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Lecture Title : Regional Anaesthesia Techniques

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Title: Slide 1 Author: ALDAMMAS FATMA Last modified by: DR.WALID Created Date: 5/6/2009 5:47:53 PM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: Lecture Title : Regional Anaesthesia Techniques


1
Lecture Title Regional Anaesthesia Techniques
  • Lecturer name DR. FATMA AL-DAMMAS
  • ASSISTANT PROFESSOR
  • DEPT OF ANAESTHESIA AND ICU
  • COLLEGE OF MEDICINE
  • KING SAUD UNIVERSITY

Lecture Date
2
Lecture Objectives..
  • Students at the end of the lecture will be able
    to understand
  • What are the risks and benefits of regional
    (epidural/spinal) anesthesia/analgesia?
  • What are the contraindications to regional
    anesthesia?
  • How do you prevent hypotension following
    epidural/spinal anesthesia?

3
Spinal Anaesthesia
  • Describe the technique of spinal anesthesia.
  • At what level does the adult spinal cord end?
  • Name some of the surgical procedures that can be
    done with a spinal anesthetic.
  • What are the contraindications to spinal
    anesthesia?
  • What are the complications?
  • Describe the patient's perception as spinal
    anesthetic takes effect.
  • What are the expected cardiovascular changes
    associated with sensory level at T10? T1?
  • What are the characteristics of post-lumbar
    puncture headache?
  • How do the size and tip design of a spinal needle
    influence the incidence of post-puncture
    headache?
  • How do you treat post-lumbar puncture headache?

4
Epidural Anaesthesia
  • Discuss the differences between spinal and
    epidural anesthesia.
  • What are the advantages and disadvantages of
    epidural compared to spinal anesthesia?
  • Study the size and tip of the epidural needle.
  • Name some of the surgical procedures that can be
    done with an epidural anesthetic.
  • Compare and contrast lumbar and thoracic
    epidural anesthesia.
  • What role does epidural has for post-operative
    pain control?
  • Local Anesthetics Pharmacology and toxicity
    (Lidocaine, Bupivacaine)

5
HISTORY
  • 1885 Corning - First attempt with epidural
    cocaine
  • 1891 Quincke - Describes the lumbar puncture
    technique
  • 1921 Pagis - First lumbar anesthesia for surgery
  • 1947 Lidocaine commercially available
  • 1949 Curbelo - First continuous lumbar analgesia
    with Touhy needle
  • 1963 Bupivicaine commercially available
  • 1979 Cousins - Epidural opioids provide analgesia
  • 1983 Yaksh - Different spinal receptor systems
    mediating pain
  • 1985 University of Kiel, Germany, Anesthesiology
    managed acute post-operative pain service

6
Regional/Neuraxial Anesthesia
  • A reversible loss of sensation in a specific
    area of the body.

Bier block Axillary, Interscalene Spinal,
Epidural Caudal Foot block, metatarsal
block Paracervical
7
  • Regional anesthetic techniques categorized as
    follows
  • Epidural and spinal anesthesia
  • Peripheral nerve blockades
  • IV regional anesthesia

8
DEFINITIONS
  • SPINAL ANESTHESIA
  • INTRATHECALadministration of medication into
    subarachnoid space

9
DEFINITIONS
  • EPIDURAL ANESTHESIA
  • EPIDURALadministration of medication into
    epidural space

10
  • OVERVIEW
  • OF THE
  • SPINAL ANATOMY

11
SPINAL CORD
  • Located and protected within vertebral column
  • Extends from the foramen magnum to lower border
    1st L1 (adult) S2 (kids)
  • SC taper to a fibrous band - conus medullaris
  • Nerve root continue beyond the conus- cauda
    equina
  • Surrounded by the meninges,(dura,arachnoid pia
    mater.)

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anatomy
  • The vertebrae are 33 number, divided by
    structural into five region cervical 7, thoracic
    12, lumber5, sacral 5, coccygeal3.

14
anatomy

15
EPIDURAL SPACE
  • Potential space
  • Between the dura mater,luigamentum flavum
  • Made up of vasculature, nerves, fat and lymphatic
  • Extends from foramen magnum to the sacrococcygeal
    ligament

16
Regional anesthesia
  • Spinal
  • lower extremities, lower abdomen, pelvis
  • Epidural
  • cervical
  • thoracic
  • lumber
  • caudal

17
INDICATIONS
  • The objective of epidural analgesia is to relieve
    pain.
  • Major surgery
  • Trauma ( ribs)
  • Palliative care (intractable pain)
  • Labour and Delivery
  • abd surgery
  • Pelvic surgery
  • lower lime surgery

18
CONTRAINDICATIONS
  • ABSOULET CONTRAINDICATION
  • Patient refusal
  • Known allergy to opioid or local anesthetic
  • Infection/abscess near the proposed injection
    site
  • Hematological disorder
  • Increase ICP

19
CONTRAINDICATIONS
  • RELATIVE CONTRAINDICATION
  • Sepsis
  • AntiCoagulant drugs
  • Hypotension
  • hypovolemia
  • Spinal deformity
  • Neurological disorder.

