GENERAL ANESTHESIA: JULIE A.

NOTES
GOALS OF ANESTHESIA:
-Hypnosis/Unconsciousness -Amnesia
-Analgesia -Muscle Relaxation/Akinesis -Autonomic & Sensory blockade
Pre-anesthesia Preparation
A. Preoxygenation/Denitrogenation B. Patient Positioning
▪ Delay/ eliminate onset of hypoxemia ▪ Sniffing position: elevate head 8-10 cm put pads under occiput; improves maintenance of the passive
▪ Allows longer duration of apnea without desaturation. pharyngeal airway with obstructive sleep apnea
▪ Safe Apnea Time: ˜9 mins (for healthy adult); time before the apneic patient desaturates ▪ Ramping/Stacking: indicated for obese & pregnant patients (due to wider A-P diameter of the chest);
▪ Goal: achieving end-tidal oxygen level >90% align ears to sternal notch using pads & cushions.
▪ For obese px: do 25⁰ head-up position → decrease atelectasis & improve V/Q matching. ▪ Manual in-line stabilization: for suspected cervical spine injury; assistant’s hand place on both sides of the
patient’s head to align it with the body

Phase 1: Induction Phase (Anesthesia Induction techniques

AWAKE RAPID SEQUENCE INDUCTION (RSI) INTRAVENOUS INHALATION
Use in -Difficult airway -Aspiration risk -With IV access -No IV access
-Aspiration risk -limit COVID transmission -Postoperative nausea and -Spontaneous breathing can be preserved
-Inadequate NPO vomiting (PONV) risk
-Malignant hyperthermia
Cons -Requires patient cooperation -Difficult airway -If with PONV risk
-Poor control of physiologic -Malignant hyperthermia
responses -Requires patient cooperation
Indications -Those with increased risk of aspiration of gastric content. -For pediatric patient (without IV access)
-Those with anticipated difficulty airway
(spontaneous respiratory efforts are preserved)
Disadvantages -Ablate protective airway reflexes & pharyngeal
muscular tone
Other features -Goals: Minimize time between onset of unconsciousness & -Most common induction techniques Volatile Induction & Maintenance Anesthesia
tracheal intubation; Reduce risk of regurgitation by in adults (VIMA)
applying CRICOID PRESSURE (downward external pressure -Use single-agent in all anesthesia phases
with thumb & index finger on the cricoid cartilage to -Steps: High volume O2 → Fill breathing system
displace the cartilaginous cricothyroid ring posteriorly with 8% Sevoflurane → Px exhales maximally →
O2 + Volatile agent via face mask → Px inhales
-Steps: Preoxygenation → IV administration of hypnotic → deeply, hold breath → Px breath deeply → Px
Immediate administration of rapid-onset neuromuscular sleeps within 1 min.
blocking drugs (ex. Succinylcholine 1-1.5 mg/kg) → Apply
cricoid pressure → Avoid ventilation via mask → Tracheal
intubation → Release of cricoid pressure after confirmation
of correct endotracheal tube placement
Pharmacologic -Propofol, Thiopental, Etomidate, -Sevoflurane: commonly used agent; Low
Agents Ketamine, & Benzodiazepine-Opioid pungency, High potency, rapid onset.
-Neuromuscular blocking drug (Ex.
Succinylcholine): facilitate direct
laryngoscopy & intubation. *Ensure
ventilate prior to giving NMB.
Roles of Pharmacologic Agents for General Anesthesia
Goals Drug Class Examples MOA Reversal Agents
• Propofol (Induction dose: 1.5-2.5 mg/kg, Infusion: 100-300 mcg/kg/min,
Clearance: 30 ml/min/kg, Decrease cerebral blood flow & ICP)
• Etomidate (Hemodynamic stability, Cerebral protection
HYPNOSIS SEDATIVE-HYPNOTIC AGENTS • Thiopental (Ultra-short-acting, Poor analgesic property, Induction dose: Adult: 3- l
5 mg/kg)
Ketamine (NMDA receptor antagonism, Only IV anesthetic possessing Deep
analgesia and dose-related CVS stimulation)
Midazolam (responsible for no competitive antagonism at GABAA
recollection of intraoperative events after receptor
AMNESIA BENZODIAZEPINES Flumazenil
neuraxial anesthesia withs sedation),
Diazepam, Lorazepam
OPIOIDS Mu-agonists: Fentanyl (Opioid analgesics), Morphine, Oxycodone, Meperidine,
ANALGESIA (toxicity: decreased respiratory rate & pinpoint Remifentanil Naloxone
pupils)
D-NMB: succinylcholine
PARALYSIS NEUROMUSCULAR BLOCKERS  Neostigmine (reverse residual atracurium)
ND-NMB: Atracurium, Rocuronium

