neuroaxial anesthesia dr. m othman

7/18/2019 Neuroaxial Anesthesia Dr. M Othman

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Neuroaxial Anesthesia:Neuroaxial Anesthesia:An overview.An overview.

Dr. Mahmoud Othman MD,Dr. Mahmoud Othman MD,

Professor Of Anesthesia and SICU,Professor Of Anesthesia and SICU,

Deart. of Anesthesia and SICU,Deart. of Anesthesia and SICU,

Mansoura !a"ult# Of Medi"ineMansoura !a"ult# Of Medi"ine

The Advantages of Neuroaxial Anaesthesia:

1.Cost..

2.Patient satisfaction.

3.Respiratory disease.

.Patent air!ay.

".#ia$etic patients.

%.&uscle relaxation.

'.(leeding.

).*planchnic $lood flo!.

+.,isceral tone.

1-.Coagulation.

**Ph#siolo$#Ph#siolo$#: ………..: ………..

--Sensor# %lo"&Sensor# %lo"& . ……………………………. …. … . ……………………………. …. …--Motor 'lo"&Motor 'lo"&………………………………………………………………………………………………--Autonomi" %lo"&Autonomi" %lo"&……………………………….…… ….……………………………….…… ….

**Anatom#Anatom#: …….. ……………..: …….. ……………..

**Pharma"olo$#Pharma"olo$#: ….. ………..: ….. ………..…………………………

Today: PNS & spinal

Tomorrow: CNS

Nervous system

Peripheral nervous syste/PN*0: nerves outside brain

and s.c.

Central nervoussyste /CN*0: brain &

spinal cord

*oatic N*: nervesgoing rom sense

organs to CNS & rom

CNS to muscles &

glands

Autonoic N*: controls !eart" blood

vesseles"intestines"

ot!er organs

*ypathetic N*: or

vigerous activity

#ig!t or lig!t$

Parasypathetic

N*: vegetative"

nonemergency

responses

Periheral NSPeriheral NS

Somati" NSSomati" NS ::(Sense or$ansSense or$ans CNSCNS mus"les andmus"les and

$lands$landsSomethin$ tou"hes le$Somethin$ tou"hes le$ messa$e to 'rainmessa$e to 'rain

messa$e from 'rain to arm mus"lemessa$e from 'rain to arm mus"le 'rush thin$ o) le$'rush thin$ o) le$

Sensor# stimulation Motor resonse

!ttp:%%www.carleton.ca%ics%courses%cgsc''(%img%')%neuron.pg !ttp:%%!ome.eart!lin+.net%,dayvdanls

%/012C.34/

Ph#siolo$#

!ttp:%%www.unm.edu%,immy%spinal5neurons.pg

Bell-Magendie law:

The entering dorsal

roots carry sensory

information to the

the exitingventral roots

carry motor

information to

the muscles andglands

In other words:

Dorsal=sensory

entral=motor

Dorsal root

(sensory in)

Ventral root

(motor out)

rostral

The Spinal Cord *he Sinal Cord *he Sinal Cord

/igure 6.7" p89 !ttp:%%www.bcs.roc!ester.edu%,dlee%bcs96%spinal5cord.pg

now above terms #or let igure$ ; terms circled in red or rig!t igure<<

To be clear" =3: collections o cell bodies o sensory neurons> cell

bodies o motor neurons are wit!in SC

Autonomi" NSAutonomi" NS::(S#matheti" NSS#matheti" NS: axons a"tivate or$ans: axons a"tivate or$ans

for +$ht or -i$htfor +$ht or -i$ht??

( # # *hora"olum'er out-ow *hora"olum'er out-ow$ :$ :T( toT( to

S#matheti" $an$lia are "losel# lin&ed andS#matheti" $an$lia are "losel# lin&ed anda"t +in s#math#/ with ea"h othera"t +in s#math#/ with ea"h other

Short 0on$

!acilitates energy

ex"enditureBehaviors#

$hysiology#

!ibers %short "re

long "ost 'T#(

Autonomi" NSAutonomi" NS :: (Paras#matheti" NSParas#matheti" NS: fa"ilitate: fa"ilitate

ve$etative, nonemer$en"# fun"tionsve$etative, nonemer$en"# fun"tions

Para means +'eside/ or +related to/1 oositePara means +'eside/ or +related to/1 oositea"tion of s#matheti" NSa"tion of s#matheti" NS

##Cranio sa"ral out-owCranio sa"ral out-ow$ :$ :Cr(-(9 & S9-6Cr(-(9 & S9-6

"onsists of "ranial nerves and nerves of"onsists of "ranial nerves and nerves of

sa"ral SCsa"ral SC

lon$ re$an$. shortost$an$.

