Department of AnesthesiologyFirst Affiliated Hospital

Anhui Medical University

Guang-Hong Xu

Local Anesthesia

Definition

Local anesthesia is any technique to

render part of the body insensitive to pain

without affecting consciousness

A local anesthetic is a drug that reversibly

inhibits the propagation of signals along

nerves

Analgesia (loss of pain sensation)

Paralysis (loss of muscle power)

Definition

General formula for local anesthetic drugs

aromaticaromatic groupgroup intermediate chainintermediate chain amineamine

The classification of local anesthetics

Esters

procaine

cocaine

chloroprocaine

tetracaine

Amides

bupivacaine

lidocaine

ropivacaine

bullThe ester linkage is rapid hydrolyzed The ester linkage is rapid hydrolyzed by plasma cholinesterase the half-life of by plasma cholinesterase the half-life of esters in the circulation is very shortesters in the circulation is very short

The amide linkage is enzymatic The amide linkage is enzymatic degradation in liver by microsomal degradation in liver by microsomal enzymes Poor hepatic functionenzymes Poor hepatic function

More susceptible to adverse reactionMore susceptible to adverse reaction

The half-life of amides is 2 to 3 hThe half-life of amides is 2 to 3 h

Structure

Effective Time

Short term procaine

Middle lidocaine

Long bupivacaine tetracaine ropivacaine

The classification of local anesthetics

Mechanism of action

Inhibiting sodium influx through sodium-specific ion channels in particular the so-called voltage-gated sodium channels

Action potential cannot arise and signal conduction is inhibited

Pharmacology

Lipid solubility determines potency as more lipophilic local anesthetic agents more easily cross nerve membranes

Protein binding regulate the duration of anaesthetic activity highly protein bound will remain for a prolonged duration of effect

Pharmacology

The pKa is the pH at which 50 of the local anesthetic which is in the uncharged form pKa determines the speed of onset of neural blockade Agents with a lower pKa value will have a faster onset The uncharged form diffuse more readily across nerve membranes

Pharmacokinetics

Absorption Absorption Drug performance

Drug dose and concentration

Delivery way IV or intramuscular

Vasoconstrictor drugs or not prolong

DistributionDistribution

Metabolism Metabolism

Elimination Elimination

Sequence of clinical anesthesia

Recovery in reverse order

Pathophysiologic factors

Pathophysiologic factors

Clinical uses of local anesthetics

1000

400-500

Local anesthetics

1 Toxicity

2 HypersensitivityAllergy

Undesired effects

Side effects

Side effects

Local anesthetic toxicity

bull Concept Concentration of local anesthetic in blood

far exceeds the tolerance limitation of human body and cause adverse effects

Central nervous system and cardiovascular system are vulnerable

Toxicity may occur if The maximum safe dose is exceeded (overdose) Transient high blood levels are achieved by accidental intravenous

injection Rapid absorption from an inflamed or a highly vascular area Use normal dose to weak patients (Systemic pathology reduce the

tolerance) Continuous infusion or cumulative effects of multiple injection

Toxic reaction of local anesthetics

Maximum recommended doses

8 10

Central nervous system

Clinic presentation of local anesthesia toxicity

CNS is more susceptible to systemic action of local anesthetic than cardiovascular system (Dose 13)

Numbness or tingling of the tongue and circumoral area dizziness visual and auditory disturbance disorientation excitatory sign including shivering muscular twitching hypertension anxiety restlessness drowsiness

Ultimately generalized convulsion will occur After seizure activity ceases respiratory depression even arrest may occur

Central nervous system

bull Excitatory or Depressive bull At lower concentrations a relatively selective depression of

inhibitory neurons results in cerebral excitation which may lead to generalized convulsions

bull A profound depression of brain functions occurs at higher concentrations which may lead to coma respiratory arrest and death

Clinic presentation of local anesthesia toxicity

Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Definition

Local anesthesia is any technique to

render part of the body insensitive to pain

without affecting consciousness

A local anesthetic is a drug that reversibly

inhibits the propagation of signals along

nerves

Analgesia (loss of pain sensation)

Paralysis (loss of muscle power)

Definition

General formula for local anesthetic drugs

aromaticaromatic groupgroup intermediate chainintermediate chain amineamine

The classification of local anesthetics

Esters

procaine

cocaine

chloroprocaine

tetracaine

Amides

bupivacaine

lidocaine

ropivacaine

bullThe ester linkage is rapid hydrolyzed The ester linkage is rapid hydrolyzed by plasma cholinesterase the half-life of by plasma cholinesterase the half-life of esters in the circulation is very shortesters in the circulation is very short

The amide linkage is enzymatic The amide linkage is enzymatic degradation in liver by microsomal degradation in liver by microsomal enzymes Poor hepatic functionenzymes Poor hepatic function

More susceptible to adverse reactionMore susceptible to adverse reaction

The half-life of amides is 2 to 3 hThe half-life of amides is 2 to 3 h

Structure

Effective Time

Short term procaine

Middle lidocaine

Long bupivacaine tetracaine ropivacaine

The classification of local anesthetics

Mechanism of action

Inhibiting sodium influx through sodium-specific ion channels in particular the so-called voltage-gated sodium channels

Action potential cannot arise and signal conduction is inhibited

Pharmacology

Lipid solubility determines potency as more lipophilic local anesthetic agents more easily cross nerve membranes

Protein binding regulate the duration of anaesthetic activity highly protein bound will remain for a prolonged duration of effect

Pharmacology

The pKa is the pH at which 50 of the local anesthetic which is in the uncharged form pKa determines the speed of onset of neural blockade Agents with a lower pKa value will have a faster onset The uncharged form diffuse more readily across nerve membranes

Pharmacokinetics

Absorption Absorption Drug performance

Drug dose and concentration

Delivery way IV or intramuscular

Vasoconstrictor drugs or not prolong

DistributionDistribution

Metabolism Metabolism

Elimination Elimination

Sequence of clinical anesthesia

Recovery in reverse order

Pathophysiologic factors

Pathophysiologic factors

Clinical uses of local anesthetics

1000

400-500

Local anesthetics

1 Toxicity

2 HypersensitivityAllergy

Undesired effects

Side effects

Side effects

Local anesthetic toxicity

bull Concept Concentration of local anesthetic in blood

far exceeds the tolerance limitation of human body and cause adverse effects

Central nervous system and cardiovascular system are vulnerable

Toxicity may occur if The maximum safe dose is exceeded (overdose) Transient high blood levels are achieved by accidental intravenous

injection Rapid absorption from an inflamed or a highly vascular area Use normal dose to weak patients (Systemic pathology reduce the

tolerance) Continuous infusion or cumulative effects of multiple injection

Toxic reaction of local anesthetics

Maximum recommended doses

8 10

Central nervous system

Clinic presentation of local anesthesia toxicity

CNS is more susceptible to systemic action of local anesthetic than cardiovascular system (Dose 13)

Numbness or tingling of the tongue and circumoral area dizziness visual and auditory disturbance disorientation excitatory sign including shivering muscular twitching hypertension anxiety restlessness drowsiness

Ultimately generalized convulsion will occur After seizure activity ceases respiratory depression even arrest may occur