20
Patient assume a sitting or side-lying position
with the back arched toward the physician.Help to
spread the vertebrae apart
21
Height of sensory block Lumbar-T4 Thoracic-T2
22
INSERTION OF EPIDURAL CATHETER
  • Positioning of patient
  • The site is dependent upon the area of pain
  • Fixing the catheter
  • Incision Level
  • Thoracic T4-T6
  • Upper abdo T6-T8
  • Lower abdo T8-T10
  • Pelvic T8-T10
  • Lower extremity L1-L4

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EPIDURAL CATHETERS
  • Ideal Placement (adult) 10-12 cm at the skin
  • Epidural catheters have markings that indicate
    their length.
  • there is a mark at the tip of the
    catheter
  • the 1st single mark up the catheter is
    5cm
  • double mark up the catheter is 10 cm
  • triple mark on the catheter is 15 cm
  • four mark together indicate 20cm
  • A change in depth of the catheter indicates
    migration either into or out of the epidural
    space.

31
CATHETER MIGRATION
  • Catheter migration into a blood vessel in the
    epidural space or subarachnoid space
  • rapid onset LOC
  • Decrease loss of sensory or motor loss (marcain)
  • Toxicity
  • Profound hypotension

32
CATHETER MIGRATION
  • Out of the epidural space
  • ineffective analgesia
  • no analgesia
  • drugs deposited into soft tissue.

33
Advantages/Disadvantages of Regional and Local
Anesthesia.
34
advantages
  • patient remains conscious
  • maintain his own airway
  • aspiration of gastric contents unlikely
  • smooth recovery requiring less skilled nursing
    care as compared to general anesthesia

35
advantages
  • postoperative analgesia
  • reduction in surgical stress
  • earlier discharge for outpatients
  • less expense

36
Disadvantages
  • patient may prefer to be asleep
  • practice and skill is required for the best
    results.
  • some blocks require up to 30 minutes or more to
    be fully effective
  • analgesia may not always be totally
    effective-patient may require additional
    analgesics, IV sedation, or a light general
    anesthetic

37
Disadvantages
  • toxicity may occur if the local anesthetic is
    given intravenously or if an overdose is injected
  • some operations are unsuitable for local
    anesthetics, e.g., thoracotomies

38
DRUGS
  • One of the most important factors influencing
    drug absorption and bioavailability is the drug
    SOLUBILITY
  • The more lipid soluble rapid onset shorter
    duration

39
MEDICATION COMMONLY USED
  • OPIOIDS-Fentanyl Morphine
  • (affect the pain transmission at
    the
  • opioid receptors)
  • L.A.-Bupivacaine(marcaine)
  • (inhibits the pain impulse
  • transmission in the nerves with
  • which it comes in contact)

40
LOCAL ANESTHETICS
  • AMIDES MAX / DOSE
  • BUPIVACAINE 2 MG/KG
  • LIDOCAINE 7 MG/KG
  • ROPIVACAINE 4 MG/KG
  • MEPIVACAINE 7 MG/KG
  • PRILOCAINE 6MG/KG

41
LOCAL ANESTHETICS
  • ESTERS MAX /DOSE
  • CHLOROPROCAINE 20 MG/KG
  • COCAINE 3 MG/KG
  • NOVOCAINE 12 MG/KG
  • TETRACAINE 3 MG/KG

42
Metabolism
  • Amides
  • Primarily hepatic
  • Plasma conc may accumulate with repeated doses
  • Toxicity is dose related, and may be delayed by
    minutes or even hours from time of dose.
  • Esters
  • Ester hydrolysis in the plasma by
    pseudocholinesterase
  • Almost no potential for accumulation
  • Toxicity is either from direct IV injection
  • tetracaine, cocaine
  • or persistent effects of exposure
  • benzocaine, cocaine

43
Clinical Pharmacology
  • Patients with genetically abnormal
    pseudocholinesterase are at increased risk for
    toxic side effects, as metabolism is slower.

44
Clinical Pharmacology
  • CSF lacks esterase enzymes, so the termination
    of action of intrathecally injected ester local
    anesthetics, eg, tetracaine, depends on their
    absorption into the bloodstream.

45
METHODS OF ADMINISTRATION
  • BOLUS (FENTANYL, DURAMORPH)
  • CONTINUOUS INFUSION(MARCAINEFENTANYL)
  • All drugs administered epidural should be
    preservative free.
  • All epidural opioids should be diluted with
    normal saline prior to intermittent bolus
    administration.

