Regional Anesthesia

OBJECTIVE
• Describe anatomy of spinal canal
• Identify anatomic landmarks for proper placement of a spinal
and epidural needles
• Define appropriate steps for placement of spinal, epidural, or
caudal needle
• Distinguish level of anesthesia after administration
• State factors affecting level and duration of spinal vs.
epidural block
• Explain potential complications and corresponding
treatments associated with administration of regional
anesthetics
 INTRODUCTION
• Regional anesthesia refers to anesthesia of a
segment of the body, achieved by selective
interruption of nerve transmission without loss of
consciousness.

• Regional anesthesia involves numbing only part of

the body by injecting local anesthetics near nerves
or bundle of nerves, where they interrupt the
transmission of pain signals to the brain.
 Cont…..
Type of RA
• Neuraxial block(Central)
Spinal
Epidural
Caudal
• Peripheral Nerve Block
• IV Regional ( Bier block )
 Cont…
• Neuraxial anesthesia includes both subarachnoid and
epidural injection.

• Subarachnoid or intrathecal anesthesia is commonly

referred to as spinal anesthesia which involves
administration of LA into subarachnoid space.
 Cont…
• Both epidural and caudal anesthesia involves
administration of LA into the epidural space.(what is
the difference?)

• The principal site of action for neuraxial blockade is

believed to be the nerve root.
• Local anesthetic is injected into CSF (spinal anesthesia)
or the epidural space (epidural and caudal anesthesia)
and bathes the nerve root in the subarachnoid space
or epidural space, respectively.
 Cont…
• Subarachnoid injection of a small dose of local
anesthetic can rapidly produce dense surgical
anesthesia.
• Subarachnoid injection is almost always done in the
lumbar region, below the termination of the spinal
cord.
 Cont…
• Subarachnoid anesthesia can provide excellent
operating conditions for lower abdominal, pelvic, and
lower extremity surgery.
• Single injection subarachnoid anesthesia will last 2 to
3 hours at most.
• Epidural anesthesia requires larger doses of local
anesthetic and takes more time to establish.
 Cont…
• Epidural injection can safely be performed in the
lumbar, thoracic, and even cervical regions.
• Thoracic epidural anesthesia is a useful adjunct to
general anesthesia for upper abdominal and thoracic
surgeries.
 Cont…
• The flexibility of continuous epidural block makes it
an excellent choice for labor pain relief.
• Dilute local anesthetic and opioid solutions can
provide labor analgesia with minimal maternal motor
block and negligible effects on the progress and
outcome of labor.
 Cont…
• The caudal canal is the lower extension of the
epidural space.
• Caudal anesthesia and analgesia are uncommon in
adults but can be useful for pediatric surgeries.
 Monitoring and Equipment
• Monitoring
Blood pressure,
Heart rate
Pulse oxymetry,
• Establishment of IV access
• Supplemental oxygen
• Resuscitation equipment(ambubag, airways of different sizes,
intubation equipment and tubes)
and appropriate resuscitation drugs must always be readily
available .
 Cont…
Indications and Contraindications
• There are no absolute indications for subarachnoid or
epidural anesthesia.
• Their use is determined by a combination of patient,
surgeon, and anesthetist preferences.
 Cont…
• Major contraindications to neuraxial anesthesia
include patient refusal, severe hypovolemia, elevated
intracranial pressure (particularly with an intracranial
mass), coagulopathy, hemodynamic instability, and
infection at the site of injection.
 Cont…
Neuraxial Anesthesia and Outcome

• Some studies suggest that postoperative morbidity—and

possibly mortality—may be reduced when neuraxial
blockade is used either alone or in combination with
general anesthesia.

• Neuraxial blocks may reduce the incidence of venous

thrombosis and pulmonary embolism, cardiac
complications in high-risk patients, bleeding and
transfusion requirements, and
 Cont…
• Pneumonia and respiratory depression following
upper abdominal or thoracic surgery in patients with
chronic lung disease.

• Neuraxial blocks may also allow earlier return of

gastrointestinal function following surgery.
 Con…
• Proposed mechanisms (in addition to avoidance of
larger doses of anesthetics and opioids) include:
 amelioration of the hypercoagulable state associated
with surgery
 sympathectomy mediated increases in tissue blood flow
 improved oxygenation from decreased splinting
 enhanced peristalsis and
 suppression of the neuroendocrine stress response to
surgery.
 Cont…
• In patients with coronary artery disease, a decreased
stress response may result in less perioperative
ischemia and reduced morbidity and mortality.

• Reduction of parenteral opioid requirements may

decrease the incidence of atelectasis,
hypoventilation, and aspiration pneumonia and reduce
the duration of ileus.
 Cont…
• Postoperative epidural analgesia may also
significantly reduce the need for mechanical
ventilation after major abdominal or thoracic surgery.
 Cont…
Risk Of Regional Anesthesia
Regional anesthesia carries the risks and complications
associated with 3major causes:
the use of local anesthetics
the risks and complications of using
needles and
excessive effects of an appropriately injected drug
 Anatomy
Vertebrae
• The spine is comprised of 33 vertebrae: 7 cervical, 12
thoracic, 5 lumbar, 5 fused sacral, and 4 fused
coccygeal.
 Cont…
Cervical
Upper cervical: C1-C2
Lower cervical: C3-C7

Thoracic: T1-T12

Lumbar: L1- L5

• Sacrococcygeal: 9 fused
vertebrae in the sacrum
and coccyx.
 Cont…
• The vertebrae surround and protect the vertebral
canal, which contains the spinal cord, cerebrospinal
fluid (CSF), meninges, spinal nerves, and epidural
space.
 Cont…
• Each vertebra has a body anteriorly, two pedicles
that project posteriorly from the body, and laminae
that connect the two pedicles.
• The transverse processes arise laterally from the
junction of the pedicle and lamina, and the spinous
process projects posteriorly from the union of the
bilateral laminae.
• The paraspinous muscles and ligaments attach to
these bony projections.
 Cont…

Vertebral Body

Pedicles Spinal canal

Transverse Lamina
processes Superior articular
process

Spinous process
 Cont…
• The pedicles form the superior and inferior vertebral
notches, through which the spinal nerves exit the
vertebral canal.