Central nervous system

bull Excitatory or Depressive bull At lower concentrations a relatively selective depression of

inhibitory neurons results in cerebral excitation which may lead to generalized convulsions

bull A profound depression of brain functions occurs at higher concentrations which may lead to coma respiratory arrest and death

Clinic presentation of local anesthesia toxicity

Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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A local anesthetic is a drug that reversibly

inhibits the propagation of signals along

nerves

Analgesia (loss of pain sensation)

Paralysis (loss of muscle power)

Definition

General formula for local anesthetic drugs

aromaticaromatic groupgroup intermediate chainintermediate chain amineamine

The classification of local anesthetics

Esters

procaine

cocaine

chloroprocaine

tetracaine

Amides

bupivacaine

lidocaine

ropivacaine

bullThe ester linkage is rapid hydrolyzed The ester linkage is rapid hydrolyzed by plasma cholinesterase the half-life of by plasma cholinesterase the half-life of esters in the circulation is very shortesters in the circulation is very short

The amide linkage is enzymatic The amide linkage is enzymatic degradation in liver by microsomal degradation in liver by microsomal enzymes Poor hepatic functionenzymes Poor hepatic function

More susceptible to adverse reactionMore susceptible to adverse reaction

The half-life of amides is 2 to 3 hThe half-life of amides is 2 to 3 h

Structure

Effective Time

Short term procaine

Middle lidocaine

Long bupivacaine tetracaine ropivacaine

The classification of local anesthetics

Mechanism of action

Inhibiting sodium influx through sodium-specific ion channels in particular the so-called voltage-gated sodium channels

Action potential cannot arise and signal conduction is inhibited

Pharmacology

Lipid solubility determines potency as more lipophilic local anesthetic agents more easily cross nerve membranes

Protein binding regulate the duration of anaesthetic activity highly protein bound will remain for a prolonged duration of effect

Pharmacology

The pKa is the pH at which 50 of the local anesthetic which is in the uncharged form pKa determines the speed of onset of neural blockade Agents with a lower pKa value will have a faster onset The uncharged form diffuse more readily across nerve membranes

Pharmacokinetics

Absorption Absorption Drug performance

Drug dose and concentration

Delivery way IV or intramuscular

Vasoconstrictor drugs or not prolong

DistributionDistribution

Metabolism Metabolism

Elimination Elimination

Sequence of clinical anesthesia

Recovery in reverse order

Pathophysiologic factors

Pathophysiologic factors

Clinical uses of local anesthetics

1000

400-500

Local anesthetics

1 Toxicity

2 HypersensitivityAllergy

Undesired effects

Side effects

Side effects

Local anesthetic toxicity

bull Concept Concentration of local anesthetic in blood

far exceeds the tolerance limitation of human body and cause adverse effects

Central nervous system and cardiovascular system are vulnerable

Toxicity may occur if The maximum safe dose is exceeded (overdose) Transient high blood levels are achieved by accidental intravenous

injection Rapid absorption from an inflamed or a highly vascular area Use normal dose to weak patients (Systemic pathology reduce the

tolerance) Continuous infusion or cumulative effects of multiple injection

Toxic reaction of local anesthetics

Maximum recommended doses

8 10

Central nervous system

Clinic presentation of local anesthesia toxicity

CNS is more susceptible to systemic action of local anesthetic than cardiovascular system (Dose 13)

Numbness or tingling of the tongue and circumoral area dizziness visual and auditory disturbance disorientation excitatory sign including shivering muscular twitching hypertension anxiety restlessness drowsiness

Ultimately generalized convulsion will occur After seizure activity ceases respiratory depression even arrest may occur

Central nervous system

bull Excitatory or Depressive bull At lower concentrations a relatively selective depression of

inhibitory neurons results in cerebral excitation which may lead to generalized convulsions

bull A profound depression of brain functions occurs at higher concentrations which may lead to coma respiratory arrest and death

Clinic presentation of local anesthesia toxicity

Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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General formula for local anesthetic drugs

aromaticaromatic groupgroup intermediate chainintermediate chain amineamine

The classification of local anesthetics

Esters

procaine

cocaine

chloroprocaine

tetracaine

Amides

bupivacaine

lidocaine

ropivacaine

bullThe ester linkage is rapid hydrolyzed The ester linkage is rapid hydrolyzed by plasma cholinesterase the half-life of by plasma cholinesterase the half-life of esters in the circulation is very shortesters in the circulation is very short

The amide linkage is enzymatic The amide linkage is enzymatic degradation in liver by microsomal degradation in liver by microsomal enzymes Poor hepatic functionenzymes Poor hepatic function

More susceptible to adverse reactionMore susceptible to adverse reaction

The half-life of amides is 2 to 3 hThe half-life of amides is 2 to 3 h

Structure

Effective Time

Short term procaine

Middle lidocaine

Long bupivacaine tetracaine ropivacaine

The classification of local anesthetics

Mechanism of action

Inhibiting sodium influx through sodium-specific ion channels in particular the so-called voltage-gated sodium channels

Action potential cannot arise and signal conduction is inhibited

Pharmacology

Lipid solubility determines potency as more lipophilic local anesthetic agents more easily cross nerve membranes

Protein binding regulate the duration of anaesthetic activity highly protein bound will remain for a prolonged duration of effect

Pharmacology

The pKa is the pH at which 50 of the local anesthetic which is in the uncharged form pKa determines the speed of onset of neural blockade Agents with a lower pKa value will have a faster onset The uncharged form diffuse more readily across nerve membranes

Pharmacokinetics

Absorption Absorption Drug performance

Drug dose and concentration

Delivery way IV or intramuscular

Vasoconstrictor drugs or not prolong

DistributionDistribution

Metabolism Metabolism

Elimination Elimination

Sequence of clinical anesthesia

Recovery in reverse order

Pathophysiologic factors

Pathophysiologic factors

Clinical uses of local anesthetics

1000

400-500

Local anesthetics

1 Toxicity

2 HypersensitivityAllergy

Undesired effects

Side effects

Side effects

Local anesthetic toxicity

bull Concept Concentration of local anesthetic in blood

far exceeds the tolerance limitation of human body and cause adverse effects

Central nervous system and cardiovascular system are vulnerable

Toxicity may occur if The maximum safe dose is exceeded (overdose) Transient high blood levels are achieved by accidental intravenous

injection Rapid absorption from an inflamed or a highly vascular area Use normal dose to weak patients (Systemic pathology reduce the

tolerance) Continuous infusion or cumulative effects of multiple injection

Toxic reaction of local anesthetics

Maximum recommended doses

8 10

Central nervous system

Clinic presentation of local anesthesia toxicity

CNS is more susceptible to systemic action of local anesthetic than cardiovascular system (Dose 13)

Numbness or tingling of the tongue and circumoral area dizziness visual and auditory disturbance disorientation excitatory sign including shivering muscular twitching hypertension anxiety restlessness drowsiness

Ultimately generalized convulsion will occur After seizure activity ceases respiratory depression even arrest may occur

Central nervous system

bull Excitatory or Depressive bull At lower concentrations a relatively selective depression of

inhibitory neurons results in cerebral excitation which may lead to generalized convulsions

bull A profound depression of brain functions occurs at higher concentrations which may lead to coma respiratory arrest and death