46
Mechanism of Action
  • Bupivacaine (marcaine)
  • - local anaesthetic works as an
  • analgesic (subanesthetic dose)
  • - inhibiting impulse transmission in
  • the nerve fibers
  • - sensory nerves are blocked first
  • before the motor fibers
  • - sensory fibers carrying the pain is
  • blocked before those carrying heat
  • cold touch and pressure.

47
Progression of local anesthesia
  • Loss of
  • 1. Pain
  • 2. Cold
  • 3. Warmth
  • 4. Touch
  • 5. Deep pressure
  • 6. Motor function

48
EPIDURAL LOCAL ANESTHETIC(MARCAINE)
  • Onset 10-15 minutes
  • Duration- 4 hrs after a bolus or after infusion
    is stopped
  • Marcaine(0.0625-0.125-0.25)
  • Extend of spread influenced by volume and
    position of patient

49
OPIOIDS
  • Mechanism of action-distribution
  • Vascular uptake by blood vessels in the epidural
    space
  • Diffusion through dura into CSF to spinal cord to
    the site of action.
  • Uptake by the fat in the epidural space.

50
Morphine (Duramorph/Astramorph)
  • Hydrophilic(water soluble)
  • Slow to diffuse across the dura on to the spinal
    cord
  • Can cause late respiratory depression
  • Monitor respiratory status for 12 hrs after the
    last dose of duramorph
  • Duration 6 hrs
  • Broad spread

51
Fentanyl (preservativefree)
  • Lipophilic(fat soluble)
  • Crossess the dura rapidly
  • Rapid onset of action(segmental)
  • Decreased risk of late respiratory depression
  • Onset 5-20 mins
  • Duration 2-4hrs
  • Excellent for breakthrough pain

52
Adverse Effects -Opioids
  • Sedation and resp.depression- IV narcan
  • N/V-Opioids stimulate the chemoreceptor trigger
    zone
  • primperan
  • Pruritus- diphenhydramine or narcan (low dose)
  • Urinary retention- low dose narcan and /or
    catheterization
  • Slowing of GI motility
  • Hypotension

53
Adverse Effects L.A
  • Hypotension-
  • -assess intravascular volume status
  • -no trendelenberg positioning
  • Teach patient to move slowly from a lying
    position to sitting to standing position.
  • Treatment
  • fluids

54
Cont.
  • Temporary lower-extremity motor or sensory
    deficits.
  • Tx lower the rate or
  • concentration.
  • Urine retention
  • Tx catheter
  • Local anesthetic toxicity (neurotoxicity)
  • Tx stop infusion.
  • Resp. insufficiency
  • Txstop infusion
  • - ABC(100 o2
  • call for help)
  • - Assess spread
  • and
  • height of block
  • - Alt.analgesia

55
OTHER COMPLICATIONS
  • Headache (dural puncture)
  • Tx symptomatic treatment
    Autologous blood patch
  • Infection
  • nausea and vomiting.
  • Intravenous placement of catheter
  • Subdural placement of catheter
  • Haematoma

56
Signs and Symptoms of Local/Regional Anesthesia
Toxicity
  • CNS
  • CV

57
S/S CNS Toxicity
  • Unconsciousness
  • Generalized convulsions
  • Coma
  • Apnea
  • Numbness of the mouth and tongue, metal taste in
    the mouth

58
S/S CNS Toxicity
  • Light-headedness
  • Tinnitus
  • Visual disturbance
  • Muscle twitching

59
Cardiovascular toxicity
  • slowing of the conduction in the myocardium
  • myocardial depression
  • peripheral vasodilatation

60
Prevention and Treatment of Local/Regional
Anesthesia Toxicity
61
prevention
  • Always use the recommended dose
  • Aspirate through the needle or catheter before
    injecting the local anesthetic. Intravascular
    injection can have catastrophic results.
  • If a large quantity of a drug is required, use a
    drug of low toxicity and divide the dose into
    small increments, increasing the total injection
    time
  • always inject slowly (lt10 ml/min) and communicate
    with the pt

62
treatment
  • All necessary equipment to perform resuscitation,
    induction, and intubation should be on hand
    before injection of local/regional anesthetics
  • Manage airway and give oxygen
  • Stop convulsions if they continue for more than
    15 to 20 seconds
  • Thiopental 100 mg to 150 mg IV
  • or Diazepam 5 mg to 20 mg IV

63
OTHER BLOCKS
64
Caudal Anaesthesia
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Anatomy of Lumbar and Sacral Plexus
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Classes The rule of i
  • Amides
  • Lidocaine Bupivacaine Levobupivacaine Ropivacaine
    Mepivacaine Etidocaine Prilocaine
  • Esters
  • Procaine Chloroprocaine Tetracaine Benzocaine Coc
    aine

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Reference book and the relevant page numbers..
75
Thank You ?
  • Dr.
  • Date
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