• The lamina and pedicles meet at the superior and

inferior articular processes, which form the joints that
connect the adjacent vertebrae.
 Cont…
• The first and second cervical vertebrae, also referred
to as the atlas and dens, have a unique appearance
in that C1 lacks a vertebral body or spinous process
and C2 has a large articulating process (dens).
• Five fused vertebrae form the sacrum.
• The fifth sacral vertebra does not fuse posteriorly,
forming the sacral hiatus, which provides access to
the most caudal point of the epidural space.
 Cont…
• The sacral hiatus is usually open in children but its
patency varies in adults.
• The four coccygeal vertebrae fuse to form the coccyx,
which represents a vestigial tail and serves as an
anchor for the attachment of tendons, ligaments,
and muscles.
 Cont…
Ligaments
• Several ligaments serve to stabilize the vertebral
column.
• Ventrally, the vertebral bodies and intervertebral
disks are connected and supported by the anterior
and posterior longitudinal ligaments .
• Dorsally, the ligamentum flavum, interspinous
ligament, and supraspinous ligament provide
additional stability.
 Cont…
Epidural space
• The epidural space is a potential space within the spinal
canal that is bounded by the dura and the ligamentum
flavum.
• It is bounded
cranially by the foramen magnum,
 caudally by the sacrococcygeal ligament,
anteriorly by the posterior longitudinal ligament,
laterally by the vertebral pedicles, and
posteriorly by both the ligamentum flavum and vertebral
lamina
 Cont…
• Consists fat-filled pockets that may play an important
role in the kinetics of epidural medications, epidural
veins which located mostly in the anterior epidural
space.
Cont…
 Cont…
THE SPINAL CORD
• The spinal canal contains the spinal cord with its
coverings (the meninges), fatty tissue, and a venous
plexus.
• The meninges are composed of three layers: the pia
mater(inner most layer&highly vascular), the
arachnoid mater(middle layer&non-vascular), and
the dura mater(outermost layer&fibrous).
 Cont…
• The dural sac and the subarachnoid and subdural
spaces usually extend to S2 in adults and often to S3
in children.
• Because of this fact and the smaller body size,
caudal anesthesia carries a greater risk of
subarachnoid injection in children than in adults.
 Cont…
• The spinal cord normally extends from the foramen
magnum to the level of L1 in adults and in children,
the spinal cord ends at L3 and moves up with age.
• There are 31 pairs of spinal nerves, each with an
anterior motor root and a posterior sensory root.
• These nerve roots arise from individual spinal cord
segments.
 Cont…
• The spinal nerves and their corresponding
dermatomes are named for the foramina through
which they exit the vertebral column.
• In the cervical region, spinal nerves are named after
the lower vertebrae (i.e., C5 exits between C4 and
C5). Elsewhere, the roots are named by the upper
vertebrae (L2 emerges between L2 and L3).
 Cont…
• The lumbar and sacral spinal nerves that extend
beyond the tip of the cord are called the cauda
equina.
• These nerve roots, covered only by pia mater, may be
more susceptible to chemical injury than more
proximal roots.
Cont….
Cont…
 Cont…
Cerbrospinal fluid
• Cerebrospinal fluid (CSF) is contained between the
pia and arachnoid maters in the subarachnoid space.

• CSF is an aqueous solution consisting of 99% water

and multiple minor components include protein,
glucose, electrolytes, and neurotransmitters.

• In adult humans, the volume of CSF is 100 to 160 mL.

 Cont…
• For many years, it was believed that CSF was primarily
produced in the choroid plexus and then flowed from
the ventricles to the subarachnoid space, where it was
absorbed by arachnoid granulations.
• This hypothesis is incomplete and probably incorrect,
the choroid plexus is not the sole site of CSF
production and the arachnoid granulations are not its
primary absorption sites.
 Cont…
• So, it is mainly produced and absorbed in the
parenchymal capillaries of the brain and spinal cord.
The lymphatic system also absorbs a considerable
amount of CSF .
• CSF movement is not unidirectional flow. Instead,
transmitted cardiac oscillations produce local mixing.
 Cont…
Blood Supply
• The blood supply to the spinal cord and nerve roots
is derived from a single anterior spinal artery and
paired posterior spinal arteries.
• The anterior spinal artery supplies the anterior two-
thirds of the cord, whereas the two posterior spinal
arteries supply the posterior one-third.
 Cont…
• The anterior and posterior spinal arteries receive
additional blood flow from the intercostal arteries in
the thorax and the lumbar arteries in the abdomen.
 History of regional anesthesia
• Cocaine was the first effective local anesthetic
• Carl Koller, first recognized the utility of cocaine in
clinical practice
• Koller arranged to demonstrate the use of topical
cocaine analgesia at the Ophthalmologic Congress in
Heidelberg, Germany, on September 15, 1884
• Cocaine still in use due to its effect
 Cont..
• The idea of injecting cocaine into nerve trunks is
credited to William Halsted (1852-1922) and Alfred
Hall
• The first report of their success is on December 6,
1884, they first injected 4% cocaine (15 mg) into the
forearm
• The term spinal anesthesia was coined in 1885 by
Leonard Corning
• Heinrich Quincke of Kiel, Germany, had described his
technique of lumbar puncture
 Cont…
• Quincke's technique was used in Kiel for the first
deliberate cocainization of the spinal cord in 1899 by
his surgical colleague, August Bier
• Professor Bier permitted his assistant, Dr.
Hildebrandt, to perform a lumbar puncture,
• A large volume of the professor's spinal fluid escaped
• 1850s Invention of the syringe and hypodermic
hollow needle
 Cont…
• Theodor Tuffier published the first series of 125
spinal anesthetics
• States that the solution should not be injected before
CSF was seen.
• During 1899, Dudley Tait and Guidlo Caglieri of
performed experimental studies in animals
• They encouraged the use of fine needles and urged
that the skin and deeper tissues be infiltrated
 Cont…
•Before 1907, anesthesiologists were sometimes disappointed
because spinal anesthetics were incomplete.
•The property of baricity was investigated by Arthur Barker, a
London surgeon.
•1911 Hirschel performs the first percutaneous axillary block.

