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Spinal & Epidural Anaesthesia
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Aditi Panditrao's Spinal & epidural anaesthesia ug

Apr 29, 2015

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Dr. Aditi discusses in detail various aspects of neuraxial blocks, spinal and epidual, with methods, complications, with beautiful graphics, figures and diagrams.
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Page 1: Aditi Panditrao's Spinal & epidural anaesthesia ug

Spinal & Epidural Anaesthesia

Page 2: Aditi Panditrao's Spinal & epidural anaesthesia ug

Dr. Aditi Mridul Panditrao

Junior Resident

Department of Anaesthesiology &

Intensive care

PDVVPF’S Medical College,

Viladghat, Ahmednagar

India

Page 3: Aditi Panditrao's Spinal & epidural anaesthesia ug

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

Page 4: Aditi Panditrao's Spinal & epidural anaesthesia ug

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.

Page 5: Aditi Panditrao's Spinal & epidural anaesthesia ug

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

Page 6: Aditi Panditrao's Spinal & epidural anaesthesia ug

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

Page 7: Aditi Panditrao's Spinal & epidural anaesthesia ug

Anatomy

Page 8: Aditi Panditrao's Spinal & epidural anaesthesia ug

Where do we give the block??

Page 9: Aditi Panditrao's Spinal & epidural anaesthesia ug
Page 10: Aditi Panditrao's Spinal & epidural anaesthesia ug
Page 11: Aditi Panditrao's Spinal & epidural anaesthesia ug

Structures crossed during Spinal:

o Skin

o Subcutaneous tissue

o Supraspinous ligament

o Interspinous ligament

o Ligamentum Flavum

o Epidural Space

o Dura

Page 12: Aditi Panditrao's Spinal & epidural anaesthesia ug

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

Page 13: Aditi Panditrao's Spinal & epidural anaesthesia ug

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

Page 14: Aditi Panditrao's Spinal & epidural anaesthesia ug
Page 15: Aditi Panditrao's Spinal & epidural anaesthesia ug

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

Page 16: Aditi Panditrao's Spinal & epidural anaesthesia ug

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

Page 17: Aditi Panditrao's Spinal & epidural anaesthesia ug

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

Page 18: Aditi Panditrao's Spinal & epidural anaesthesia ug

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

Page 19: Aditi Panditrao's Spinal & epidural anaesthesia ug

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

Page 20: Aditi Panditrao's Spinal & epidural anaesthesia ug

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

Page 21: Aditi Panditrao's Spinal & epidural anaesthesia ug
Page 22: Aditi Panditrao's Spinal & epidural anaesthesia ug

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

Page 23: Aditi Panditrao's Spinal & epidural anaesthesia ug
Page 24: Aditi Panditrao's Spinal & epidural anaesthesia ug

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

Page 25: Aditi Panditrao's Spinal & epidural anaesthesia ug
Page 26: Aditi Panditrao's Spinal & epidural anaesthesia ug

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

Page 27: Aditi Panditrao's Spinal & epidural anaesthesia ug

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

Page 28: Aditi Panditrao's Spinal & epidural anaesthesia ug

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.

Page 29: Aditi Panditrao's Spinal & epidural anaesthesia ug
Page 30: Aditi Panditrao's Spinal & epidural anaesthesia ug

Complications of Epidural

o Accidental puncture of dura

o Hematoma

o Extradural abcess

o Urinary retention

o Hypotension

o Nausea - vomiting

o Backache

Page 31: Aditi Panditrao's Spinal & epidural anaesthesia ug

Thank You!