AIRWAY MANAGEMENT
▪ Implemented AFTER the induction of anesthesia
AWAKE INTUBATION VENTILATION VIA MASK SUPRAGLOTTIC AIRWAY ENDOTRACHEAL INTUBATION DIRECT LARYNGOSCOPY & INTUBATION
Indication -those with -those with difficulty/ impossible face -Elderly patient, with Mallampati 2
anticipated difficulty mask ventilation airway classification, with
of ventilation -ex. Adequately fasted bearded male hematemesis, taking Apixaban for
-Facial trauma for excision of lipomas on the chest dysrhythmia
-Cervical spine injury
-Chronic cervical
spine diseases
-Lesions in the
upper airway
-Full stomach
Other -advantage: less risk of airway -Important to confirm correct -Laryngoscopic view of glottis by -Three exes that must be aligned to obtain a line
features trauma positioning of SGA by observing End- CORMACK & LEHANE SCORE: of vision: Oral, Pharyngeal, & laryngeal
-Adequate Ventilation tidal CO2 & auscultation of breath ▪ Grade I: Most of glottis is -Steps: Laryngoscope held by left hand →
Technique: Open airway, Place sounds after insertion. visible Patient’s mouth is manually opened →
the mask making tight seal, & -No airway protection: most notable ▪ Grade II: Only the posterior laryngoscope blade is inserted on right side of
deliver high quality ventilations. disadvantage of SGA portion of glottis is visible the mouth → Tongue swept towards the left →
▪ Grade III: epiglottis but no part scope advanced towards epiglottis → scope
-Predictors of difficult mask -Advantages over endotracheal: of the glottis can be seen lifted to displace soft tissues & expose glottic
ventilation: ▪ Place quick & without use of ▪ Grade IV: no airway structures opening → endotracheal tube introduced
▪ >55 years old laryngoscope are visible towards glottis → Tube inserted 1-2cm past the
▪ BMI > 30 mg/m2 ▪ Less hemodynamic changes vocal cords → scope blade removed from mouth
▪ Beard (inadequate seal) ▪ Less coughing → Pilot balloon of ETT is inflated to create seal
▪ Lack of teeth ▪ No need for muscle relaxants against tracheal mucosa → Confirm correct
▪ History of snoring or OSA ▪ Preserved laryngeal competencies placement of ETT → Tube secured with tape
▪ Mallampati class III or IV & mucociliary function
▪ History of neck radiation ▪ Less laryngeal trauma -Confirmation of ETT:
▪ Male sex ▪ Used for difficult ventilation & ▪ Identification of CO2 in the exhaled tidal
▪ Limited ability to protrude intubations volume
the mandible ▪ Does not require use of ▪ Auscultation: Symmetric chest rise, bilateral
▪ History of airway neuromuscular blockers breath sounds, absence of breath sounds over
mass/tumor epigastrium
-Difficult SGA in: ▪ Palpation of ETT cuff in the suprasternal notch
 ▪ After multiple laparoscopy
attempts
-Cause of difficult face mask
ventilation: (may lead to
Hypoxic Brain Damage)
▪ Inadequate
mask/supraglottic airway
seal
▪ Excessive gas leak
▪ Excessive resistance to the
ingress or egress of gas
-Steps: Face mask apposed to
the patient’s face → Left hand
lifts the mandible to the face
mask → Pressure on the
submandibular soft tissue is
avoided to avoid airway
obstruction → Left thumb &
index finger apply
counterpressure on facemask →
Anterior pressure on angle of
the mandible (jaw thrust),
atlanto-occipital joint extension,
& chin lift maximize pharyngeal
space → Right hand generate
positive pressure by squeezing
the reservoir bag of anesthesia
breathing circuit → Ventilation
pressure less than 20 cm H2O to
avoid insufflation of the
stomach.
▪ Small mouth opening ▪ Maintenance of arterial oxygenation
▪ Supra- / Extraglottic disease
▪ Fixed cervical spine deformity ESOPHAGEAL INTUBATION:
▪ Use of cricoid pressure -Breath sounds OVER epigastrium
▪ Poor dentition/ Large incision - (+) Voice
▪ Male sex - No EtCO2
▪ Surgical table rotation -Pull out ETT, repeat attempt
▪ Increased BMI
ENDOBRONCHIAL INTUBATION:
-Contraindications: -Unintentional placement of ETT in mainstem or
▪ At risk for regurgitation segmental bronchitis
▪ Non-supine position -Result to hyperventilation of one lung &
▪ Obesity, pregnant hypoventilation
▪ Long surgical time -Asymmetric Breath Sounds
▪ Intra-abdominal/ airway -Adjust ETT
procedures
Secure ETT:
-Complications of Laryngeal mask A. Head flexion: ETT advancing towards carina
airway (LMA): ➔ Endobronchial Intubation
▪ Bronchospasm B. Head extension: ETT away from carina →
▪ Postoperative swallowing inadvertent EXtubation
difficulties
▪ Respiratory obstruction
▪ Laryngeal nerve injury
▪ Edema
▪ Hypoglossal nerve paralysis
▪ Aspiration