•Lincoln Sise in 1935 introduced the use of hyperbaric solutions

of tetracaine (Pontocaine).
•John Adriani advanced the concept further in 1946 when he
used a hyperbaric solution to produce “saddle block,” or
perineal anesthesia.
 Cont…
• In 1949, Martinez Curbelo of Havana, Cuba, used
Tuohy's needle and a ureteral catheter to perform
the first continuous epidural anesthetic.
NEURAXIAL
ANESTHESIA
 Components of block
Sensory Block
• Interrupt the afferent transmission of painful stimuli.
• Sensory blockade interrupts both somatic and
visceral painful stimuli.
Motor Block
• By abolishing the efferent impulses responsible for
skeletal muscle tone, neuraxial blocks can provide
excellent operating conditions.
Assessing level of motor block
 Cont…
• The effect of local anesthetics on nerve fibers varies
according to:
 The size and characteristics of the nerve
fiber(whether it is myelinated, the length of nerve
that is bathed by the local anesthetic, and the
concentration of the local anesthetic)
• Spinal nerve roots contain varying mixtures of these
fiber types.
 Cont…
• Smaller and myelinated fibers are generally more
easily blocked than larger and unmyelinated ones.
• The size and character of the fiber types, and the fact
that the concentration of local anesthetic decreases
with increasing distance from the level of injection,
explains the phenomenon of differential blockade.
 Cont…
Differential Block
• The phenomenon in which nerve fibers display
different sensitivity to local anesthetic.
• Typically results in sympathetic blockade (judged by
temperature sensitivity) that may be two segments
or more cephalad than the sensory block (pain, light
touch), which, in turn, is usually several segments
more cephalad than the motor blockade.
 Cont…
Autonomic Block
• Interruption of efferent autonomic transmission at
the spinal nerve roots during neuraxial blocks
produces sympathetic blockade.
• Sympathetic outflow from the spinal cord may be
described as thoracolumbar, whereas
parasympathetic outflow is craniosacral.
 Cont…
• Sympathetic preganglionic nerve fibers exit the spinal
cord with the spinal nerves from T1–L2.
• In contrast, parasympathetic preganglionic fibers exit
the spinal cord with the cranial and sacral nerves.
 Cont…
• Neuraxial anesthesia does not block the vagus
nerve (tenth cranial nerve).
• The physiological responses (systematic effect)of
neuraxial blockade therefore result from decreased
sympathetic tone and/or unopposed
parasympathetic tone.
 Systematic Effects
1. Cardiovascular Manifestations
• Neuraxial blocks produce variable decreases in blood
pressure that may be accompanied by a decrease in
heart rate.
• These effects are generally proportional to the
dermatomal level and extent of sympathectomy.
• Vasomotor tone is primarily determined by
sympathetic fibers arising from T5– L1, innervating
arterial and venous smooth muscle.
 Cont…
• Blocking these nerves causes vasodilation of the
venous capacitance vessels and pooling of blood in
the viscera and lower extremities, thereby decreasing
the effective circulating blood volume and venous
return to the heart.
• Arterial vasodilation may also decrease systemic
vascular resistance.
• The effects of arterial vasodilation may be minimized
by compensatory vasoconstriction above the level of
the block.
 Cont…
• A high sympathetic block not only prevents
compensatory vasoconstriction, but may also block
the sympathetic cardiac accelerator fibers that arise
at T1–T4.
• Profound hypotension may result from arterial
dilation and venous pooling combined with
bradycardia
• These effects are exaggerated if venous pooling is
further augmented by a head-up position or the
weight of a gravid uterus.
 Cont…
• Unopposed vagal tone may explain the
sudden cardiac arrest sometimes seen with
spinal anesthesia.
 Cont…
Management:
• Deleterious cardiovascular effects should be anticipated
and steps undertaken to minimize the degree of
hypotension.
 Volume loading(preloading) with 10–20 mL/kg before
initiation of the block (However it has been shown
repeatedly to fail to prevent hypotension in the absence
of preexisting hypovolumia)
 Cont…
 Left uterine displacement in the third trimester of
pregnancy helps to minimize physical obstruction to
venous return.
 Placing the patient in a head-down position.
 A bolus of intravenous fluid (5–10 mL/kg) may be
helpful in patients who have adequate cardiac and
renal function to be able to handle the fluid load
after the block wears off.
 Cont…
 Excessive or symptomatic bradycardia should be
treated with atropine, and hypotension should be
treated with vasopressors.
 Direct α-adrenergic agonists (such as phenylephrine)
primarily produce arteriolar constriction and may
reflexively increase bradycardia, increasing systemic
vascular resistance
 Cont…
• The “mixed” agent ephedrine has direct and indirect
β-adrenergic effects that increase heart rate and
contractility and indirect effects that also produce
vasoconstriction.
• Small doses of epinephrine (2–5 mcg boluses) are
particularly useful in treating spinal anesthesia
induced hypotension.
• If profound hypotension and/or bradycardia persist,
vasopressor infusions may be required.
 Cont…
2. Pulmonary Manifestations
• Alterations in pulmonary physiology are usually
minimal with neuraxial blocks because the
diaphragm is innervated by the phrenic nerve, with
fibers originating from C3–C5.
• Even with high thoracic levels, tidal volume is
unchanged; there is only a small decrease in vital
capacity, which results from a loss of the abdominal
muscles contribution to forced expiration.
 Cont…
• Patients with severe chronic lung disease may rely
upon accessory muscles of respiration (intercostal and
abdominal muscles) to actively inspire or exhale.
• High levels of neural blockade will impair these
muscles.
• Similarly, effective coughing and clearing of secretions
require these muscles for expiration.
• For these reasons, neuraxial blocks should be used
with caution in patients with limited respiratory
reserve.
 Cont…
• These deleterious effects need to be weighed against
the advantages of avoiding airway instrumentation
and positive-pressure ventilation.
 Cont…
3. Gastrointestinal Manifestations
• Neuraxial block-induced sympathectomy allows vagal tone
dominance and results in a small, contracted gut with
active peristalsis.
• This can improve operative conditions during laparoscopy
when used as an adjunct to general anesthesia.
• Postoperative epidural analgesia with local anesthetics
and minimal systemic opioids hastens the return of
gastrointestinal function after open abdominal
procedures.
 Cont…
• Hepatic blood flow will decrease with reductions in
mean arterial pressure from neuraxial anesthesia.
 Cont…
4. Urinary Tract Manifestations
• Renal blood flow is maintained through
autoregulation, and there is little effect of neuraxial
anesthesia on renal function.
• Neuraxial anesthesia at the lumbar and sacral levels
blocks both sympathetic and parasympathetic
control of bladder function.
• Loss of autonomic bladder control results in urinary
retention until the block wears off.
 Cont…
• If no urinary catheter is placed perioperatively, it is
prudent to use the regional anesthetic of shortest
duration sufficient for the surgical procedure and to
administer the minimal safe volume of intravenous
fluid.
• Patients with urinary retention should be checked for
bladder distention after neuraxial anesthesia.
 Cont…
. Metabolic & Endocrine Manifestations
5