Clinic presentation of local anesthesia toxicity

Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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The classification of local anesthetics

Esters

procaine

cocaine

chloroprocaine

tetracaine

Amides

bupivacaine

lidocaine

ropivacaine

bullThe ester linkage is rapid hydrolyzed The ester linkage is rapid hydrolyzed by plasma cholinesterase the half-life of by plasma cholinesterase the half-life of esters in the circulation is very shortesters in the circulation is very short

The amide linkage is enzymatic The amide linkage is enzymatic degradation in liver by microsomal degradation in liver by microsomal enzymes Poor hepatic functionenzymes Poor hepatic function

More susceptible to adverse reactionMore susceptible to adverse reaction

The half-life of amides is 2 to 3 hThe half-life of amides is 2 to 3 h

Structure

Effective Time

Short term procaine

Middle lidocaine

Long bupivacaine tetracaine ropivacaine

The classification of local anesthetics

Mechanism of action

Inhibiting sodium influx through sodium-specific ion channels in particular the so-called voltage-gated sodium channels

Action potential cannot arise and signal conduction is inhibited

Pharmacology

Lipid solubility determines potency as more lipophilic local anesthetic agents more easily cross nerve membranes

Protein binding regulate the duration of anaesthetic activity highly protein bound will remain for a prolonged duration of effect

Pharmacology

The pKa is the pH at which 50 of the local anesthetic which is in the uncharged form pKa determines the speed of onset of neural blockade Agents with a lower pKa value will have a faster onset The uncharged form diffuse more readily across nerve membranes

Pharmacokinetics

Absorption Absorption Drug performance

Drug dose and concentration

Delivery way IV or intramuscular

Vasoconstrictor drugs or not prolong

DistributionDistribution

Metabolism Metabolism

Elimination Elimination

Sequence of clinical anesthesia

Recovery in reverse order

Pathophysiologic factors

Pathophysiologic factors

Clinical uses of local anesthetics

1000

400-500

Local anesthetics

1 Toxicity

2 HypersensitivityAllergy

Undesired effects

Side effects

Side effects

Local anesthetic toxicity

bull Concept Concentration of local anesthetic in blood

far exceeds the tolerance limitation of human body and cause adverse effects

Central nervous system and cardiovascular system are vulnerable

Toxicity may occur if The maximum safe dose is exceeded (overdose) Transient high blood levels are achieved by accidental intravenous

injection Rapid absorption from an inflamed or a highly vascular area Use normal dose to weak patients (Systemic pathology reduce the

tolerance) Continuous infusion or cumulative effects of multiple injection

Toxic reaction of local anesthetics

Maximum recommended doses

8 10

Central nervous system

Clinic presentation of local anesthesia toxicity

CNS is more susceptible to systemic action of local anesthetic than cardiovascular system (Dose 13)

Numbness or tingling of the tongue and circumoral area dizziness visual and auditory disturbance disorientation excitatory sign including shivering muscular twitching hypertension anxiety restlessness drowsiness

Ultimately generalized convulsion will occur After seizure activity ceases respiratory depression even arrest may occur

Central nervous system

bull Excitatory or Depressive bull At lower concentrations a relatively selective depression of

inhibitory neurons results in cerebral excitation which may lead to generalized convulsions

bull A profound depression of brain functions occurs at higher concentrations which may lead to coma respiratory arrest and death

Clinic presentation of local anesthesia toxicity

Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Effective Time

Short term procaine

Middle lidocaine

Long bupivacaine tetracaine ropivacaine

The classification of local anesthetics

Mechanism of action

Inhibiting sodium influx through sodium-specific ion channels in particular the so-called voltage-gated sodium channels

Action potential cannot arise and signal conduction is inhibited

Pharmacology

Lipid solubility determines potency as more lipophilic local anesthetic agents more easily cross nerve membranes

Protein binding regulate the duration of anaesthetic activity highly protein bound will remain for a prolonged duration of effect

Pharmacology

The pKa is the pH at which 50 of the local anesthetic which is in the uncharged form pKa determines the speed of onset of neural blockade Agents with a lower pKa value will have a faster onset The uncharged form diffuse more readily across nerve membranes

Pharmacokinetics

Absorption Absorption Drug performance

Drug dose and concentration

Delivery way IV or intramuscular

Vasoconstrictor drugs or not prolong

DistributionDistribution

Metabolism Metabolism

Elimination Elimination

Sequence of clinical anesthesia

Recovery in reverse order

Pathophysiologic factors

Pathophysiologic factors

Clinical uses of local anesthetics

1000

400-500

Local anesthetics

1 Toxicity

2 HypersensitivityAllergy

Undesired effects

Side effects

Side effects

Local anesthetic toxicity

bull Concept Concentration of local anesthetic in blood

far exceeds the tolerance limitation of human body and cause adverse effects

Central nervous system and cardiovascular system are vulnerable

Toxicity may occur if The maximum safe dose is exceeded (overdose) Transient high blood levels are achieved by accidental intravenous

injection Rapid absorption from an inflamed or a highly vascular area Use normal dose to weak patients (Systemic pathology reduce the

tolerance) Continuous infusion or cumulative effects of multiple injection

Toxic reaction of local anesthetics

Maximum recommended doses

8 10

Central nervous system

Clinic presentation of local anesthesia toxicity

CNS is more susceptible to systemic action of local anesthetic than cardiovascular system (Dose 13)

Numbness or tingling of the tongue and circumoral area dizziness visual and auditory disturbance disorientation excitatory sign including shivering muscular twitching hypertension anxiety restlessness drowsiness

Ultimately generalized convulsion will occur After seizure activity ceases respiratory depression even arrest may occur

Central nervous system

bull Excitatory or Depressive bull At lower concentrations a relatively selective depression of

inhibitory neurons results in cerebral excitation which may lead to generalized convulsions

bull A profound depression of brain functions occurs at higher concentrations which may lead to coma respiratory arrest and death

Clinic presentation of local anesthesia toxicity

Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Mechanism of action

Inhibiting sodium influx through sodium-specific ion channels in particular the so-called voltage-gated sodium channels

Action potential cannot arise and signal conduction is inhibited

Pharmacology

Lipid solubility determines potency as more lipophilic local anesthetic agents more easily cross nerve membranes

Protein binding regulate the duration of anaesthetic activity highly protein bound will remain for a prolonged duration of effect

Pharmacology

The pKa is the pH at which 50 of the local anesthetic which is in the uncharged form pKa determines the speed of onset of neural blockade Agents with a lower pKa value will have a faster onset The uncharged form diffuse more readily across nerve membranes

Pharmacokinetics

Absorption Absorption Drug performance

Drug dose and concentration

Delivery way IV or intramuscular

Vasoconstrictor drugs or not prolong

DistributionDistribution

Metabolism Metabolism

Elimination Elimination

Sequence of clinical anesthesia

Recovery in reverse order

Pathophysiologic factors

Pathophysiologic factors

Clinical uses of local anesthetics

1000

400-500

Local anesthetics

1 Toxicity

2 HypersensitivityAllergy

Undesired effects

Side effects

Side effects

Local anesthetic toxicity

bull Concept Concentration of local anesthetic in blood

far exceeds the tolerance limitation of human body and cause adverse effects

Central nervous system and cardiovascular system are vulnerable

Toxicity may occur if The maximum safe dose is exceeded (overdose) Transient high blood levels are achieved by accidental intravenous

injection Rapid absorption from an inflamed or a highly vascular area Use normal dose to weak patients (Systemic pathology reduce the

tolerance) Continuous infusion or cumulative effects of multiple injection

Toxic reaction of local anesthetics

Maximum recommended doses

8 10

Central nervous system

Clinic presentation of local anesthesia toxicity

CNS is more susceptible to systemic action of local anesthetic than cardiovascular system (Dose 13)

