epidural/spinal hematoma, abscess Careful evaluation to determine if a common/benign complication or something more serious
  20. 20. Postdural Puncture Headache Caused by disrupting the integrity of the dura Can occur due to: spinal anesthesia, “wet” tap with epidural, epidural catheter migration, tip of the epidural needle “indenting” the dura enough to cause a leak. Headache occurs due to leakage of CSF through the dura Decrease in intracranial pressure occurs due to the leak Upright position in the patient leads to traction on the dura, tentorium, and blood vessels resulting in pain.
  21. 21. Postdural Puncture Headache- Symptoms Onset is generally within 12-72 hours Headache associated with upright position (i.e. sitting or standing). Relief found with a supine position Headache may be bilateral, frontal, retroorbital and/or occipital with or without radiation to the neck Described as “throbbing” or constant May be associated with nausea and/or photophobia Traction on the 6th cranial nerve can result in diplopia and tinnitus
  22. 22. Postdural Puncture Headache- Conservative Treatment Hydration- theoretically helps to encourage the production of CSF. Analgesics- will decrease the severity of symptoms and include acetaminophen and NSAIDS Caffeine- Helps to decrease symptoms by vasoconstriction of the cerebral vessels. A dose of 300 mg of oral caffeine has been shown to decrease the intensity of PDPH Epidural blood patch.
  23. 23. 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)
  24. 24. Epidural Anatomy Safest point of entry is midline lumbar Spread of epidural anesthesia parallels spinal anesthesia ◦ Nerve rootlets ◦ Nerve roots ◦ Spinal cord
  25. 25. Epidural Anesthesia Order of Blockade B fibers C & A delta fibers  Pain  Temperature  Proprioception A gamma fibers A beta fibers A alpha fibers
  26. 26. 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 ◦ 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
  27. 27. 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
  28. 28. Epidural Anesthesia Complications Penetration of a blood vessel Hypotension (nausea & vomiting) Intravascular catheterization Back pain Wet tap Infection
  29. 29. Differences between Spinal and Epidural Anesthesia Spinal anaesthesia Extradural Anaesthesia Level: below L1/L2, where the spinal cord ends Level: at any level of the vertebral column. Injection: subarachnoid space i.e punture of the dura mater Injection: epidural space (between Ligamentum flavum and dura mater) i.e without punture of the dura mater Identification of the subarachnoid space: When CSF appears Identification of the Peridural space: Using the Loss of Resistance technique. Dosis: 2.5- 3.5 ml bupivacaine 0.5% heavy Doses: 15- 20 ml bupivacaine 0.5% Onset of action: rapid (2-5 min) Onset of action: slow (15-20 min) Density of block: more dense Density of block: less dense Hypotension: rapid Hypotension: slow Headache: is a probably complication Headache: is not a probable. 32
  30. 30. Caudal Anaesthesia Block of the sacral and lumbar nerve roots. This technique is popular in pediatric patients. The S5 processes are remnants and form the cornua, which provide the main landmarks for indentifying the sacral hiatus. The hiatus is covered by the sacro-coccygeal membrane. The canal contains areolar connective tissue, fat, sacral nerves, lymphatics, the filum terminale and a rich venous plexus.
  31. 31. Caudal anaesthesia Indications of caudal anaesthesia: Surgical procedures below the umbilicus As an adjuvant to GA Sole anaesthetic technique in fully awake ex-premature infants younger than 60 wk of post conceptual age Contraindications to caudal anaesthesia: Major malformations of sacrum (myelomeningocele, open spina bifida) Meningitis Intracranial hypertension
  32. 32. Caudal Doses Pediatric population 0.5 ml/kg, 0.25% bupivacaine (sacro-lumbar block) 1 ml/kg, 0.25% bupivacaine (upper abdominal block) 1.2 ml/kg,0.25% bupivacaine (mid-thoracic block) (Doses described by Armitage). Adults: 20-30 ml 0.25-0.5% bupivacaine. Average volume of the sacral canal is 30-35 ml.
  33. 33. 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
  34. 34. Caudal Anesthesia Post Operative Problems Pain at injection site is most common Slight risk of neurological complications Risk of infection
  35. 35. Complications and side effects of neuraxial methods
  36. 36. THE END 39