•Surgical trauma produces a systemic neuroendocrine

response via activation of somatic and visceral afferent
nerve fibers, in addition to a localized inflammatory
response.
•This systemic response includes :
increased concentrations of adrenocorticotropic hormone
cortisol
epinephrine, norepinephrine, and vasopressin levels and
activation of the renin–angiotensin–aldosterone system.
 Cont…
• Clinical manifestations include :
 intraoperative and postoperative hypertension
 tachycardia
 hyperglycemia
 protein catabolism
 suppressed immune responses and
 altered renal function.
• Neuraxial blockade can partially suppress (during major
invasive surgery) or totally block (during lower extremity
surgery) the neuroendocrine stress response.
 Cont…
• To maximize this blunting of the neuroendocrine
stress response, neuraxial block should precede
incision and continue into the postoperative period.
 Clinical Considerations
Indications
• Neuraxial blocks may be used alone or in conjunction with
general anesthesia for most procedures below the neck.
• As a primary anesthetic, neuraxial blocks have proved
most useful in
 Lower abdominal
 Inguinal
 Urogenital
 Rectal and lower extremity surgery
 Cont…
Contraindications
Absolute
 Infection at the site of injection
 Patient refusal
 Coagulopathy or other bleeding diathesis
 Severe hypovolemia
 Increased intracranial pressure
 Severe aortic and mitral stenosis
 Cont…
Relative
 Sepsis
 Uncooperative patient
 Preexisting neurological deficits
 Mild to moderate stenotic valvular heart lesions
 Left ventricular outflow obstruction (hypertrophic
obstructive cardiomyopathy)
 Severe spinal deformity
 Cont…
Controversial
 Prior back surgery at the site of injection
 Complicated surgery
 Prolonged operation
 Major blood loss
 Maneuvers that compromise respiration
 Neuraxial Blockade in the Setting of
Anticoagulants & Antiplatelet Agents
• Whether a block should be performed in the setting
of anticoagulants and antiplatelet agents can be
problematic.
• The use of anticoagulant and antiplatelet
medications continues to increase, placing an ever
larger number of patients at potential risk of epidural
hematomas.
 Cont…
A. Oral Anticoagulants
• If neuraxial anesthesia is to be used in patients receiving
warfarin therapy, a normal
prothrombintime(PT) and international normalized
ratio should be documented prior to the block.
• Warfarin should be discontinued for at least 5 days
before elective procedure.
• Anesthesia staff should always consult with the patient’s
primary physicians whenever considering the
discontinuation of antiplatelet or antithrombotic therapy.
 Cont…
B. Antiplatelet Drugs
 Aspirin and other nonsteroidal antiinfl ammatory
drugs (NSAIDs) drugs do not increase the risk of
spinal hematoma from neuraxial anesthesia
procedures or epidural catheter removal.
• More potent agents should be stopped, and
neuraxial blockade should generally be administered
only after their effects have worn off.
 Cont…
• The waiting period depends on the specific
agent: for
 ticlopidine (Ticlid), 14 days
 clopidogrel (Plavix), 7 days
 abciximab (Rheopro), 48 hr and
 eptifibatide (Integrilin), 8 hr.
 Cont…
• In patients with a recently placed cardiac stent,
discontinuation of antiplatelet therapy can result in
stent thrombosis and acute STsegment elevation
myocardial infarction.
• Risks versus benefits of a neuraxial technique should
be discussed with the patient and the patient’s
primary doctors.
 Cont…
C. Standard (Unfractionated) Heparin
 “Minidose” subcutaneous heparin prophylaxis is not
a contraindication to neuraxial anesthesia or epidural
catheter removal.
 In patients who are to receive systemic heparin
intraoperatively, blocks may be performed 1 hr or
more before heparin administration.
 Cont…
 Removal of an epidural catheter should occur 1 hr prior
to, or 4 hr following, subsequent heparin dosing.
 Neuraxial anesthesia should be avoided in patients on
therapeutic doses of heparin and with increased partial
thromboplastin time(PTT).
 If the patient is started on heparin after the placement
of an epidural catheter, the catheter should be removed
only after discontinuation or interruption of heparin
infusion and evaluation of the coagulation status.
 Cont…
D. Low-Molecular-Weight Heparin (LMWH)
 If postoperative LMWH thromboprophylaxis
will be utilized, epidural catheters should be
removed 2 hr prior to the first LMWH dose.
 If already present, the catheter should be
removed at least 10 hr after a dose of LMWH,
and subsequent dosing should not occur for
another 2 hr.
 Cont…
 If an unusually bloody needle or catheter placement
occurs, LMWH should be delayed until 24 hr
postoperatively, because this trauma may increase
the risk of spinal hematoma
 Cont…
E. Fibrinolytic or Thrombolytic Therapy
 Neuraxial anesthesia should not be performed if a
patient has received fibrinolytic or thrombolytic
therapy.
 Timing of neuraxial blockade at least 10 d after or 10
d before thrombolytic therapy.
 Cont…
 If thrombolytics are given at or near the time of
neuraxial block, continue neurologic monitoring for
an appropriate interval.
 If thrombolytics are administered while neuraxial
catheter is in place, minimize sensory and motor
block to allow for monitoring of neurologic function
 No recommendation for removal of neuraxial
catheters can be made; consider measuring
fibrinogen levels, and monitor neurologic function
 Awake or Asleep?
• The major arguments for having the patient asleep
are that
 Most patients, if given a choice, would prefer to be
asleep, and
 The possibility of sudden patient movement causing
injury is markedly diminished.
 Pediatric neuraxial blocks, particularly caudal and
epidural blocks, are usually performed under general
anesthesia.
 Cont…
• The major argument for neuraxial blockade while the
patient is still awake is:
 The patient can alert the clinician to paresthesias and
pain on injection, both of which have been
associated with postoperative neurological deficits.
 Easy to identify complications like high spinal and
total spinal than with sedation.
 History and PE
 The core pre anesthetic Hx, P/E and lab assessment
should be the same as for GA
 A complete medication Hx.(coagulation profile )may
be indicated in patient who have received major
anticoagulant preoperatively or in whom the review
of system suggests bleeding diatheses.
 Any abnormality in nurological Hx or examination
should be documented on the patient chart.
 The planned skin puncture site and bony land marks
should examined to confirm that RA is technically
feasible.
 Technical Considerations
• Neuraxial blocks should be performed only in a
facility in which all the equipment and drugs needed
for intubation, resuscitation, and general anesthesia
are immediately available.
• Regional anesthesia is greatly facilitated by adequate
patient premedication.
 Cont..

