aditi panditrao's spinal & epidural anaesthesia ug
DESCRIPTION
Dr. Aditi discusses in detail various aspects of neuraxial blocks, spinal and epidual, with methods, complications, with beautiful graphics, figures and diagrams.TRANSCRIPT
Spinal & Epidural Anaesthesia
Dr. Aditi Mridul Panditrao
Junior Resident
Department of Anaesthesiology &
Intensive care
PDVVPF’S Medical College,
Viladghat, Ahmednagar
India
Neuraxial Anaesthesia
o Type of regional anaesthesia.
o Definition:
Anaesthesia affecting only a part of the body.
• Central
• Peripheral
o Neuraxial – central technique
o Neuraxial Anaesthesia:
• Spinal
• Epidural
Why???
o Cheap, feasible for patient
o General anaesthesia is not without faults
o Cannot be used in severe COPD, certain Nervous disorders, laryngeal problems, hypersensitivity, etc.
o May cause trauma to oropharynx, larynx, malignant hyperthermia, myocardial depression, hepatotoxicity, nephrotoxicity, teratogenicity, etc.
o Regional – no direct effect on Brain, viscera, lungs, heart.
History
o August Bier – 16th August, 1898
o J. Leonard Corning??
o Quincke – Lumbar Puncture
o Scleich – Infilteration Anaesthesia
o Oberst – Cocaine in regional block
Spinal Anaesthesia
o Sub-Arachnoid Block
o 1898 – Augustus Karl Gustav Bier
o Small amounts of local anaesthetics injected in the lower part of the spinal cord to achieve regional analgesia, without loss of consciousness
o Anaesthesia?? No…analgesia
Anatomy
Where do we give the block??
Structures crossed during Spinal:
o Skin
o Subcutaneous tissue
o Supraspinous ligament
o Interspinous ligament
o Ligamentum Flavum
o Epidural Space
o Dura
Needles
o Quincke, Whitacre, Sprotte, Gertie Marx
o Bore of the needle – important
o Earlier – 22, 20, 18 ---- Complications
o Now – 30, 27, 26, 25
o Bevelled tip – cut the fibres, smaller hole
o Parts –
o Tip
o Body
o Hub
o Stylet
Procedure
o Position
o Sitting
o Lateral
o Painting And Draping
o Identify Space
o Local Anaesthetic
o Introduce Spinal Needle
o Free CSF flow
o Syringe containing drug – aspirate, inject
o Make patient Supine
Mechanism of Action
o Blockade of sympathetic nervous system
o Sensory affected earlier than motor
o Pain, touch, temperature, vibration fibres
o Pain – First: A ð
Then: C
o Motor – last to be affected
o Baricity
o No sedation
o Hypotension, Visceral vasoconstriction, peripheral pooling of blood
Indications
o Operations below the umbilicus : lower abdominal, hernia repairs , gynaecological and urological operations
o Lower extremity operations, except amputations
o Especially beneficial in those with severe respiratory problems, hepatic & renal disorders
o Diabetes Mellitus
o Anatomical abnormalities of oropharynx
Contra-indications
o Patient refusal, unco-operative patient
o Bleeding diathesis
o Hypovolemia
o Infection – local, generalised
o Stenosing conditions
o Increased ICP
o Spinal deformities
o Demyelinating disorders, neurological deficit
Advantages
o Complete anaesthesia with just one injection
o Cost – effective
o Alternative for GA in difficult airway, respiratory disorders
o Patients who are not NBM
o Surgeries with expected blood loss
o Thrombosis, embolization less
o Diabetics
o Early reversal
Complications
o On table – hypotension, aortocaval compression
o Post-dural puncture headache
o 6th Cranial Nerve Palsy (Abducent)
o Infection – local, meningitis arachnoiditis, peridural abcess
o Meningism – meningeal inflammation without infection
o Cauda equina syndrome
o Urinary retention
o Nausea-vomiting
o Backache
Epidural Anaesthesia
o 1921 – Fidel Pages
o In the epidural space, outside the dura.
o Potential space – fat, nerves in their dural cuffs, epidural venous plexuses
o Negative pressure
o Act on the nerve roots through dural cuffs, paravertebral spaces, diffusion in CSF
o Continuous block possible
Needle
o Epidural Kit:
o Tuohy Needle – 17G, 18G (Huber point)
o Epidural Catheter
o Loss of resistance syringe
o Catheter connecter
o Epidural Filter
o Sterile Syringe
o Epidural needle has larger bore – identify epidural space easily
o Patient has to be in sitting position
Procedure
o Sitting Position
o Painting and Draping
o Local Anaesthesia
o Introduce needle upto Supraspinatus
o Identify Epidural Space:
o Loss of resistance method
o Hanging drop method
o Introduce catheter
o Clean the wound
Uses
o Labor analgesia
o Surgeries like, C-section, Total hip replacement
o Post-op analgesia
o Crush injury to chest
o Peripheral Vascular Disease
o Palliative for Chronic & Visceral pain
o Single shot steroid inj for spondylosis or Prolapsed intervertebral disc
Sr.No.
Spinal Anaesthesia Epidural Anaesthesia
1Level: below L1/L2, where the spinal cord ends
Level: at any level of the vertebral column
2Injection: subarachnoid space i.e punture of the dura mater
Injection: epidural space i.e without punture of the dura mater
3Single shot procedure Continuous analgesia can be
provided by indwelling catheter
4Doses: 2.5- 3.5 ml bupivacaine 0.5% heavy
Doses: 15- 20 ml bupivacaine 0.5%heavy
5Onset of action: rapid (2-5 min) Onset of action: slow (15-20 min)
6Density of block: more denseMore muscle relaxation
Density of block: less dense
7Hypotension: rapid Hypotension: slow
8Headache may be a post-op complication
Not a probable complication
9Finite procedure, short surgeries Longer surgeries, surgeries with
complications
Combined Spinal-Epidural
o Epidural block takes 15 minutes to act, does not have good muscle relaxation
o May be done in the same intervertebral space using combipack, or different spaces
o Usually, spinal is given one or two spaces below
o Widely used in C-sections, trauma, orthopedic cases, etc.
Complications of Epidural
o Accidental puncture of dura
o Hematoma
o Extradural abcess
o Urinary retention
o Hypotension
o Nausea - vomiting
o Backache
Thank You!