!acilitates energy

conservation

Behaviors#

$hysiology#

!ibers %long "re

short "ost 'T#(

NeurotransmittersNeurotransmitters

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/ew eAceptions:

sweat glandsstimulated by 2c!.

B!y does t!at matter =rugs<< DTC cold meds bloc+ parasymp or increase symp

activity b%c low o sinus luids is parasympat!etic. Side eect: in! salivation & digestionand inc E

Sinal anesthesiaSinal anesthesia

Sinal nervesSinal nerves

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web%Courses%=EFF69%images%spin5nerves.GP3

eHuina

M#elin SheathM#elin Sheath::

*#es of Nerve !i'ers *#es of Nerve !i'ers::

Physiology of neuroaxial $locagePhysiology of neuroaxial $locage

11..one of differential $locone of differential $loc::

level $loc /sypathetic sensory oter 0level $loc /sypathetic sensory oter 0

22..nervous systenervous syste *odiu channel $loc :*odiu channel $loc : nerve root 4spinal cordnerve root 4spinal cord

33..cardiovascular systecardiovascular syste

Autonoic denervationAutonoic denervation

vasodilatationvasodilatation

decrease venousdecrease venous

returnreturn

decrease C5decrease C5

hypotensionhypotension

#ecrease 6R#ecrease 6R

..respiratory systerespiratory syste

""..78 syste78 syste parasypatheticparasypathetic

increase $o!el oveincrease $o!el ove

rupture of distened $o!elrupture of distened $o!el

%%..9iver and idney9iver and idney ..

0um'er 2erte'rae Anatom#0um'er 2erte'rae Anatom#

Sinal Cord *erminalSinal Cord *erminal

T!e spinal cord usually ends at the level of 91in adults and 93 in children.

=ural puncture above t!ese levels is

associated wit! a slig!t ris of daaging the

spinal cord and is best avoided.

An iportant landar to ree$er is that a

line oining the top of the iliac crests is at9 to 9;"

0o"al Anesthesti"0o"al Anesthesti"::

) substance which reversibly inhibits nerve) substance which reversibly inhibits nerve

conduction when a""lied directly to tissues at non-conduction when a""lied directly to tissues at non-

toxic concentrationstoxic concentrations

*ocal )nesthetics- +istory*ocal )nesthetics- +istory

,./ - cocaine isolated from,./ - cocaine isolated from erythroxylum cocaerythroxylum coca

0 1oller - ,2 uses cocaine for to"ical anesthesia1oller - ,2 uses cocaine for to"ical anesthesia

0 +alsted - ,3 "erforms "eri"heral nerve bloc4 with+alsted - ,3 "erforms "eri"heral nerve bloc4 withlocallocal

0 Bier - ,55 first s"inal anestheticBier - ,55 first s"inal anesthetic

*ocal anesthetics - Mechanism*ocal anesthetics - Mechanism

*imit influx of sodium thereby limiting "ro"agation of*imit influx of sodium thereby limiting "ro"agation ofthe action "otential6the action "otential6

Iec!anism o actionIec!anism o action

0ocal anest!etics bloc+ generation"0ocal anest!etics bloc+ generation"

propagation" and oscillations o electricalpropagation" and oscillations o electrical

impulses in electrically eAcitable tissue.impulses in electrically eAcitable tissue.

Mainl# '# a"tin$ on SodiumMainl# '# a"tin$ on Sodium

"hannels."hannels.

<sters

*ocal )nesthetics - 7lasses*ocal )nesthetics - 7lasses

<sters

PE2I2CD0D3J 2N=PE2I2CD0D3J 2N=

PE2I2CD=JN2I4CSPE2I2CD=JN2I4CSKK Clinically used local anest!etics consist o lipid-Clinically used local anest!etics consist o lipid-

soluble" substituted benLene ring lin+ed tosoluble" substituted benLene ring lin+ed to

amine group via al+yl c!ain containing eit!er anamine group via al+yl c!ain containing eit!er an

amideamide oror ester ester lin+age.lin+age.

KK Type o lin+age separates local anest!etics intoType o lin+age separates local anest!etics into

eit!ereit!er aminoamidesaminoamides #metaboliLed in liver$#metaboliLed in liver$ oror

aminoestersaminoesters #metaboliLed in liver or by plasma#metaboliLed in liver or by plasma

c!olinesterase$.c!olinesterase$.