• Nonpharmacologic patient preparation is also very

helpful, patient should be told what to expect so as
to minimize anxiety.
• Supplemental oxygen via a face mask or nasal
cannula may be required to avoid hypoxemia when
sedation is used.
 Cont...
Surface Anatomy
• Spinous processes are generally palpable and help to
define the midline.
• The spinous processes of the cervical and lumbar
spine are nearly horizontal, whereas those in the
thoracic spine slant in a caudal direction and can
overlap significantly.
 Cont…
• Therefore, when performing a lumbar or cervical
epidural block (with maximum spinal flexion), the
needle is directed with only a slight cephalad angle,
whereas for a thoracic block, the needle must be
angled significantly more cephalad to enter the
thoracic epidural space.
Surface landmarks for identifying spinal levels.

1. In the cervical area the most prominent one is C7

(vertebra prominens).
2. Spinous process of T7 is usually at the same level as
the inferior angle of the scapulae
3. A line drawn between the highest points of both
iliac crests (Tuffi er’s line) usually crosses either the
body of L4 or the L4–L5 interspace.
4. line connecting the posterior superior iliac spine
crosses the S2 posterior foramina.
Cont…
 Cont…
Patient Positioning
 Sitting position
 Lateral Decubitus position
 Buie’s (Jackknife) Position
 Cont…
Sitting Position
• Easier to appreciate when the patient is sitting
than when the patient is in other position.
• Flexion of the spine (arching the back “like a
mad cat” maximizes the “target” area
between adjacent spinous processes and
brings the spine closer to the skin surface.
 Cont…
Lateral Decubitus
• Patients lie on their side with their knees flexed and
pulled high against the abdomen or chest.
• An assistant can help the patient assume and hold
this position.
 Cont…
Buie’s (Jackknife) Position
• This position may be used for anorectal procedures
utilizing an isobaric or hypobaric anesthetic solution
• Advantage: the block is done in the same position as
the operative procedure, so that the patient does not
have to be moved following the block.
• Disadvantage: CSF will not freely flow through the
needle, so that correct subarachnoid needle tip
placement will need to be confirmed by CSF aspiration.
 Cont…
Anatomic Approach
 Midline approach
 Paramedian approach
 Lumbosacral approach
 Cont…
Midline Approach
• The midline approach is the most straightforward
• After positioning the patient, identify the midline by
palpating the spinous processes.
• In obese patients, estimate the midline by imagining
a line between the C7 prominence and the
intergluteal cleft.
• Insert the needle in the middle of the desired
interspace.
 Cont…
• In patients with poor landmarks, insert the needle in
the presumed midline and explore.
• If the needle strikes bone, assess your location
(intermediate or shallow depth: spinous process;
deeper: lamina) and adjust your approach
accordingly.
 Cont…
Paramedian Approach
• The paramedian technique may be selected if
epidural or subarachnoid block is difficult,
particularly in patients who cannot be positioned
easily (eg, severe arthritis, kyphoscoliosis, or prior
spine surgery)
 Cont…
• After skin preparation and sterile draping ,  Identify
the lower tip of spinous process and move your
finger 1-2 cm lateral.
• The needle is directed and advanced at a 10–25°
angle toward the midline.
 Cont…
• If bone is encountered at a shallow depth with the
paramedian approach, the needle is likely in contact
with the medial part of the lower lamina and should
be redirected mostly upward and perhaps slightly
more laterally.
 Cont…
• If bone is encountered deeply, the needle is usually
in contact with the lateral part of the lower lamina
and should be redirected only slightly craniad, more
toward the midline.
 Cont….
Lumbosacral Approach
• This approach may be useful when anatomic
constraints make other approaches difficult.
• The point of needle insertion is about 1 cm caudal
and 1 cm medial from the posterior superior iliac
spine.
• In this technique, a 5-inch spinal needle is directed
upward and medially.
 Cont…
• The needle is then advanced so that its point
enters the lumbosacral space between the
sacrum and the last lumbar vertebra at the
L5–S1 interspace.
 Cont…
Ultrasound-Guided Neuraxial Blockade
• Ultrasound guidance can facilitate neuraxial
blockade in patients with poorly palpable
landmarks.
Some Common Surgical Procedures That Can Be Done with Subarachnoid Spinal
Anesthesia
SPINAL ANESTHESIA
 Spinal Anesthesia
• SAB is a regional anesthesia involving injection of a
local anesthesia into the subarachnoid space which
extends from the foramen magnum to S1 in adults
and S3 in children.
• Injection of local anesthetic below L1 in adults and L3
in children helps to avoid direct trauma to the spinal
cord.
 Cont…
Spinal Needles
• All should have a tightly fitting removable stylet that
completely occludes the lumen to avoid tracking
epithelial cells into the subarachnoid space.
(2) types
 sharp (cutting)-tipped
Example:Quincke needle
 blunt-tipped needles.
Example:Whitacre and Sprotte
 Cont…
• The introduction of blunt tip (pencil-point)
needles has markedly decreased the incidence
of postdural puncture headache.
• Quincke needle is a cutting needle with higher
incidence of postdural puncture headache
than pencil point needles.
Specific Technique for Spinal Anesthesia
• The midline, or paramedian, approaches, with
the patient positioned in the lateral decubitus,
sitting, or prone positions, can be used for
spinal anesthesia.
• The needle is advanced from skin through the
deeper structures until two “pops” are felt.
• The first is penetration of the ligamentum fl
avum, and the second is penetration of the
dura–arachnoid membrane.
 Cont…
• Successful dural puncture is confirmed by
withdrawing the stylet to verify free flow of CSF.
• Aspiration may be necessary to detect CSF.
• If free flow occurs initially, but CSF cannot be
aspirated after attaching the syringe, the needle likely
will have moved.
 Cont…
• Persistent paresthesias or pain with injection of
drugs should alert the clinician to withdraw and
redirect the needle.
• If a midline introducer needle is inserted in the
center of an interspace and the spinal needle
contacts bone ,it is most likely lamina of the lower
vertebra.
• By slowly redirecting the needle cephalad, you
should be able to “walk” off the lamina and into the
subarachnoid space.
 Cont…
• If you still do not enter the subarachnoid space,
remove the spinal needle, palpate the back, and
reassess the insertion site of your introducer needle.
• Patients will occasionally report a transient
paresthesia during spinal needle insertion.
• These paresthesias may be from needle to nerve root
contact within the subarachnoid space.
• If a transient paresthesia occur, stop advancing the
spinal needle, and withdraw the stylet, if you see CSF,
inject the medication into the subarachnoid space.
Continuous Subarachnoid Spinal Anesthesia