-Signs of Inadequate Mask

Ventilation:
▪ Absent/minimal chest rise
▪ Absent/inadequate breath
sounds
▪ Cyanosis
▪ Gastric Air entry
▪ Decreasing/inadequate
SpO2
▪ Absent/inadequate EtCO2
▪ Hemodynamic changes
associated with
hypoxemia/hypercarbia
DIFFICULT AIRWAY MANAGEMENT
• Difficult patient cooperation & consent
• Difficult mask ventilation (inadequate mask seal, excessive gas leak, excessive resistance to the ingress or egress of gas)
• Difficult supraglottic airway placement (difficult SGA placement, multiple attempts of placement, inadequate SGA seal, excessive gas leak, excessive resistance to ingress or egress of gas)
• Difficult laryngoscopy (cannot visualize vocal cords)
• Difficult or failed intubation or extubation (loss of airway patency)
• Difficult or failed surgical airway access (anatomical abnormalities)
Phase 2: Maintenance
Goals: STAGES OF ANESTHETIC DEPTH
• Stage III surgical anesthesia Stage III (SURGICAL Stage IV (MEDULLARY
Stage I (ANALGESIA STATE) Stage II (DELIRIUM STAGE)
• Physiologic hemostasis (oxygenation, ventilation, ANESTHESIA) DEPRESSION)
hemodynamic stability, temperature control) Conscious, rational, decreased Unconscious, body respond reflexively, Increased muscle relaxation, Depressed cardiovascular and
• Avoidance of anesthetic recall perception of pain irregular patter with breath holding unable to protect airway respiratory centers
• Analgesia (+) Aberration of vital signs (hypertension,
• Muscle Relaxation tachycardia, arrhythmia, laryngospasm)

TYPES INHALATION ANESTHESIA INTRAVENOUS ANESTHESIA

Advantages/ - Able to monitor anesthetic depth (via gas analyzers) - Contraindicated to volatile agents (PONV risk)
Indication - Easy administration & titratable - Procedural requirements (spine surgery)
- Reliable dose dependent responses (blockade of autonomic responses, decreased skeletal &
smooth muscle tone, bronchodilation, increased cerebral blood flow, decreased cerebral oxygen
requirement)
Disadvantages - Increased PONV - Suppression of airway reflexes & respiratory depression
- Malignant hyperthermia (especially volatile agents) - Vasodilation & myocardial depression
- Dose dependent myocardial depression & vasodilation - Blood concentration not easily maintained
- Maintenance phase - Anesthetic depth not always ensured
- During anesthesia emergence (associated with coughing & airway hyperreactivity) - Drug levels affected by IV tubing problems.