*ocal anesthetics - 7lasses %8ule of 9is;(*ocal anesthetics - 7lasses %8ule of 9is;(

<sters<sters 7ocaine7ocaine

7hloro"rocaine7hloro"rocaine

$rocaine$rocaine

TetracaineTetracaine

)m;i;des)m;i;des

Bu"Bu"iivacainevacaine

**iidocainedocaine

8o"8o"iivacainevacaine

<t<tiidocainedocaine

Me"Me"iivacainevacaine

Cinchocaine #Nupercaine" =ibucaine"Procaine" Sovcaine$. '.M !yperbaric #!eavy$

solution is similar to bupivacaine.

Aethocaine #Tetracaine" Pantocaine"

Pontocaine" =ecicain" @utet!anol" 2net!aine"=i+ain$. 2 (M solution can be prepared wit!

deAtrose" saline or water or inection.

&epivacaine #Scandicaine" Carbocaine"

Ieaverin$. 2 6M !yperbaric #!eavy$ solution

is similar to lignocaine.

(upivacaine /&arcaine0. '.M !yperbaric#!eavy$ bupivacaine is t!e best agent to use iit is available. -."= plain $upivacaine isalso popular . @upivacaine lasts longer t!an

most ot!er spinal anaest!etics: usually 2>3hours.

9ignocaine /9idocaine;?ylocaine0. @est

results are obtained wit! M !yperbaric

#!eavy$ lignocaine w!ic! lasts 6-' minutes.

9ocal Anaesthetics for *pinal Anaesthesia.

0ocal anaest!etic agents are eit!er !eavier

#!yperbaric$" lig!ter #!ypobaric$" or !ave t!e

same speciic gravity #isobaric$ as t!e CS/.

Eyperbaric solutions tend to spread below t!e

level o t!e inection" w!ile isobaric solutionsare not inluenced in t!is way. 4t is easier to

predict t!e spread o spinal anaest!esia w!en

using a !yperbaric agent.

Eypobaric agents are not generally available.

2==4T4OS TD 0DC20 2==4T4OS TD 0DC20

2NSTET4CS 2NSTET4CS

#($pinep!rine#($pinep!rine ::

KK pinep!rine added to local anest!etic maypinep!rine added to local anest!etic may prolong bloc+ prolong bloc+

increase intensity o bloc+ increase intensity o bloc+

decrease systemic absorption decrease systemic absorptionKK pinep!rine analgesia may act via interactionpinep!rine analgesia may act via interaction

wit! 9-adrenergic receptors in spinal cord andwit! 9-adrenergic receptors in spinal cord and

brainbrain

Addatives to sinal anesthesiaAddatives to sinal anesthesia

3Cont.43Cont.4

##99$$Anal$esi"sAnal$esi"s:: ……

AOioids : .. .. . 5.. As : 6!entan#l

9-Colinidine

%Nonoioids: 5555 As : 6

*ramadol 7Mida8olam

Advanta$esAdvanta$es ::

--"ost"ost. …………………………………... …………………………………..--Patient Satsifa"tionPatient Satsifa"tion……………………………………--9esirator# Diseases9esirator# Diseases. ………………. ………………--Dia'eti" PatientsDia'eti" Patients…………………………………………--Mus"le 9elaxationMus"le 9elaxation………………….………………….--Sur$i"al %leedin$Sur$i"al %leedin$…………………………………… --2is"eral *one2is"eral *one. ………………………... ………………………..--Coa$ulation3D2*, P4Coa$ulation3D2*, P4………………….………………….

8ndications8ndications forfor Neuroaxial Neuroaxial AnaesthesiaAnaesthesia::

AA-- Spinal anaest!esiaSpinal anaest!esia isis $est reserved$est reserved for for operations $elo! the u$ilicusoperations $elo! the u$ilicus e.ge.g. !ernia repairs. !ernia repairs ""

gynaecologicalgynaecological andand urologicalurological oper oper

ations and any operation on t!e perineumations and any operation on t!e perineum or genitor genit

aliaalia..

((- Spinal anest!esia applied or- Spinal anest!esia applied or All operations onAll operations on

the legthe legss /orthopedic>,ascular0/orthopedic>,ascular0 butbut anan

aputationaputation "" t!oug!t!oug! painless" may be anpainless" may be an unpleasunpleas

ant experience for an a!ae patientant experience for an a!ae patient..

C >C > 55lder patientslder patients andand t!oset!ose wit!wit! systemicsystemic

C C 5 5lder patientslder patients andand t!oset!ose wit!wit! systemicsystemic

diseasedisease suc! as c!ronic respiratory disease" !epatic" resuc! as c!ronic respiratory disease" !epatic" re

nal and endocrine disorders suc! as diabetesnal and endocrine disorders suc! as diabetes..