• After identifying the subarachnoid space with a large-

gauge needle, insert an appropriate sized catheter 2
to 3 cm into the subarachnoid space.
• The catheter will advance more easily and be more
likely to lie cephalad to the insertion site if the bevel
or orifice of the needle is directed toward the
patient’s head.
• Caudally directed catheters may cause pooling and
maldistribution of local anesthetic, which has been
associated with permanent neurologic injury.
Factors Influencing Level of Spinal Block

Most important factors

 Baricity of anesthetic solution
 Position of the patient
During injection
Immediately after injection
 Drug dosage
 Site of injection
 Cont…
Other factors
 Age
 Cerebrospinal fluid volume
 Curvature of the spine
 Drug volume
 Intraabdominal pressure
 Needle direction
 Patient height
 Pregnancy
 Baricity
• Baricity is defined as the ratio of the density of
the local anesthetic solution divided by the
density of CSF, which averages 1.0003 ±
0.0003 g/mL at 37°C.
 Cont…
Hyperbaric solution: local anesthetic is denser (heavier)
than CSF.
• Hyperbaric solutions tend to move to the most dependent
area of the spine (normally T4–T8 in the supine position).
• With the patient in a head-down position, a hyperbaric
solution spreads cephalad and caudad if head-up position
is assumed.
• when a patient remains in a lateral position, a hyperbaric
spinal solution will have a greater effect on the dependent
(down) side
 Cont…
 The local anesthetic solutions can be made
hyperbaric by the addition of glucose.
 Cont…
Hyporbaric Solution: is less dense (lighter) than
CSF.
• with the patient in a head-down position, a
hypobaric anesthetic solution moves caudad
and a head-up position causes a hypobaric
solution to ascend cephalad.
• When a patient remains in a lateral position, a
a hypobaric solution will achieve a higher level
on the nondependent (up) side.
 Cont…
• The local anesthetic solutions can be made
hypobaric by the addition of sterile water or
fentanyl.
 Cont…
• Isobaric Solution : has equal density with the
CSF.
• Tends to remain at the level of injection.
 Spinal Anesthetic Agents

• Only preservative-free local anesthetic solutions are

used.
• Hyperbaric bupivacaine and tetracaine are two of the
most commonly used agents for spinal anesthesia.
• Both are relatively slow in onset (5–10 min) and have
a prolonged duration (90–120 min).
 Spinal Anesthetic Additives

Vasoconstrictors: prolong the duration of spinal

anesthesia.
• They seem to delay the uptake of local anesthetics from
CSF and may have weak spinal analgesic properties.
Example: epinephrine (0.1–0.2 mg)
Phenylephrine (2 to 5 mg)
• The α2-agonists clonidine and dexmedetomidine prolong
the duration of subarachnoid anesthesia and analgesia.
Clonidine(75 to 150 mg)
 Cont…
Opioid: enhance the quality and prolong the duration of spinal
anesthesia.
•Example:fentanyl (5 to 10 μg)
morphine(0.1-0.2mg)
sulfentanil(1.25-5 μg)
•Intrathecal morphine can provide prolonged (12 to 24 hours)
postoperative analgesia but side effects, including itching and
nausea and vomiting, are common and challenging to treat.
•Rarely, intrathecal morphine can produce delayed respiratory
depression.
 Cont…
 Sodium bicarbonate : addition of 1 mEq/10 mL of
local anesthetics immediately before injection
accelerate the onset of the neural blockade.
 saddle block
• Can be achieved by keeping the patient sitting
for 3–5 min following injection, so that only
the lower lumbar nerves and sacral nerves are
blocked.
EPIDURAL ANESTHESIA
 Epidural Anesthesia
Epidural Anesthesia :is administration of local
anesthetic agent into the epidural space.
• An epidural block can be performed at the lumbar,
thoracic, or cervical level.
• Thoracic epidural blocks are technically more
difficult to accomplish than are lumbar blocks
because of greater angulation and the
overlapping of the spinous processes at the
vertebral level
 Cont…
• Epidurals can be used as a single shot technique or
with a catheter that allows intermittent boluses or
continuous infusion.
• The motor block can range from none to complete.
 Cont…
• By using relatively dilute concentrations of a local
anesthetic combined with an opioid, an epidural
provides analgesia without motor block which is
commonly employed for labor and postoperative
analgesia.
• A segmental block is characterized by a well-defined
band of anesthesia at certain nerve roots; leaving
nerve roots above and below unblocked.
 Cont…
• This can be seen with a thoracic epidural that
provides upper abdominal anesthesia while sparing
cervical and lumbar nerve roots.
 Cont…
Epidural Needles
• The standard epidural needle is typically 17–18
gauge, 3 or 3.5 inches long, and has a blunt bevel
with a gentle curve of 15–30° at the tip.
• The blunt, curved tip helps to push away the dura
after passing through the ligamentum flavum instead
of penetrating it.
 Cont…
Epidural Catheters
• Placing a catheter into the epidural space allows for
continuous infusion or intermittent bolus techniques.
• In addition to extending the duration of the block, it
may allow a lower total dose of anesthetic to be
used.
• A 19- or 20-gauge catheter is introduced through a
17- or 18-gauge epidural needle and the catheter is
advanced 2–6 cm into the epidural space.
 Cont…
• The shorter the distance the catheter is advanced,
the more likely it is to become dislodged.
• Conversely, the further the catheter is advanced, the
greater the chance of a unilateral block.
 Cont…
• After advancing the catheter the desired depth, the
needle is removed, leaving the catheter in place.
• The catheter can be taped or otherwise secured
along the back.
• Some have spiral wire-reinforced catheters are very
resistant to kinking.
Specific Techniques for Epidural Anesthesia

• Using the midline or paramedian approaches ,

the epidural needle is passed through the skin
and the ligamentumflavum.
• Two techniques to determine when the tip of
the needle has entered epidural space:
 “Loss of resistance” and
 “Hanging drop” techniques
 Cont…
The loss of resistance technique
• The needle is advanced through the subcutaneous
tissues with the stylet in place until the interspinous
ligament is entered, as noted by an increase in tissue
resistance.
• The stylet or introducer is removed, and a glass
syringe filled with approximately 2 mL of saline or air
is attached to the hub of the needle.
 Cont…
• As the tip of the needle just enters the epidural
space, there is a sudden loss of resistance, and
injection is easy.
 Cont…
Hanging drop techniques
• Once the interspinous ligament has been entered and
the stylet has been removed, the hub of the needle is
filled with solution so that a drop hangs from its
outside opening.
• As long as the tip of the needle remains within the
ligamentous structures, the drop remains “hanging.”
• However, as the tip of the needle enters the epidural
space, it creates negative pressure, and the drop of
fluid is sucked into the needle.
 Activating an Epidural
• The quantity (volume and concentration) of
local anesthetic needed for epidural anesthesia
is larger than that needed for spinal anesthesia.
• Toxic side effects are likely if a “full epidural
dose” is injected intrathecally or intravascularly.