Numbness or tingling of the tongue and circumoral area dizziness visual and auditory disturbance disorientation excitatory sign including shivering muscular twitching hypertension anxiety restlessness drowsiness

Ultimately generalized convulsion will occur After seizure activity ceases respiratory depression even arrest may occur

Central nervous system

bull Excitatory or Depressive bull At lower concentrations a relatively selective depression of

inhibitory neurons results in cerebral excitation which may lead to generalized convulsions

bull A profound depression of brain functions occurs at higher concentrations which may lead to coma respiratory arrest and death

Clinic presentation of local anesthesia toxicity

Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Pharmacology

Lipid solubility determines potency as more lipophilic local anesthetic agents more easily cross nerve membranes

Protein binding regulate the duration of anaesthetic activity highly protein bound will remain for a prolonged duration of effect

Pharmacology

The pKa is the pH at which 50 of the local anesthetic which is in the uncharged form pKa determines the speed of onset of neural blockade Agents with a lower pKa value will have a faster onset The uncharged form diffuse more readily across nerve membranes

Pharmacokinetics

Absorption Absorption Drug performance

Drug dose and concentration

Delivery way IV or intramuscular

Vasoconstrictor drugs or not prolong

DistributionDistribution

Metabolism Metabolism

Elimination Elimination

Sequence of clinical anesthesia

Recovery in reverse order

Pathophysiologic factors

Pathophysiologic factors

Clinical uses of local anesthetics

1000

400-500

Local anesthetics

1 Toxicity

2 HypersensitivityAllergy

Undesired effects

Side effects

Side effects

Local anesthetic toxicity

bull Concept Concentration of local anesthetic in blood

far exceeds the tolerance limitation of human body and cause adverse effects

Central nervous system and cardiovascular system are vulnerable

Toxicity may occur if The maximum safe dose is exceeded (overdose) Transient high blood levels are achieved by accidental intravenous

injection Rapid absorption from an inflamed or a highly vascular area Use normal dose to weak patients (Systemic pathology reduce the

tolerance) Continuous infusion or cumulative effects of multiple injection

Toxic reaction of local anesthetics

Maximum recommended doses

8 10

Central nervous system

Clinic presentation of local anesthesia toxicity

CNS is more susceptible to systemic action of local anesthetic than cardiovascular system (Dose 13)

Numbness or tingling of the tongue and circumoral area dizziness visual and auditory disturbance disorientation excitatory sign including shivering muscular twitching hypertension anxiety restlessness drowsiness

Ultimately generalized convulsion will occur After seizure activity ceases respiratory depression even arrest may occur

Central nervous system

bull Excitatory or Depressive bull At lower concentrations a relatively selective depression of

inhibitory neurons results in cerebral excitation which may lead to generalized convulsions

bull A profound depression of brain functions occurs at higher concentrations which may lead to coma respiratory arrest and death

Clinic presentation of local anesthesia toxicity

Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Pharmacology

The pKa is the pH at which 50 of the local anesthetic which is in the uncharged form pKa determines the speed of onset of neural blockade Agents with a lower pKa value will have a faster onset The uncharged form diffuse more readily across nerve membranes

Pharmacokinetics

Absorption Absorption Drug performance

Drug dose and concentration

Delivery way IV or intramuscular

Vasoconstrictor drugs or not prolong

DistributionDistribution

Metabolism Metabolism

Elimination Elimination

Sequence of clinical anesthesia

Recovery in reverse order

Pathophysiologic factors

Pathophysiologic factors

Clinical uses of local anesthetics

1000

400-500

Local anesthetics

1 Toxicity

2 HypersensitivityAllergy

Undesired effects

Side effects

Side effects

Local anesthetic toxicity

bull Concept Concentration of local anesthetic in blood

far exceeds the tolerance limitation of human body and cause adverse effects

Central nervous system and cardiovascular system are vulnerable

Toxicity may occur if The maximum safe dose is exceeded (overdose) Transient high blood levels are achieved by accidental intravenous

injection Rapid absorption from an inflamed or a highly vascular area Use normal dose to weak patients (Systemic pathology reduce the

tolerance) Continuous infusion or cumulative effects of multiple injection

Toxic reaction of local anesthetics

Maximum recommended doses

8 10

Central nervous system

Clinic presentation of local anesthesia toxicity

CNS is more susceptible to systemic action of local anesthetic than cardiovascular system (Dose 13)

Numbness or tingling of the tongue and circumoral area dizziness visual and auditory disturbance disorientation excitatory sign including shivering muscular twitching hypertension anxiety restlessness drowsiness

Ultimately generalized convulsion will occur After seizure activity ceases respiratory depression even arrest may occur

Central nervous system

bull Excitatory or Depressive bull At lower concentrations a relatively selective depression of

inhibitory neurons results in cerebral excitation which may lead to generalized convulsions

bull A profound depression of brain functions occurs at higher concentrations which may lead to coma respiratory arrest and death

Clinic presentation of local anesthesia toxicity

Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Pharmacokinetics

Absorption Absorption Drug performance

Drug dose and concentration

Delivery way IV or intramuscular

Vasoconstrictor drugs or not prolong

DistributionDistribution

Metabolism Metabolism

Elimination Elimination

Sequence of clinical anesthesia

Recovery in reverse order

Pathophysiologic factors

Pathophysiologic factors

Clinical uses of local anesthetics

1000

400-500

Local anesthetics

1 Toxicity

2 HypersensitivityAllergy

Undesired effects

Side effects

Side effects

Local anesthetic toxicity

bull Concept Concentration of local anesthetic in blood

far exceeds the tolerance limitation of human body and cause adverse effects

Central nervous system and cardiovascular system are vulnerable

Toxicity may occur if The maximum safe dose is exceeded (overdose) Transient high blood levels are achieved by accidental intravenous

injection Rapid absorption from an inflamed or a highly vascular area Use normal dose to weak patients (Systemic pathology reduce the

tolerance) Continuous infusion or cumulative effects of multiple injection

Toxic reaction of local anesthetics

Maximum recommended doses

8 10

Central nervous system

Clinic presentation of local anesthesia toxicity

CNS is more susceptible to systemic action of local anesthetic than cardiovascular system (Dose 13)

Numbness or tingling of the tongue and circumoral area dizziness visual and auditory disturbance disorientation excitatory sign including shivering muscular twitching hypertension anxiety restlessness drowsiness

Ultimately generalized convulsion will occur After seizure activity ceases respiratory depression even arrest may occur

Central nervous system

bull Excitatory or Depressive bull At lower concentrations a relatively selective depression of

inhibitory neurons results in cerebral excitation which may lead to generalized convulsions

bull A profound depression of brain functions occurs at higher concentrations which may lead to coma respiratory arrest and death