##-- 4t is suitable or managing patients wit!4t is suitable or managing patients wit! trauatraua i t!eyi t!ey

!ave been adeHuately resuscitated and!ave been adeHuately resuscitated and are notare not

!ypovolaemic!ypovolaemic..

<<-- 4n4n o$stetricso$stetrics" it is ideal or manual" it is ideal or manual reoval ofreoval of aa

retained placentaretained placenta #again" provided t!ere is no !ypovola#again" provided t!ere is no !ypovola

emia$.emia$. 2lso spinal anest!esia is best c!oice or 2lso spinal anest!esia is best c!oice or

casearan sectioncasearan section andand instrumental dliveryinstrumental dlivery T!ere are deiT!ere are dei

nite advantages or bot! mot!er and babynite advantages or bot! mot!er and baby inincomparison to general anest!esiacomparison to general anest!esia

Preoerative 2isitPreoerative 2isit::

Indi"ations of sinal anesthesiaIndi"ations of sinal anesthesia ::

--;eneral sur$er#;eneral sur$er# … … ….… … ….

--Orthoedi" sur$er#Orthoedi" sur$er#……………………… …….……………………… …….

--;#na"olo$i"al sur$er#;#na"olo$i"al sur$er#…………………… ………………………… ……

--O'estatri" sur$er#O'estatri" sur$er#……………………………….……………………………….--Urolo$i"al sur$er#Urolo$i"al sur$er#……………………. ……………………………. ………

--2as"ular sur$er#2as"ular sur$er#……………………………….……………………………….

Medi"al xaminationMedi"al xamination::

0a'orator# Investi$ations0a'orator# Investi$ations::

Intravenous Preloadin$Intravenous Preloadin$::

i di i f i l

Contraindi"tions Of NeuroaxialContraindi"tions Of Neuroaxial

AnesthesiaAnesthesia::..Inada<uat 9esus"itation !a"ilitiesInada<uat 9esus"itation !a"ilities. …. …

=#ovolaemia=#ovolaemia…………………… ………………………… ……

..Patient 9efusalPatient 9efusal………………………………………………

..seti"aemiaseti"aemia…………………… ..…………………… ..

..0o"al infe"tion0o"al infe"tion……………………………………

..Neurolo$i"al DiseasesNeurolo$i"al Diseases . . …. . …

--Coa$ulation Defe"tsCoa$ulation Defe"ts………………………….…………………………...Infants and "hildern3exert anesthetist4Infants and "hildern3exert anesthetist4

……

A$solute contraindicationA$solute contraindicationss::

11.. sepsissepsis

22.. $actereia$actereia

33.. sin infection at inection sitesin infection at inection site .. severe hypovoleiasevere hypovoleia

"".. coagulopathycoagulopathy

%%..increase intracranial pressureincrease intracranial pressure

''..lac of consentlac of consent

Relative contraindicationRelative contraindicationss::

11..peripheral neuropathyperipheral neuropathy..22..uncooperative patientsuncooperative patients

33..psychosispsychosis or eotional insta$ilityor eotional insta$ility..

..&ini dose heparin&ini dose heparin ..

""..aspirin or antiaspirin or anticoagulantcoagulant drugdrug ..%%..deyelating CN*deyelating CN* ..

''..certain cardiac lesionscertain cardiac lesions /valve/valve stenosisstenosis00..

)).. prolongprolongeded surgerysurgery..

++..surgery of uncertain durationsurgery of uncertain duration 1-1-@@.@@.infants and young childern /experience0infants and young childern /experience0..

Pre>operative ,isit.

Patients s!ould be told a$out their

anaesthetic during the pre>operative visit.

4t is important to eAplain t!at alt!oug! spinal

anaest!esia abolis!es pain" t!ey may be

a!are of soe sensation in t!e relevantarea" but it will not be uncomortable and is

Huite normal.

T!ey must be reassured t!at" i t!ey feel pain

they !ill $e given a general anaesthetic.

Preedication is not al!ays necessary4 $utif a patient is apprehensive4

a $enodiaepine such as ">1- g ofdiaepa ay $e given orally 1 hour

$efore the operation.

5ther sedative or narcotic agents ay also$e used. Anticholinergics such as atropine

or scopolaine /hyoscine0 are

unnecessary

Preparation for 9u$ar Puncture.:

( . spinal needle.

9 . 8ntroducer

F . "l syringe or t!e spinal anaest!etic solution.