• Safeguards against toxic epidural side effects

include test and incremental dosing.
 Cont…
• Test dose is designed to detect both subarachnoid
and intravascular injection .
• The classic test dose combines local anesthetic and
epinephrine, typically 3 mL of 1.5% lidocaine with
1:200,000 epinephrine (0.005 mg/mL).
• The 45 mg of lidocaine, if injected intrathecally, will
produce spinal anesthesia that should be rapidly
apparent.
 Cont…
• The 15 mcg dose of epinephrine, if injected
intravascularly, should produce a noticeable increase
in heart rate (20% or more), with or without
hypertension.
 Cont…
Incremental dosing is a very effective method of
avoiding serious complications.
• If aspiration is negative, a fraction of the total
intended local anesthetic dose is injected, typically 5
mL.
• This dose should be large enough for mild symptoms
of intravascular injection to occur, but small enough
to avoid seizure or cardiovascular compromise.
 Cont…
• Following the initial 1–2 mL per segment bolus (in
fractionated doses), repeat doses delivered through
an epidural catheter are done:
 on a fixed time interval or
 when the block demonstrates some degree of
regression.
• Once some regression in sensory level has occurred,
one-third to one-half of the initial activation dose can
generally safely be reinjected in incremental doses
 Factors Affecting Level of Block
 Volume: In adults, 1–2 mL of local anesthetic
per segment to be blocked is a generally
accepted guideline.
For example, to achieve a T4 sensory level from an L4–
L5 injection would require about 12–24 mL.
 Age: dose required to achieve the same level of
anesthesia decreases with age because of age-
related decreases in the size or compliance of the
epidural space.
 Cont…
 Height: affects the extent of cephalad spread.
• Thus, shorter patients may require only 1 mL of local
anesthetic per segment to be blocked, whereas taller
patients generally require 2 mL per segment.
 Additives to the local anesthetic: particularly opioids,
tend to have a greater effect on the quality of
epidural anesthesia and epinepheren prolongs their
action.
 Failed Epidural Blocks
• Unlike spinal anesthesia, in which the endpoint is
usually very clear (free flowing CSF) and the
technique is associated with a very high success rate,
epidural anesthesia is dependent on detection of a
more subjective loss of resistance (or hanging drop).
 Cont…
• Causes:
 In some patients, the spinal ligaments are soft , and
either good resistance is never appreciated or a false
loss of resistance is encountered.
 Intrathecal, subdural, and intravenous injection)
 A unilateral block can occur if the medication is
delivered through a catheter that has either exited
the epidural space or coursed laterally.
 Cont…
• When unilateral block occurs, the problem may be
overcome by withdrawing the catheter 1–2 cm and
reinjecting it with the patient turned with the
unblocked side down
CAUDAL ANESTHESIA
 Cont…
Caudal epidural anesthesia is a common regional
technique in pediatric patients and it may also be
used for anorectal surgery in adults.
 Cont…
Landmarks
• The posterior superior iliac spines and the
sacral hiatus define an equilateral triangle.
 Cont…
• Calcification of the sacrococcygeal ligament may
make caudal anesthesia difficult or impossible in
older adults.
• The patient is placed in the lateral or prone position
with both hips flexed, and the sacral hiatus is
palpated.
 Cont…
• After sterile skin preparation, a needle or intravenous
catheter (18–23 gauge) is advanced at a 45° angle
cephalad until a pop is felt as the needle pierces the
sacrococcygeal ligament.
• The angle of the needle is then flattened and
advanced.
• Aspiration for blood and CSF is performed, and, if
negative, injection can proceed.
 Cont…
• Some clinicians recommend test dosing as with other
epidural techniques, although many simply rely on
incremental dosing with frequent aspiration.
 Cont…
• A dosage of 0.5–1.0 mL/kg of 0.125–0.25%
bupivacaine is used.
• Repeated injections can be accomplished via
repeating the needle injection or via a catheter.
 Cont…
• Higher dermatomal levels of epidural
anesthesia/analgesia can be accomplished with
epidural catheters threaded cephalad into the
lumbar or even thoracic epidural space from the
caudal approach in infants and children.
Complications Of Regional
Anesthesia
 Cont…
• The complications of epidural, spinal, or caudal
anesthetics range from the bothersome to life-
threatening.
• The complications can be:
 resulting from excessive effects of an appropriately
injected drug
 placement of the needle (or catheter), and
 systemic drug toxicity
 1. Complications Associated with Excessive
Responses to Appropriately Placed Drug

A. High Neural Blockade

• Exaggerated dermatomal spread of neural blockade can
occur readily with either spinal or epidural anesthesia.
• Causes can be:
 failure to reduce standard doses in selected patients
(eg, the elderly, pregnant, obese, or very short),
 unusual sensitivity or spread of local anesthetic may
be responsible
 Cont…
Sign and symptoms:
 nausea often precedes hypotension
 numbness or weakness in the upper extremities
 apnea is more often the result of severe sustained
hypotension and medullary hypoperfusion.
 Cont…
 severe hypotension
 bradycardia and
 Unconsciousness
Management:
 Maintaining an adequate airway and
ventilation and supporting the circulation.
 Cont…
• When respiratory insufficiency becomes evident, in
addition to supplemental oxygen, assisted
ventilation, intubation, and mechanical ventilation
may be necessary.
• Hypotension can be treated with rapid
administration of intravenous fluids, a head-down
position, and intravenous vasopressors.
• Bradycardia can be treated early with atropine.
 Cont…
B. Cardiac Arrest During Spinal Anesthesia
• Many physicians believed over sedation and
unrecognized hypoventilation and hypoxia were the
cause
• Vagal responses and decreased preload as key factors
and suggests that patients with high baseline vagal
tone are at risk.
 Cont…
C. Urinary Retention
• Local anesthetic block of S2–S4 root fibers decreases
urinary bladder tone and inhibits the voiding reflex.
 2.Complications Associated with Needle or Catheter Insertion