Clinic presentation of local anesthesia toxicity

Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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• Slide 3
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Sequence of clinical anesthesia

Recovery in reverse order

Pathophysiologic factors

Pathophysiologic factors

Clinical uses of local anesthetics

1000

400-500

Local anesthetics

1 Toxicity

2 HypersensitivityAllergy

Undesired effects

Side effects

Side effects

Local anesthetic toxicity

bull Concept Concentration of local anesthetic in blood

far exceeds the tolerance limitation of human body and cause adverse effects

Central nervous system and cardiovascular system are vulnerable

Toxicity may occur if The maximum safe dose is exceeded (overdose) Transient high blood levels are achieved by accidental intravenous

injection Rapid absorption from an inflamed or a highly vascular area Use normal dose to weak patients (Systemic pathology reduce the

tolerance) Continuous infusion or cumulative effects of multiple injection

Toxic reaction of local anesthetics

Maximum recommended doses

8 10

Central nervous system

Clinic presentation of local anesthesia toxicity

CNS is more susceptible to systemic action of local anesthetic than cardiovascular system (Dose 13)

Numbness or tingling of the tongue and circumoral area dizziness visual and auditory disturbance disorientation excitatory sign including shivering muscular twitching hypertension anxiety restlessness drowsiness

Ultimately generalized convulsion will occur After seizure activity ceases respiratory depression even arrest may occur

Central nervous system

bull Excitatory or Depressive bull At lower concentrations a relatively selective depression of

inhibitory neurons results in cerebral excitation which may lead to generalized convulsions

bull A profound depression of brain functions occurs at higher concentrations which may lead to coma respiratory arrest and death

Clinic presentation of local anesthesia toxicity

Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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• Slide 88
• Slide 89
• Slide 90
• Slide 91

Pathophysiologic factors

Pathophysiologic factors

Clinical uses of local anesthetics

1000

400-500

Local anesthetics

1 Toxicity

2 HypersensitivityAllergy

Undesired effects

Side effects

Side effects

Local anesthetic toxicity

bull Concept Concentration of local anesthetic in blood

far exceeds the tolerance limitation of human body and cause adverse effects

Central nervous system and cardiovascular system are vulnerable

Toxicity may occur if The maximum safe dose is exceeded (overdose) Transient high blood levels are achieved by accidental intravenous

injection Rapid absorption from an inflamed or a highly vascular area Use normal dose to weak patients (Systemic pathology reduce the

tolerance) Continuous infusion or cumulative effects of multiple injection

Toxic reaction of local anesthetics

Maximum recommended doses

8 10

Central nervous system

Clinic presentation of local anesthesia toxicity

CNS is more susceptible to systemic action of local anesthetic than cardiovascular system (Dose 13)

Numbness or tingling of the tongue and circumoral area dizziness visual and auditory disturbance disorientation excitatory sign including shivering muscular twitching hypertension anxiety restlessness drowsiness

Ultimately generalized convulsion will occur After seizure activity ceases respiratory depression even arrest may occur

Central nervous system

bull Excitatory or Depressive bull At lower concentrations a relatively selective depression of

inhibitory neurons results in cerebral excitation which may lead to generalized convulsions

bull A profound depression of brain functions occurs at higher concentrations which may lead to coma respiratory arrest and death

Clinic presentation of local anesthesia toxicity

Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Pathophysiologic factors

Clinical uses of local anesthetics

1000

400-500

Local anesthetics

1 Toxicity

2 HypersensitivityAllergy

Undesired effects

Side effects

Side effects

Local anesthetic toxicity

bull Concept Concentration of local anesthetic in blood

far exceeds the tolerance limitation of human body and cause adverse effects

Central nervous system and cardiovascular system are vulnerable

Toxicity may occur if The maximum safe dose is exceeded (overdose) Transient high blood levels are achieved by accidental intravenous

injection Rapid absorption from an inflamed or a highly vascular area Use normal dose to weak patients (Systemic pathology reduce the

tolerance) Continuous infusion or cumulative effects of multiple injection

Toxic reaction of local anesthetics

Maximum recommended doses

8 10

Central nervous system

Clinic presentation of local anesthesia toxicity

CNS is more susceptible to systemic action of local anesthetic than cardiovascular system (Dose 13)

Numbness or tingling of the tongue and circumoral area dizziness visual and auditory disturbance disorientation excitatory sign including shivering muscular twitching hypertension anxiety restlessness drowsiness

Ultimately generalized convulsion will occur After seizure activity ceases respiratory depression even arrest may occur

Central nervous system

bull Excitatory or Depressive bull At lower concentrations a relatively selective depression of

inhibitory neurons results in cerebral excitation which may lead to generalized convulsions

bull A profound depression of brain functions occurs at higher concentrations which may lead to coma respiratory arrest and death

Clinic presentation of local anesthesia toxicity

Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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• Slide 91

Clinical uses of local anesthetics

1000

400-500

Local anesthetics

1 Toxicity

2 HypersensitivityAllergy

Undesired effects

Side effects

Side effects

Local anesthetic toxicity

bull Concept Concentration of local anesthetic in blood

far exceeds the tolerance limitation of human body and cause adverse effects

Central nervous system and cardiovascular system are vulnerable

Toxicity may occur if The maximum safe dose is exceeded (overdose) Transient high blood levels are achieved by accidental intravenous

injection Rapid absorption from an inflamed or a highly vascular area Use normal dose to weak patients (Systemic pathology reduce the

tolerance) Continuous infusion or cumulative effects of multiple injection

Toxic reaction of local anesthetics

Maximum recommended doses

8 10

Central nervous system

Clinic presentation of local anesthesia toxicity

CNS is more susceptible to systemic action of local anesthetic than cardiovascular system (Dose 13)

Numbness or tingling of the tongue and circumoral area dizziness visual and auditory disturbance disorientation excitatory sign including shivering muscular twitching hypertension anxiety restlessness drowsiness

Ultimately generalized convulsion will occur After seizure activity ceases respiratory depression even arrest may occur

Central nervous system

bull Excitatory or Depressive bull At lower concentrations a relatively selective depression of

inhibitory neurons results in cerebral excitation which may lead to generalized convulsions

bull A profound depression of brain functions occurs at higher concentrations which may lead to coma respiratory arrest and death

Clinic presentation of local anesthesia toxicity

Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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1000

400-500

Local anesthetics

1 Toxicity

2 HypersensitivityAllergy

Undesired effects

Side effects

Side effects

Local anesthetic toxicity

bull Concept Concentration of local anesthetic in blood

far exceeds the tolerance limitation of human body and cause adverse effects

Central nervous system and cardiovascular system are vulnerable

Toxicity may occur if The maximum safe dose is exceeded (overdose) Transient high blood levels are achieved by accidental intravenous

injection Rapid absorption from an inflamed or a highly vascular area Use normal dose to weak patients (Systemic pathology reduce the

tolerance) Continuous infusion or cumulative effects of multiple injection

Toxic reaction of local anesthetics

Maximum recommended doses

8 10

Central nervous system

Clinic presentation of local anesthesia toxicity

CNS is more susceptible to systemic action of local anesthetic than cardiovascular system (Dose 13)