6 . 2 l syringe or local anaest!etic to be used or s+in

iniltration.

. selection of needles or drawing up t!e local

anaest!etic solutions and or iniltrating t!e s+in.

) . gallipot wit! a suitable antiseptic or cleaning t!e

s+in" eg c!lor!eAidine" iodine" or met!yl alco!ol.

' . *terile gaue swabs or s+in cleansing.

8 . sticing plaster to cover t!e puncture site.

T!e local anaest!etic to be inected intrat!ecally s!ouldbe in a single use ampoule.

Never use local anaesthetic fro a ulti>dose vialfor intrathecal inection.

Pre>loading.

All patients !aving spinal anaest!esia must !ave a

large intravenous cannula inserted and be givenintravenous luids immediately $efore the spinal.

T!e volume o luid given will vary !ith the age of the

patient and the extent of the proposed $loc. 2

young" it man !aving a !ernia repair may only need'' mls. Dlder patients are not able to compensate

as eiciently as t!e young or spinal-induced

vasodilation and !ypotension and may need ('''mls

or a similar procedure. 8f a high $loc is planned4at least a 1---ls should $e given to all patients.

Caesarean section patients need at least 1"--

-T!e luid s!ould preerably be noral saline or6artanns solution.

-Colloids li+e !etasrac!" deAtran" can be used.

>"= dextrose is readily metabolised and so is noteffective in maintaining t!e blood pressure.

COsinal !luidthra#

PositionPosition

11..9ateral / 9t lateral 09ateral / 9t lateral 0

22..*itting*itting

33..ProneProne

Postionin$ Of PatientPostionin$ Of Patient

The sitting position is prefera$le in the o$ese

w!ereas t!e lateral is better or uncooperative or

sedated patients.

Iales tend to !ave wider s!oulders t!an !ips and so

are in a slig!t Q!ead upQ position w!en lying on t!eir

sides" w!ilst or emales wit! t!eir wider !ips" t!e

opposite is true.

approachapproach

11..edian approachedian approach

22..paraedian approachparaedian approach

Sinal *e"hni<ueSinal *e"hni<ue::

Anatoy.

The sin.

*u$cutaneous fat..

The supraspinous ligaent

The interspinous ligaent

The ligaentu flavu

The epidural space

The dura. sac.

The su$arachnoid space.

0a#ers to 'e ier"ed0a#ers to 'e ier"ed::

(-S&in :

9-S"tissues :

F-Su Sin0i$:

6-Inter Sin0i$

-0i$ !lavum:

)-idural S.

7-Dura Matter

8-Ara"henoid:

Continuous

sinal anesthesia

Assessing the (loc.

(. t!e patient is unable to lit !is legs rom t!e bed" t!e

bloc+ is at least up to t!e mid-lumbar region.9. 4t is unnecessary to test sensation wit! a s!arp

needle

F. 4t is better to test or a loss o temperature sensation

using a swab soa+ed in eit!er et!er or alco!ol.

6. t!e patient can be gently pinc!ed wit! artery orceps

or ingers on bloc+ed and unbloc+ed segments

. Surgeons and patients s!ould be reminded t!at w!en

a bloc+ is successul" a patient may still be aware o

touc! but will not eel pain.

Assessin$ Of SinalAssessin$ Of Sinal

AnesthesiaAnesthesia**-S. $r.3CS!4

>6.??@6.??

**-S.$ravit#5.3'uiva"aine4

?.B3heav#4>6.?7……..

**-S.$ravit#..53'uiva"aine4

'.M#iso'ari"$

R(.'')………

!a"tors A)e"tin$ Sread Of!a"tors A)e"tin$ Sread Of

0o"al Anestheti"0o"al Anestheti"::

((--%ari"it#1 3heav#Iso'ari"4%ari"it#1 3heav#Iso'ari"4…..………….…..………….

99--PositionPosition……………………………. .. .……………………………. .. .FF--2olume ine"ted2olume ine"ted………… .. . ….………… .. . ….

66--0evel of Ine"tion0evel of Ine"tion……""" ……….……….……""" ……….……….--Con"entration Of lo"al anesthCon"entration Of lo"al anesth. … … .. … … .))--Seed Of ine"tionSeed Of ine"tion…….. . ... ….…….. . ... ….

77--A'domial ressure53asitesA'domial ressure53asitesre$nan"#tumours4re$nan"#tumours4 ..