Phase 3: Emergence
Concerns:
- Titration of anesthetic agents to ensure recovery
- Monitor for residual NMB blockade & need for
reversal to prepare for extubation
- Pain medications & antiemetics
Examples: Steps: Administer 100% O2 → Reverse residual neuromuscular blockade → suction
- Extensive neck surgery for big anterior neck mass oropharynx & place bite block → once extubation criteria is met, remove ETT → deliver
→ postponed Extubation (expect airway edema) 100% O2 via face mask; confirm airway patency, adequate ventilation, & oxygenation.
- Posterior fossa surgery → prolonged intubation

Types AWAKE EXTUBATION DEEP EXTUBATION

Features • Endotracheal extubation during light levels of anesthesia • Tracheal extubation BEFORE return of protective airway reflexes
• Assoc. with less coughing
Indications • Those with difficult airway • Ophthalmologic surgeries
• High aspiration risk • At risk for bleeding (thyrodectomies)
• Pulmonary condition (obese)
Complications/ Laryngospasm (forceful involuntary spasm of the laryngeal musculature) • Difficult ventilation & intubation
Contraindication • Clinical signs: disconjugate gaze, breath-holding, or coughing, not responsive • Aspiration risk
to commands. • Restricted access to airway
• Occurs during extubation in Stage II anesthesia • Obstructive sleep apnea
• Triggers: Oral & tracheal secretion • Obese
• TX: Positive pressure ventilation, IV lidocaine (1-1.5 mg/kg), Succinylcholine • Procedure resulting in airway edema, bleeding, or increased irritability
(0.25-0.5 mg/kg), (+/-) small dose of propofol • Risk for pulmonary compromise
Extubation Criteria After anesthesia IMMEDIATE EXTUBATION DELAYED EXTUBATION
• Adequate oxygenation • Awake • Recommended for those who underwent extensive thyroidectomy & bilateral neck
• Adequate ventilation • Following commands dissection for large anterior neck mass
• Hemodynamically stable • Breathing spontaneously (well oxygenated, not excessively • Hypoxic
• Full reversal of muscle relaxation hypercarbic) • Excessively hypercarbic
• Neurologically intact • Fully recovered from neuromuscular blockers (sustained head lift, • Hypothermic
• Appropriate acid-base status strong hand grip, strong tongue protrusion) • Residual neuromuscular block present
• Normal metabolic status • Positive gag and coughing reflex • Unable to protect airway (swelling, impaired cough/gag reflex, vocal cord paralysis)
• Normothermic • Excessively long surgical procedure
• Unexplained hemodynamic instability
Monitoring Recovery by MODIFIED ALDRETE SCORE
Components:
• Respiration, Oxygenation (color), Circulation, Consciousness, Activity
• Minimum score: 9 (allow discharge from PACU)