Numbness or tingling of the tongue and circumoral area dizziness visual and auditory disturbance disorientation excitatory sign including shivering muscular twitching hypertension anxiety restlessness drowsiness

Ultimately generalized convulsion will occur After seizure activity ceases respiratory depression even arrest may occur

Central nervous system

bull Excitatory or Depressive bull At lower concentrations a relatively selective depression of

inhibitory neurons results in cerebral excitation which may lead to generalized convulsions

bull A profound depression of brain functions occurs at higher concentrations which may lead to coma respiratory arrest and death

Clinic presentation of local anesthesia toxicity

Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Local anesthetics

1 Toxicity

2 HypersensitivityAllergy

Undesired effects

Side effects

Side effects

Local anesthetic toxicity

bull Concept Concentration of local anesthetic in blood

far exceeds the tolerance limitation of human body and cause adverse effects

Central nervous system and cardiovascular system are vulnerable

Toxicity may occur if The maximum safe dose is exceeded (overdose) Transient high blood levels are achieved by accidental intravenous

injection Rapid absorption from an inflamed or a highly vascular area Use normal dose to weak patients (Systemic pathology reduce the

tolerance) Continuous infusion or cumulative effects of multiple injection

Toxic reaction of local anesthetics

Maximum recommended doses

8 10

Central nervous system

Clinic presentation of local anesthesia toxicity

CNS is more susceptible to systemic action of local anesthetic than cardiovascular system (Dose 13)

Numbness or tingling of the tongue and circumoral area dizziness visual and auditory disturbance disorientation excitatory sign including shivering muscular twitching hypertension anxiety restlessness drowsiness

Ultimately generalized convulsion will occur After seizure activity ceases respiratory depression even arrest may occur

Central nervous system

bull Excitatory or Depressive bull At lower concentrations a relatively selective depression of

inhibitory neurons results in cerebral excitation which may lead to generalized convulsions

bull A profound depression of brain functions occurs at higher concentrations which may lead to coma respiratory arrest and death

Clinic presentation of local anesthesia toxicity

Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Local anesthetic toxicity

bull Concept Concentration of local anesthetic in blood

far exceeds the tolerance limitation of human body and cause adverse effects

Central nervous system and cardiovascular system are vulnerable

Toxicity may occur if The maximum safe dose is exceeded (overdose) Transient high blood levels are achieved by accidental intravenous

injection Rapid absorption from an inflamed or a highly vascular area Use normal dose to weak patients (Systemic pathology reduce the

tolerance) Continuous infusion or cumulative effects of multiple injection

Toxic reaction of local anesthetics

Maximum recommended doses

8 10

Central nervous system

Clinic presentation of local anesthesia toxicity

CNS is more susceptible to systemic action of local anesthetic than cardiovascular system (Dose 13)

Numbness or tingling of the tongue and circumoral area dizziness visual and auditory disturbance disorientation excitatory sign including shivering muscular twitching hypertension anxiety restlessness drowsiness

Ultimately generalized convulsion will occur After seizure activity ceases respiratory depression even arrest may occur

Central nervous system

bull Excitatory or Depressive bull At lower concentrations a relatively selective depression of

inhibitory neurons results in cerebral excitation which may lead to generalized convulsions

bull A profound depression of brain functions occurs at higher concentrations which may lead to coma respiratory arrest and death

Clinic presentation of local anesthesia toxicity

Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Toxicity may occur if The maximum safe dose is exceeded (overdose) Transient high blood levels are achieved by accidental intravenous

injection Rapid absorption from an inflamed or a highly vascular area Use normal dose to weak patients (Systemic pathology reduce the

tolerance) Continuous infusion or cumulative effects of multiple injection

Toxic reaction of local anesthetics

Maximum recommended doses

8 10

Central nervous system

Clinic presentation of local anesthesia toxicity

CNS is more susceptible to systemic action of local anesthetic than cardiovascular system (Dose 13)

Numbness or tingling of the tongue and circumoral area dizziness visual and auditory disturbance disorientation excitatory sign including shivering muscular twitching hypertension anxiety restlessness drowsiness

Ultimately generalized convulsion will occur After seizure activity ceases respiratory depression even arrest may occur

Central nervous system

bull Excitatory or Depressive bull At lower concentrations a relatively selective depression of

inhibitory neurons results in cerebral excitation which may lead to generalized convulsions

bull A profound depression of brain functions occurs at higher concentrations which may lead to coma respiratory arrest and death

Clinic presentation of local anesthesia toxicity

Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Maximum recommended doses

8 10

Central nervous system

Clinic presentation of local anesthesia toxicity

CNS is more susceptible to systemic action of local anesthetic than cardiovascular system (Dose 13)

Numbness or tingling of the tongue and circumoral area dizziness visual and auditory disturbance disorientation excitatory sign including shivering muscular twitching hypertension anxiety restlessness drowsiness

Ultimately generalized convulsion will occur After seizure activity ceases respiratory depression even arrest may occur

Central nervous system

bull Excitatory or Depressive bull At lower concentrations a relatively selective depression of

inhibitory neurons results in cerebral excitation which may lead to generalized convulsions

bull A profound depression of brain functions occurs at higher concentrations which may lead to coma respiratory arrest and death

Clinic presentation of local anesthesia toxicity

Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

• Slide 1
• Slide 2
• Slide 3
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Central nervous system

Clinic presentation of local anesthesia toxicity

CNS is more susceptible to systemic action of local anesthetic than cardiovascular system (Dose 13)

Numbness or tingling of the tongue and circumoral area dizziness visual and auditory disturbance disorientation excitatory sign including shivering muscular twitching hypertension anxiety restlessness drowsiness

Ultimately generalized convulsion will occur After seizure activity ceases respiratory depression even arrest may occur

Central nervous system

bull Excitatory or Depressive bull At lower concentrations a relatively selective depression of

inhibitory neurons results in cerebral excitation which may lead to generalized convulsions

bull A profound depression of brain functions occurs at higher concentrations which may lead to coma respiratory arrest and death

Clinic presentation of local anesthesia toxicity

Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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• Slide 89
• Slide 90
• Slide 91

Central nervous system

bull Excitatory or Depressive bull At lower concentrations a relatively selective depression of

inhibitory neurons results in cerebral excitation which may lead to generalized convulsions

bull A profound depression of brain functions occurs at higher concentrations which may lead to coma respiratory arrest and death

Clinic presentation of local anesthesia toxicity

Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Cardiovascular systembull Bradycardia or tachyarrhythmia bull Inhibit the myocardial sodium channel and cause negative

inotropic action reduction of CO ventricular arrhythmia even cardiac arrest

Clinic presentation of local anesthesia toxicity

Rapid fluid and some medications used for cardiovascular support (atropine ephedrine norepinephrine)

A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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A benzodiazepam premedication is recommended Do not exceed the maximum safe dose for the particular local anaesthetic used

choose suitable dose according to evaluation of patients and the blockage site

All injections should be given slowly and the dose should be fractionated Aspiration for blood and CSF should always be performed Use of a test dose Anaesthetic containing 1200000 adrenaline is advocated Correction of acidosis hyperthermia anemia and hypovolemia preoperatively