In the horiontal su"ine "osition hy"erbaric local anesthetic solutions

in>ected at the height of the lumbar lordosis %circle( flow down thelumbar lordosis to "ool in the sacrum and in the thoracic 4y"hosis6

$ooling in the thoracic 4y"hosis is thought to ex"lain the fact that

hy"erbaric solutions "roduce bloc4s with an average height of T2-.6

pinal ane the ia: level and duration of

duration

uration

44 T1010 T44

Heavy(

eavy(0.50.5% )

bupivacaine

upivacaine

6-86-8

8-(98-(9gg (6-9'(6-9'gg '-((''-(('

! obaric( obaric(

0.50.5%

) bupivacaine

bupivacaine

('('--(9(9gg

(9(9--((gg

(-9'(-9' gg

(8'(8' inin

Bactors Affecting the *pread of the 9ocalAnaesthetic *olution.

•1> The $aricity of the local anaesthetic

solution

•2> position

•3> #osage 4 concentration

•> volue inected

•"> the level of inection

•%> *peed of inection

•'> A$doinal pressure.

Pro'lems Eith Sinal %lo"&Pro'lems Eith Sinal %lo"&::

((--NO 'lo"& at allNO 'lo"& at all…………………… .. ..…………………… .. ..

99--%lo"& is one sided%lo"& is one sided………… … ……. …………… … ……. …

FF--%lo"& is not hi$h enou$h%lo"& is not hi$h enou$h…… … ….…… … ….

66--%lo"& is too hi$h%lo"& is too hi$h…………………………..…………………………..--Nausea F2omitin$Nausea F2omitin$…………… . ….. ......…………… . ….. ......

))--Shiverin$Shiverin$………………………… ….. .………………………… ….. .

&onitoring.

4t is essential to monitor

10 Pulse

20 (lood pressure 30 Respiration

0 Consiosness

Monitorin$Monitorin$::

((--C; tra"eC; tra"e……………. .……………. .

99--=eart rate=eart rate…………"……………………. .…………"……………………. .

FF--Artial 'lood ressureArtial 'lood ressure. " "" .. .. .. … .. " "" .. .. .. … .

66--9esirator# attern9esirator# attern.." …""… .. . ...." …""… .. . ..

--Artial SO7Artial SO7…………"". ……………… .…………"". ……………… .

))--0evel of "ons"iousness0evel of "ons"iousness…""""……………..…""""……………..

Disadvanta$es Of sinalDisadvanta$es Of sinal

AnesthesiaAnesthesia::

((--Di)"ult# 3A$ein$Deformit#4Di)"ult# 3A$ein$Deformit#4….. … …….….. … …….

99--h#otension3hi$h level4h#otension3hi$h level4…………………….…………………….

FF-- *otal sinal *otal sinal……………………….… ……….……………………….… ……….

66--0on$er Sur$er#3more than 7 hs40on$er Sur$er#3more than 7 hs4…..…..………………

--Ps#"holo$i"al ase"t3sedation4Ps#"holo$i"al ase"t3sedation4………………………………

CONt SinalCONt Sinal

CONt. SinalCONt. Sinal

Anesth.DisadaventAnesth.Disadavent..::))--Postdural un"ture heade"hePostdural un"ture heade"he.. ……… ….... ……… ….. 77--9is& of infe"tion3menin$itis49is& of infe"tion3menin$itis4…………….…….…………….…….

88--9is& of heamtoma3"lottin$ defe"ts49is& of heamtoma3"lottin$ defe"ts4…......…......

--Neurolo$i"al inur#3"auda e<uina4Neurolo$i"al inur#3"auda e<uina4………… ….………… ….

('('--Urine retensionUrine retension……………………………......……………………………......

CoplicationsCoplications::

11..8ediate coplications8ediate coplications ::

>>hypotensionhypotension

>>total spinal $loctotal spinal $loc

>>systeic toxicitysysteic toxicity

22..9ate coplications9ate coplications::

>>post dural puncture headache /P#P60post dural puncture headache /P#P60..

>><pidural heatoa<pidural heatoa..

>>focal neurological deficitfocal neurological deficit .. >>$acterial eningitis$acterial eningitis..

5ther Coplications5ther Coplications ::

As theAs the sacral autonoic fi$res are aong the last tosacral autonoic fi$res are aong the last to

recover follo!ing a spinal anaestheticrecover follo!ing a spinal anaesthetic44 urinaryurinary

retentionretention ay occur. 8f fluid pre>loading has $een exay occur. 8f fluid pre>loading has $een excessive4 a painful distended $ladder ay result and tcessive4 a painful distended $ladder ay result and t

he patient ay need to $ehe patient ay need to $e catherisedcatherised..