A. Inadequate Anesthesia or Analgesia

 Cont…
B. Intravascular Injection
• Accidental intravascular injection of the local
anesthetic for epidural and caudal anesthesia can
produce very high serum levels.
• Extremely high levels of local anesthetics affect the
central nervous system (seizure and
unconsciousness) and the cardiovascular system
(hypotension, arrhythmias, and depressed
contractility).
 Cont…
• The incidence of intravascular injection can be minimized
by:
 carefully aspirating the needle (or catheter) before every
injection
 using a test dose
 always injecting local anesthetic in incremental doses and
 close observation for early signs of intravascular injection
(tinnitus, lingual sensations).
• Treatment : resuscitative, and lipid rescue should be
employed.
 Cont…
C. Total Spinal Anesthesia
• Total spinal anesthesia can occur following attempted
epidural/caudal anesthesia if there is accidental
intrathecal injection.
• Onset is usually rapid, because the amount of
anesthetic required for epidural and caudal anesthesia
is 5–10 times that required for spinal anesthesia.
• Careful aspiration, use of a test dose, and incremental
injection techniques during epidural and caudal
anesthesia can help avoid this complication.
 Cont…
D. Subdural Injection
• Accidental administration of local anesthetic drug
into subdural space during attempted epidural
anesthesia is much more serious than during
attempted spinal anesthesia.
Sign and symptom: similar with high and total spinal
• Onset may be delayed for 15–30 min.
Management: like high spinal or total spinal
 Cont…
E. Backache
• As a needle passes through skin, subcutaneous tissues,
muscle, and ligaments it causes varying degrees of tissue
trauma.
• Bruising and a localized inflammatory response with or
without reflex muscle spasm may be responsible for
postoperative backache.
• Postoperative back ache is usually mild and self-limited but
it may be an important clinical sign of much more serious
complications, such as epidural hematoma and abscess
 Cont…
Treatment : acetaminophen, NSAIDs, and warm
or cold.
 Cont…
F. Postdural Puncture Headache
• Any breach of the dura may result in a postdural
puncture headache (PDPH).
• The incidence of PDPH is strongly related to needle
size, needle type.
 Factors that increase the risk of PDPH include :
 young age
 female sex and
 pregnancy.
 Cont…
Sign and symptom
 PDPH is bilateral, frontal or retroorbital, or occipital
and extends into the neck.
 May be throbbing or constant and associated with
photophobia and nausea.
 The hallmark of PDPH is its association with body
position.
 Cont…
 The pain is aggravated by sitting or standing and
relieved or decreased by lying down flat.
 onset of headache is usually 12–72 hr following the
procedure
Cause: leakage of CSF from a dural defect and
intracranial hypotension.
 Cont…
• Loss of CSF at a rate faster than it can be produced
causes traction on structures supporting the brain,
particularly the meninges, dura, and tentorium.
• Increased traction on blood vessels and cranial
nerves may also contribute to the pain
 Cont…
Treatment
Conservative treatment involves:
 recumbent positioning(Keeping the patient supine will
decrease the hydrostatic pressure driving fluid out of the
dural hole and minimize the headache)
 analgesics(Analgesic medication may range from
acetaminophen to NSAIDs and opioids. )
 intravenous or oral fluid administration(Hydration and
caffeine work to stimulate production of CSF.) and
 caffeine (Caffeine further helps by vasoconstricting
intracranial vessels.)
 Cont…
Effective treatment
 Epidural blood patch
• It involves injecting 15–20 mL of autologous blood
into the epidural space at the level of the dural
puncture.
• It is believed to stop further leakage of CSF by
coagulation.
 Cont…
G. Neurological Injury
• Postoperative peripheral neuropathies can be due to
direct physical trauma to nerve roots
• Although most resolve spontaneously, some are
permanent.
• Some of these deficits have been associated with
paresthesia from the needle or catheter or
complaints of pain during injection.
 Cont…
• Any sustained paresthesia should alert the clinician to
redirect the needle.
• Injections should be immediately stopped and the needle
withdrawn, if they are associated with pain.
• Direct injection into the spinal cord can cause paraplegia.
• Damage to the conus medullaris may cause isolated sacral
nerve dysfunction, including paralysis of the biceps
femoris muscles; anesthesia in the posterior thigh, saddle
area, or great toes; and loss of bowel or bladder function.
 Cont…
H. Spinal or Epidural Hematoma
• A clinically significant spinal hematoma can occur
following spinal or epidural anesthesia, particularly in
the presence of abnormal coagulation or a bleeding
disorder.
• The pathological insult to the spinal cord and nerves
is due to the hematoma’s mass effect, compressing
neural tissue and causing direct pressure injury and
ischemia
 Cont…
Symptoms include: sharp back and leg pain with
a motor weakness and/or sphincter dysfunction
Treatment: When hematoma is suspected,
neurological imaging (magnetic resonance imaging
[MRI] or computed tomography [CT]) and neurosurgical
consultation must be obtained immediately
• Surgical decompression
 Cont…
I. Meningitis
• Infection of the subarachnoid space can follow
neuraxial blocks as the result of contamination of the
equipment or injected solutions, or as a result of
organisms tracked in from the skin.
 Cont…
J. Epidural Abscess
• Spinal epidural abscess (EA) is a rare but potentially devastating
complication of neuraxial anesthesia.
DX: Blood culture
MRI or CT scanning should be performed to confirm or rule out
the diagnosis.
Mgt:
 antibiotics
 percutaneous drainage with fluoroscopic or CT guidance
 decompression
 Cont…
K. Sheering of an Epidural Catheter
• There is a risk of neuraxial catheters sheering and
breaking off inside of tissues if they are withdrawn
through the needle.
• If a catheter must be withdrawn while the needle
remains in situ, both must be carefully withdrawn
together.
 3.Complications Associated with Drug
Toxicity
A. Systemic Toxicity
• Absorption of excessive amounts of local
anesthetics can produce toxic blood level.
 Cont…
B. Transient Neurological Symptoms
• The pathogenesis of TNS is believed to represent
concentration-dependent neurotoxicity of local
anesthetics.
• Characterized by back pain radiating to the legs without
sensory or motor deficits, occurring after the resolution
of spinal anesthesia and resolving spontaneously within
several days.
• Most commonly associated with hyperbaric lidocain but
also seen with other local anesthetic drugs.
 Cont…
C) Cauda equina syndrome
• Cauda equina nerve roots travel long distances
within the spinal canal and are not extensively
myelinated, thus they are susceptible to direct
chemical injury.
• Pooling or “maldistribution” of hyperbaric solutions
of lidocaine can damage the nerve roots of the cauda
equina.
 Cont…
• CES is characterized by bowel and bladder
dysfunction together with evidence of multiple nerve
root injury.
THE END