Prevention of toxicity

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

• Slide 1
• Slide 2
• Slide 3
• Slide 4
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• Slide 87
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• Slide 89
• Slide 90
• Slide 91

Treatment of toxicity

bull Stop injection or infusion local anesthetics immediatelybull ABC airway breathing circulation

Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Treatment of toxicity

bull Oxygenation and airway maintenance the airway is maintained and oxygen administered by face-mask using artificial ventilation if apnoea occurs

bull Control of convulsions with small increments of either Midazolam (1-4mg)or Propofol 80-100mg iv

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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• Slide 2
• Slide 3
• Slide 4
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• Slide 91

Treatment of toxicity

bull Circulatory support Respiratory assistance and sustaining the HR and blood pressure

Hypotension may need to be treated with vasopressor or inotropic drugs (Ephedrine in 6mg increments)

Arrhythmia must be managed and if cardiac arrest happened CPCR should be performed immediately

Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Allergic reactions are rare especially with amide local anesthetics Urticarial rashes are most

common but more serious responses also occur

Mild skin reactions are treated with antihistamines more serious reactions require

epinephrine

Hypersensitivityallergy

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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• Slide 2
• Slide 3
• Slide 4
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• Slide 91

Local anesthesia Methods

Local anesthesia

Surface anesthesia

Local infiltration anesthesia

Regional block

Nerve block

Epidural or spinal anesthesia

Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Nerve Block

Cervical plexus block

Brachial plexus block

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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• Slide 2
• Slide 3
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• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91

General introductionbull Traditional technique of nerve block is to localize

the neural structures usually by anatomy knowledge and elicited paresthesia

bull Development of nerve block

Nerve stimulator untrasound

bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
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bull Indication Surgical area consciousness and cooperation skill level of handler

bull ContraindicationInfection of the puncture area tumor serious

malformation on the puncture site allergy to local anesthetics Clinically significant coagulation disorder Personality disorders or mental illness the potential risk of respiratory emergency in case of pneumothorax or phrenic nerve block

Nerve Block

Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Cervical plexus blockIndication

Superficial and deep operations

in the region of neck and should

(thyroid operationcervical lymph node biopsy or excision)

bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
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bull ComplicationsSuperficial block rarely cause any complicationComplications are possible with deep cervical block The close proximity of needle to neural and vascular structures 1 Local anesthetic toxicity 2 Intrathecal injection (spinal or epidural anesthesia) 3 Phrenic nerve blockage 4 Laryngeal recurrent nerve blockage(hoarseness) 5 Honorrsquos syndrome 6 Hemorrhage of vertebral artery

Cervical plexus block

bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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bull Superficail cevical plexus block

1In the thyroid cartilage plane

2Along the posterior border of the sternocleidomastoid

10ml of local anestheticThe head turns toward the opposite side

Technique

Landmarks

bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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bull Deep cervical plexus block Draw a line connecting the tip of the mastoid process and clavicle middle the

middle of the line (The fourth cervical vertebra transverse process) The C-2 transverse process can be palpated 1 to 2 cm caudad to the mastoid process the thyroid cartilage Along the posterior border of the sternocleidomastoid C-4

transverse process insert a 22-gauge the needle perpendicular to the skin with

caudal angulation until it contacts the C-4 transverse process

After aspiration for CSF or blood 10ml of local anesthetic

Position the patient supine

Technique

Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Brachial plexus block

bull Anatomy of brachial plexus The brachial plexus are

sandwiched between the fascial sheaths of the anterior and middle scalene muscles

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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• Slide 2
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• Slide 91

bull Indication the areas of the upper extremity

bull Position the patient supine with the head turned slightly away from the side to be blocked

Brachial plexus block

1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
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1 ） Interscalene block

bull Technique Paresthesia seeking methodbull Advantage Upper armand shoulder blockage bull Shortage Difficult to block ulnar nerve hematoma spinal or epidural injection pneumothorax systemic local anesthetic toxicity phrenic nerve block sympathetic nerve block with development of Hornerrsquos

syndrome

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
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• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91

2 ） Axillary block

bull IndicationForearm hand and wrist surgerybull Position Abduct the arm at shoulder bull Pharmacologic choice High volume and low concentration 025Ropivacaine+1Lidocaine 30ml Analgesia last 4-6 hrs

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
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• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91

3 ） Supraclavicular block

INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

• Slide 1
• Slide 2
• Slide 3
• Slide 4
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INDICATIONS

The supraclavicular block provide anesthesia for any surgery on the upper extremity that does not involve the shoulder

1048766It is an excellent choice for elbow and hand surgery

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
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• Slide 90
• Slide 91

The most complication of a supraclavicular block is pneumothorax with rates quoted to be as high as 61

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
• Slide 10
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• Slide 80
• Slide 81
• Slide 82
• Slide 83
• Slide 84
• Slide 85
• Slide 86
• Slide 87
• Slide 88
• Slide 89
• Slide 90
• Slide 91

4 ） Infraclavicular block

Provide excellent coverage for surgery distal to the mid-humerus

Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Perioperative management of nerve block

Intravenous sedation titrated to patientrsquos comfort

The sedation requirements vary from patient-to-patient

small intermittent boluses of midazolam andor fentanyl

a propofol drip at 25-50 mcgkgmin

light general anesthesia

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

• Slide 1
• Slide 2
• Slide 3
• Slide 4
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• Slide 87
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• Slide 89
• Slide 90
• Slide 91

Case discussion

Female 54y Diagnosis humeral fracture Surgery Open reduction and internal fixation Anesthesia Interscalene block with 2 lidocaine 25ml with

epinephrine (1200000) Maneuver ldquoImmobile needlerdquo+careful aspiration

After 5 min patient notes numbness of the operative arm but starts to complain of increasing dyspnea

1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

• Slide 1
• Slide 2
• Slide 3
• Slide 4
• Slide 5
• Slide 6
• Slide 7
• Slide 8
• Slide 9
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1 What could be appropriate management

2 What are the most likely causes

What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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What could be appropriate management

1 Apply full monitoring ECG NIBP SPO2 2 Supplemental oxygen3 Preparation of general anesthesia induction tracheal

intubationLMAface mask controlled ventilation4 Vasoactive agent atropineephedrine5 Mental status assessed and ventilatory exchange

What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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What are the most likely causes

1 Spinal injection 2 Cervical epidural injection3 Phrenic nerve block4 Pneumothorax5 Anxiety

Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Spinal Epidural and Caudal Anesthesia

Contents

Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Epidural anaesthesia is a central neuraxial block technique with many applications The epidural space was first described by Corning in 1901 and Fidel Pages first used epidural anaesthesia in humans in 1921 In 1945 Tuohy introduced the needle which is still most commonly used for epidural anaesthesia

Both single injection and catheter continuous injection techniques can be used which means it can be used as an anaesthetic as an analgesic adjuvant to general anaesthesia and for postoperative analgesia

Introduction

Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Epidural Spinal and Caudal Anesthesia the local anaesthetics inject into epidural space CSF and caudal space block the nerve root in the epidural space or subarachnoid to produce regional paralysis

Definition

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop Adding appropriate amount of adrenaline to local anesthetics can slow down the absorption and extend the action time