Peranent neurological coplicationsPeranent neurological coplications are extreelyare extreely

rare. &any of those that have $een reported !ere durare. &any of those that have $een reported !ere du

e to thee to the inection of inappropriate drugsinection of inappropriate drugs or cheicalor cheical

s into the C*B producings into the C*B producing eningitis4eningitis4 arachnoiditis4 tr arachnoiditis4 tr

ansverse yelitis or the cauda euina sansverse yelitis or the cauda euina syyndroendroe !it!ith varying patterns ofh varying patterns of neurological ipairent and spneurological ipairent and sp

hincter distur$anceshincter distur$ances..

,asopressors

1. <phedrine 9.-)mg titrated against t!e blood

pressure. 4ts eect generally lasts about (' minutesand it may need repeating.

4t can also be given intramuscularly but its onset time

is delayed alt!oug! its duration is prolonged..

2. &etarainol #2ramine$.

3. &ethoxaine #OasoAine$.

. Phenylephrine.". Noradrenaline #0evop!ed$.

%. Adrenaline;<pinephrine.

Treatent of spinal 6ypotension.

Eypotension is due to vasodilation and a unctional

decrease in the effective circulating volue.1.vasoconstrictor drugs

9.2ll !ypotensive patients s!ould be given 5?D7<N by

mas+ until t!e blood pressure is restored.

F. raising their legs t!us increasing the return of

venous $lood to the heart. spinal anaest!etic !asbeen inected in t!e preceding 1" inutes as it will

result in t!e bloc+ spreading !ig!er and t!e

!ypotension becoming more severe.

.8ncrease the speed of the intravenous infusion tomaAimum until t!e blood pressure is restored toacceptable levels .

. pulse is slo!" give atropine intravenously.

Treatent of Total *pinal.:

1. 6ypotension - emember t!at nausea may be t!e

irst sign o !ypotension. give vassopressors. 2. (radycardia - give atropine

3. 8ncreasing anxiety - reassure.

. Nu$ness or !eaness of the ars and hands"

indicating t!at t!e bloc+ !as reac!ed t!e cervico-

t!oracic unction.

". #ifficulty $reathing - as t!e intercostal nerves are

bloc+ed t!e patient may state t!at t!ey cant ta+e a

deep breat!. 2s t!e p!renic nerves #C F"6"$ w!ic!

supply t!e diap!ragm become bloc+ed" t!e patient

will initially be unable to tal+ louder t!an a w!isper

and will t!en stop breat!ing.

%. 9oss of consciousness.

As for help - several pairs o !ands may be

useul<8ntu$ate and ventilate t!e patient wit! (''M

oAygen.

Dnce t!e airway !as been controlled and t!e circulation

restored" consider sedating t!e patient wit! a

$enodiaepine

6eadache6eadache /P#P60/P#P60::..

/ 0/ 0

A characteristic headache ay occur follo!ing spinalA characteristic headache ay occur follo!ing spinal

anaesthesia. 8t $eginsanaesthesia. 8t $egins !ithin 2>'2 hours and ay la!ithin 2>'2 hours and ay la

st a !ee or orest a !ee or ore..

8t is postural4 $eing ade8t is postural4 $eing ade !orse $y standing or even!orse $y standing or even

raising the head and relieved $y lying do!nraising the head and relieved $y lying do!n..

8t is often8t is often occipital and ay $e associated !ith a stiffoccipital and ay $e associated !ith a stiff

nec. Nausea4 voiting4 diiness and photopho$ia f nec. Nausea4 voiting4 diiness and photopho$ia f

reuently accopany itreuently accopany it.. 8t is ore coon in the8t is ore coon in the young4 in feales andyoung4 in feales and

especially in o$stetric patientsespecially in o$stetric patients..

8t is thought to $e caused $y the8t is thought to $e caused $y the continuing loss ofcontinuing loss of

C*B through the holeC*B through the hole ade in the dura $y the spinalade in the dura $y the spinal

needle. This results in traction on the eninges andneedle. This results in traction on the eninges and

painpain..

The incidence of headache is related directly to theThe incidence of headache is related directly to the

sie of the needle used. Asie of the needle used. A 1% gauge needle !ill cause1% gauge needle !ill cause

headache in a$out '"= of patients4 a 2- gauge needlheadache in a$out '"= of patients4 a 2- gauge needle in a$out 1"= and a 2" gauge needle in 1>3=e in a$out 1"= and a 2" gauge needle in 1>3=..

