Spinal Anesthesia

Spinal anesthesia is induced by injecting small amounts of local anesthetic into the cerebro-
spinal fluid (CSF).

 We use lidocaine or bupivacaine.

Spinal anesthesia is easy to perform and has the potential to provide excellent operating
conditions for surgery below the umbilicus.

Layers to puncture:
 Skin
 Subcutaneous tissue
 Supraspinous ligament
 Interspinous ligament
 Ligamentum flavum
 Epidural space
 Dura
 Subarachnoid space.

Equipments:

Assemble the necessary equipment on a sterile surface. It will include:

 A spinal needle. The ideal would be 24-25 gauge with a pencil point tip to minimize the
risk of the patient developing a post-spinal headache.
 An introducer, if using a fine gauge needle as they are thin and flexible, and therefore
difficult to direct accurately. A standard 19 gauge (white) disposable needle is suitable
for use as an introducer.
 A 5ml syringe for the spinal anesthetic solution.
 A 2ml syringe for local anesthetic to be used for skin infiltration.
 A selection of needles for drawing up the local anesthetic solutions and for infiltrating
the skin.
 antiseptic for cleaning the skin, e.g. chlorhexidine, iodine, or methyl alcohol.
 Sterile gauze swabs for skin cleansing.
 A sticking plaster to cover the puncture site.
 The local anesthetic to be injected intrathecally should be in a single use ampoule.
Never use local anesthetic from a multi-dose vial for intrathecal injection. Spare
equipment and drugs should be readily available if needed.
Types of spinal needles

 Smaller gauge atraumatic needles, such as the Conical-point Whitacre , Gertie Marx
needles, and the pencil-point Sprotte needle(with side orifice) are commonly used for
spinal anesthesia(less PDPH)
 Quincke needles with sharp cutting bevel

Indications For Spinal Anesthesia:

 Spinal anesthesia is best reserved for operations below

the umbilicus e.g. hernia repairs, gynecological and
urological operations and any operation on the
perineum or genitalia.
 Spinal anesthesia is particularly suitable for older
patients and those with systemic disease such as
chronic respiratory disease, hepatic, renal and
endocrine disorders such as diabetes.
 Many patients with mild cardiac disease benefit from
the vasodilatation that accompanies spinal anesthesia
except those with stenotic valvular disease or uncontrolled hypertension.
 In obstetrics, it is ideal for manual removal of a retained placenta.

Contraindications to Spinal Anesthesia

 Inadequate resuscitation drugs and equipment. No regional anesthetic technique should

be attempted if drugs and equipment for resuscitation are not immediately to hand.
 Clotting disorders. If bleeding occurs into the epidural space because the spinal needle
has punctured an epidural vein, a hematoma could form and compress the spinal cord.
 Hypovolemia from whatever cause e.g. bleeding, dehydration due to vomiting, diarrhea
or bowel obstruction. Patients must be adequately rehydrated or resuscitated before
spinal anesthesia or they will become very hypertensive.
 Patient refusal.
  Infection on the back near the site of lumbar puncture lest infection be introduced into
the epidural or intrathecal space.

Epidural anesthesia

Involves the insertion of a hollow needle and a small, flexible catheter into the space between
the spinal column and outer membrane of the spinal cord (epidural space) in the middle or
lower back.

 We use lidocaine or bupivacaine.

Equipment:

Modern epidural kits are usually disposable and packed in a sterile fashion. All equipment and
drugs used should be sterile, and drugs should be preservative free.

 The epidural needle is typically 16-18G, 8cm long with surface markings at 1cm
intervals, and has a blunt bevel with a 15-30 degree curve at the tip.
 The most commonly used version of this needle is the Tuohy needle, and the tip is
referred to as the Huber tip.
 Traditionally, a glass syringe with a plunger(LOR), which slides very easily, has been
used to identify the epidural space.
 Epidural catheters are designed to pass
through the lumen of the needle and are made
of a durable but flexible plastic, and have
either a single end-hole or a number of side
holes at the distal end.

Indication

 Epidural anaesthesia can be used as sole anesthetic for procedures involving the lower
limbs, pelvis, perineum and lower abdomen.
  The advantage of epidural over spinal anaesthesia is the ability to maintain continuous
anaesthesia after placement of an epidural catheter, thus making it suitable for procedures
of long duration.
 This feature also enables the use of this technique into the postoperative period for
analgesia, using lower concentrations of local anesthetic drugs or in combination with
different agents.

Contraindications

 Absolute:-
 Patient refusal
 Coagulopathy. Insertion of an epidural needle or catheter into the epidural space may
cause traumatic bleeding into the epidural space.
 Clotting abnormalities may lead to the development of a large hematoma leading to
spinal cord compression.
 Therapeutic anticoagulation. As above
 Skin infection at injection site. Insertion of the epidural needle through an area of skin
infection may introduce pathogenic bacteria into the epidural space, leading to serious
complications such as meningitis or epidural abscess.
 Raised intracranial pressure. Accidental dural puncture in a patient with raised ICP may
lead to brainstem herniation (coning).
 Hypovolemia. The sympathetic blockade produced by epidurals, in combination with
uncorrected Hypovolaemia, may cause profound circulatory collapse.

Epidural needles

 The epidural needles are designed to allow the passage of epidural catheters through
them.
 Accidental dural puncture causing CSF leak

EPIDURAL CATHETER

 Made up of nylon or polyvinyl chloride.

  Radiopaque.
 The tip is traumatic, rounded has lateral holes, and is closed-end.
 Connector with Luer-lock cap.
 Catheter length: 90–100 cm

COMPLICATIONS OF EPIDURAL NEEDLES

 Epidural hematoma:
 Postdural puncture headache—due to accidental dural puncture.
 Backache.
 Epidural abscess.

Caudal Epidural

Caudal epidural block is a commonly used technique for surgical anesthesia in children
and chronic pain management in adults. It is performed by inserting a needle through the sacral
hiatus to gain entrance into the sacral epidural space.
  Advantages of Caudal Block
 Good postoperative pain relief.
 Useful along with GA in pediatric patients, reduces the requirements of analgesics,
inhalational agents and muscle relaxants.

Saddle Block

 After giving a spinal, the patient is made to sit for 5 minutes so that the hyperbaric spinal
LA settles to the lowest point of dural sac with gravity. The volume of the spinal
anesthetic injected is very little, i.e. 1.5–2 mL of 0.5% bupivacaine. After 5 minutes of
the injection, the spinal LA get fixed to the lower sacral nerve roots.

indications for saddle block:

 Rectal surgeries like hemorrhoidectomy.

 Perineal surgeries
 Obstetrics—suture of episiotomy
 The advantage of this saddle block is that there is a great amount of hemodynamic
stability as very few spinal nerve roots are blocked.

Infusion and Syringe Pumps

 A medical device used to deliver fluids into a patient’s body in a controlled manner.

Types of Infusion Devices

 A simple IV set with its controlling C air clamp is the most basic infusion delivery
system.
 Dial a flow.
 Automated infusion Pumps.
 Syringe Pumps.

Types of Infusion Devices

Syringe pump machine:

 mechanical or electronic devices that deliver and adjust doses on their own based on the
preset criteria decided by the clinician.
 delivery systems to maintenance of blood pressure at a desired level using a vasopressor.
 insulin pumps.
 Patient-controlled Analgesia (PCA) Pumps.
Syringe Pumps:

Feature and knobs:

 Bolus dose.
 Syringe size recognition.
 Occlusion alarms.
 Near empty and empty syringe alarm.