Mechanism of action

Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Contraindications

Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Preparing For Anesthesia

Preoperative assessment of the patient is similar to that of general anesthesia

Giving a detailed explanation of the procedure such as the risks and benefits

Monitoring and intravenous access

Oxygen

Equipment for intubation and positive-pressure ventilation

Drugs to maintain hemodynamic steady

AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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AnatomySkin subcutaneous tissue supraspinous ligament interspinous ligament ligamentum flavum epidural space subarachnoid space spinal cord

Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Anatomy

Damage the spinal cord to induce paraplegia

Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Anatomy

The spinal needle is placed in this area

The spinal cord ends the position

Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Patient position of spinal or epidural anesthesia

In the lateral position the knees are drawn up toward the chest and the chin is flexed downward onto the chest to obtain maximal flexion of the spine

Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Approach

Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Confirm the needle position

Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Approach of epidural anesthesia1 Palpation of landmarks

2 Skin preparation disinfect a large area of skin with an antiseptic solution avoiding

contamination

3 draping

4 Check the stylet for correct fit within the needle

5 Local infiltration anesthesia with 1 lidocaine

Midliner to decrease risk of puncturing epidural veinsspinal arterites spinal nerve roots

Paramedian the patients who cannot adequately flex their back or the old patients

Paramedian

Midliner

Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Loss of resistance technique to confirm the needle position

Small careful advances of the epidural needle Avoid damaging the spinal cord to induce paraplegia

Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Distribution of spinal nerves

A knowledge of the sensory motor and autonomic distribution of spinal nerves

determine the correct segmental level required for a particular operation

anticipate the potential physiologic effects of producing a block to that level

prevent or decrease the complications

The distribution of spinal nerves

Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Determinants of level of spinal blockade

Major factorsBaricity of solution Hyperbaric hypobaric or isobaric in relation to the specific gravity of CSF (1004 to 1007gml)

Position of patients (except isobaric solution) Limit or increase the spread of these mixtures

Dose and volume of drug injected

The anesthetic level varies directly with the dose of the agent used

The greater the volume of the injected drug the further the drug will spread within the CSF especially applicable to hyperbaric solutions

Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Determinants of level of spinal blockade

Minor factorsLevel of injection

Speed of drug injection1ml5s

Size of needle

Physical status of patients

Intra-abdominal pressure

Interspace of penetration

Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Determinants of duration of spinal blockade

Drug used

The duration is specific for each drug

The addition of opioids to the injected solution can modify the character of the block

hydrophilic opioids (morphine) slow in onset and long in duration delayed respiratory depression

lipophilic opioids (fentanyl) onset is fast and duration is moderate less risk of delayed respiratory depression

Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Determinants of duration of spinal blockade

Vasoconstrictors

The addition of epinephrine 02mg (02ml of 11000) or phenylephrine 2 to 5 mg can prolong the duration of some spinal anesthetics by up to 50

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

Epidural anesthesia required dose of 5 ~ 10 times larger than subarachnoid gap anesthesia (A small dose and volume of local anesthetic) such as the local anaesthetic was injected into subarachnoid gap carelessly can cause systemic spinal anesthesia induce breath and heartbeat stop

Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Injection of local anesthetic

agent in epidural anesthesia

A test dose of local anesthetic agent

A test dose of local anesthetic agent usually consists of 3 ml 2 lidocaine

The test dose has little effect in the epidural space

The test dose has been injected into the CSF a spinal block will occur rapidly

If the test dose has been injected into an epidural vein a 20 to 30 increase in heart rate may be seen

Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Injection of local anesthetic

agent in epidural anesthesia

Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Complications of spinal anesthesia

Direct nerve injury

relate to the needle or catheter placement

Pain is a warning sign for potential nerve injury

To requires repositioning of the needle or catheter

Transient paresthesias are often without any long- term sequelae

Neurologic

Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Transient neurologic syndrome

is a spontaneous severe radicular pain that is evident after resolution of the spinal anesthetic and may last for 2 to 7 days The incidence is highest with lidocaine tetracainebupivacaine

Neurologic

Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Neurologic

Bloody tap

puncture of an epidural vein during needle insertion may result in either blood or a mixture of blood and CSF emerging from the spinal needle If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Neurologic

Spinal hematoma usually present within 48 h Clinical symptoms

severe back pain

persistent neurologoc deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Neurologic

Spinal hematoma

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Postdural puncture headache

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

Spinal headache is frontal and occipital in distribution

visual disturbanceshearing impairment

Risks younger age and female gender

The incidence may be reduce by using smaller needles and noncutting needles (pencil-point)

Treatments rehydrationsupine positionpain medication

Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Cardiovascular Hypotension Bradycardia

Hypotension

treatment IV administration of 500 to 1000ml of Ringer lactate solution before performing the spinal anesthesia

treatment increasing venous return treating severe bradycardiaephedrine or phenylephrineoxygen

risk Patients with decreased cardiac function could produce volume overload and pulmonary edema require care in administering large volumes of IV fluid

Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Bradycardia

Treatment atropine 025 05 mg IV

If bradycardia is severe and accompanied by hypotension ephedrineepinephrine may be injected

Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Dyspnea is a common complaint with high spinal levels

proprioceptive blockade of afferent fibers from abdominal and chest wall muscles

Treatment reassuringensure adequate ventilation oxygen

Apnea direct blockade of C-3 TO C-5

Total spinal anesthesia

Treatment Immediate ventilatory support is required

Respiratory

Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Prolonged the sensory and motor blockade

place urinary catheter

Urinary retention

Nausea and vomitingHypotension or unopposed vagal stimulation

Treatment involves

restore the blood pressure

IV atropine

ephedrine

administering oxygen

Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Complications of epidural anesthesia

Dural puncture

About 1 of epidural catheter placementsepidural needle

Developing within 3 days 70 of headaches resolve within 7 days 90 within 6 months The headache is exacerbated by upright posture and relieved by lying down

visual disturbanceshearing impairment

Postdural puncture headache is higher than spinal anesthesia

Treatments rehydrationsupine positionpain medication

Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Risk is higher among patients who are anticoagulated

Blood taps are not thought to cause a spinal hematoma in patients with normal coagulation

Bloody tap

Puncture of an epidural vein during needle insertion may result in blood fluid If the fluid dose not rapidly clear the needle should be withdrawn and reinserted

Close postoperative monitoring for signs consistent with hematoma is warranted

Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Unintentional subarachnoid injectionLarge volume of local anesthetic into subarachnoid space

total spinal anesthesia

convulsion

cardiopulmonary arrest

CPCR

Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Local anesthetic overdoseInadvertent intravascular injection

Epinephrine decreases the incidence of toxicity by decreasing the rate of absorption of the local anesthetic

Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Direct spinal cord injury paraplegiaThe epidural injection is above L-2

Unilateral paresthesia during needle insertion suggests entry into the epidural space

Further injection or insertion of a catheter at this point may produce trauma to a nerve root

Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Epidural hematoma extremely rare

severe back pain

persistent neurologic deficit

Risk is higher among patients who are coagulopathy or anticoagulated

Blood taps are not thought to cause a epidural hematoma in patients with normal coagulation

Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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Close postoperative monitoring for signs consistent with hematoma is warranted

Diagnosis is made with magnetic resonance imaging

Treatment is via emergent hematoma evacuation

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