As the fi$res of the dura run parallel to the long axis ofAs the fi$res of the dura run parallel to the long axis of

the spine4 if the $evel of the needle is parallel to thethe spine4 if the $evel of the needle is parallel to the

4 it !ill part rather than cut the and therefore4 leav4 it !ill part rather than cut the and therefore4 leave a saller holee a saller hole..

Treatent of spinal headacheTreatent of spinal headache

((..emainemain lying lat in bedlying lat in bed as t!is relieves t!e painas t!is relieves t!e pain..

99.. T!ey s!ould be encouraged toT!ey s!ould be encouraged to drin+drin+ reely or" ireely or" i

necessary" be givennecessary" be given intravenous luids to maintain adeHintravenous luids to maintain adeH

uate !ydrationuate !ydration..

FF.. Simple analgesicsSimple analgesics suc! as paracetamol" aspirin orsuc! as paracetamol" aspirin or

codeine may be !elpulcodeine may be !elpul""

66..44ncreasencreasedd intra-abdominalintra-abdominal and !ence epiduraland !ence epiduralpressure.pressure. #2bdominal binder$#2bdominal binder$..

..Caeine containing drin+sCaeine containing drin+s suc! as tea" coee orsuc! as tea" coee or

Coca-Cola are oten !elpulCoca-Cola are oten !elpul..

))..Prolonged or severe !eadac!esProlonged or severe !eadac!es may be treatedmay be treated

wit!wit! epidural blood patc!epidural blood patc! perormed by asepticallyperormed by aseptically

inecting (-9'ml o t!e patients own blood into t!inecting (-9'ml o t!e patients own blood into t!

e epidural space. T!is t!ene epidural space. T!is t!en clotsclots and seals t!e !oland seals t!e !ol

e and prevents urt!er lea+age o CS/e and prevents urt!er lea+age o CS/..

4t used to be t!oug!t t!at bedrest or 96 !ours4t used to be t!oug!t t!at bedrest or 96 !ours

ollowing a spinal anaest!etic would !elp reduce tollowing a spinal anaest!etic would !elp reduce t

!e incidence o !eadac!e" but t!is is now no long!e incidence o !eadac!e" but t!is is now no longer believed to be t!e caseer believed to be t!e case..

8t is !idely considered that8t is !idely considered that pencil>point needlespencil>point needles

/Ehiteacre or *protte0/Ehiteacre or *protte0 ae a saller hole in the dur ae a saller hole in the dur

a and are associated !ith a lo!er incidence of headaa and are associated !ith a lo!er incidence of heada

che /1=0 than conventionalche /1=0 than conventional cutting>edged needles /Fcutting>edged needles /Fuince0uince0

*o minimi8e PDP=

=eada"he roh#laxis with sinal

anesthesia

8f8f inadeuate sterile precautionsinadeuate sterile precautions are taenare taen $acterial$acterial

eningitis or an epidural a$scesseningitis or an epidural a$scess

Binally4 peranent paralysis can occur due toBinally4 peranent paralysis can occur due to anterioranterior

spinal artery syndroespinal artery syndroe.. This is ost liely to affectThis is ost liely to affect elderly patientselderly patients !ho are!ho are

su$ected to prolonged periods ofsu$ected to prolonged periods of hypotension andhypotension and

ay result in peranent paralysis of the lo!er li$say result in peranent paralysis of the lo!er li$s..

Other"omli"ations :

SSummar#

Summar#Summar###(($$Advanta$esAdvanta$es::

##99$$Ph#siolo$# G Anatom#G Pharma"olo$#Ph#siolo$# G Anatom#G Pharma"olo$#::##FF$$Preoerative visit.. : Indi"ationsPreoerative visit.. : Indi"ations ………. ……….xaminationxamination……….……….Investi$ationsInvesti$ations……..……..

Intravenous Preload of -uidsIntravenous Preload of -uids ##66$$Contraindi"ations to neuroaxial anesthesiaContraindi"ations to neuroaxial anesthesia………..………..

##$$ *e"hni<ue of neuroaxial anesthesia *e"hni<ue of neuroaxial anesthesia..........................................

##))$$!a"tors a)e"t sread of neuroaxial sianl anesthes!a"tors a)e"t sread of neuroaxial sianl anesthes

##77$$Monitorin$ durin$ neuroaxial anesthesiaMonitorin$ durin$ neuroaxial anesthesia………….………….

##88$$Comli"ations and man$ement of neuroaxial 55Comli"ations and man$ement of neuroaxial 55anesthesiaanesthesia

*han&s !or Hour Attention *han&s !or Hour Attention

Dr.Mahmoud Othman

neuroaxial anesthesia dr. m othman

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