Complications of General Anesthesia

Type ASPIRATION AIRWAY TRAUMA PHYSIOLOGIC RESPONSES RESPIRATORY COMPLICATION
Features/ • Full stomach • Sore throat • Hypoxia, hypercarbia • Airway obstruction by: laryngospasm, blood,
predisposing • Large amount of gas in the stomach • Hoarseness • Hypertension, tachycardia foreign object, glottic edema, vocal cord
factors • dental trauma • Cardiac arrhythmia paralysis, external airway compression, residual
• Oropharyngeal injury • Laryngospasm drug effects
• Tracheal injury • Bronchospasm • Hypoxemia
• Intracranial hypertension • Hypoventilation
• Intraocular hypertension
Prevention • Avoid GA if possible, delay surgery to meet NPO • Pre-operative assessment Some are transient, if prolonged give • Ensure oxygenation & ventilation
• Avoid anesthetic agent which decrease lower • Document dentition appropriate intervention • Manual airway measures/adjunct
esophageal tone • Bag-mask ventilation
• Suctioning of secretion
Type MALIGNANT HYPERTHERMIA AWARENESS UNDER ANESTHESIA DELAYED EMERGENCE PONV
Features • Autosomal dominant hypermetabolic muscle • Recall & helplessness while • Failure to regain consciousness • Any nausea, retching, vomiting occurring during
disease with exposure to volatile anesthetics (ex. paralyzed. within 20-30 minutes at the end of a the first 24-48 hours after surgery
Halothane) or depolarizing NMB (ex. • Common in: Obstetrics, trauma, & surgery. • Evaluated by: SIMPLIFIED APFEL SCORE (female
succinylcholine) major cardiac procedures (have • Cause: multifactorial (ex. Residual sex, non-smoking status, history of PONV,
• Pathophysio: Impaired ability of sarcoplasmic high fluid shift → difficult to drug effects) Postoperative opioid use.
reticulum to sequester calcium resulting to maintain the plasma concentration • Risk factor: Laparoscopic surgery
activation of the contractile process of medication
• Signs:
o Markedly increased metabolism (high CO2
produced, high O2 consumption, reduced
mixed venous O2 tension, metabolic
acidosis, cyanosis, mottling)
o Increased sympathetic activity (tachycardia,
hypertension, arrhythmia)
o Muscle damage (masseter spasm,
generalized rigidity, increased serum
creatinine kinase, hyperkalemia,
hypernatremia, hyperphosphatemia,
myoglobinemia, myoglobinuria)
o Hyperthermia (fever, sweating)
Prevention • Always screen for history of MH (ex. Anesthetic • Ensure anesthetic depth (using gas • Ensure adequate oxygenation & • Pharmacologic:
history of relatives) analyzer, drug dosages & timing, ventilation o 5-HT3 antagonist
• Dantrolene: Interferes with release of calcium Bispectral Index Scale) • Check all agents have been o Neruokinin antagonist
from sarcoplasmic reticulum via ryanodine o BIS: modification of EEG, show discontinued. o Histaminic agent
receptor channel, prevents excitation- numerical value that indicates • Review doses o Muscarinic agents
contraction coupling awake, sedate, & unconscious • Check neuromuscular function o D2 receptor antagonists
state o Dexamethasone
• Total intravenous anesthesia (TIVA): anesthetic
of choice since propofol has anti-emetic effects
Local and Regional Anesthesia
REGIONAL ANESTHESIA:
• Advantage over GA: Allows neurologic monitoring • Avoid adverse effects of GA
• Blocks neuroendocrine response • Postoperative Analgesia
• Avoids complications from airway management • Preservation of consciousness during surgery
• Avoids postoperative nausea and vomiting from GA • Sympathetic blockade and attenuation of the stress response to surgery
• Use of the technique may be extended for postoperative analgesia
Evaluation of the patient for regional anesthesia: standard pre-anesthesia evaluation: Considerations before the performance of Regional Anesthesia (RA):
• Examination of back (potential difficulties deformities, signs of infection) • Technique should be appropriate for the contemplated surgery
• Bleeding tendencies / coagulopathies • Duration of surgery and likelihood of change in procedure intraoperatively
• Medication History (Antiplatelet / anticoagulant / herbal use) – stop 1 week prior to • The site of surgery. In multiple sites, can it be done using one block?
surgery • If the technique is meant to provide postoperative analgesia
• Assessment of volume status (e.g. hypovolemia, hemorrhage) • Local anesthetics may be given as: single dose/ continuous infusion or repeated intermittent boluses via
• Possible contraindications to the technique (e.g. preload dependent cardiac conditions, indwelling catheter
neurologic disease, intracranial hypertension)
• Documentation of preexisting neuropathies and weakness
• Patient should also consent to the performance of the technique

Types Of RA NEURAXIAL ANESTHESIA PERIPHERAL NERVE BLOCK

• Provide optimal operating conditions in the lower extremities & abdomen • Superficial & deep operations of the extremities (requires cooperation; contraindicated for
Procedure
those with altered mental status)
• Higher level of neuraxial anesthesia result in more profound sympathectomy • Systemic hypotension is rare (advantage over neuraxial anesthesia)
Systemic Effects • Expected finding if with T4 sensory blockade: Bradycardia, Impaired cough, &
vomiting
Postoperative • Continuous catheter infusion of low concentration of local anesthetic may be given • Procedures with significant postoperative pain may benefit from long-acting peripheral nerve
Analgesia block or perineural catheter placement
Ambulatory • Those with prolonged recovery time when long-acting local anesthetics are used
surgery

LOCAL •Produce transient and reversible loss of sensation or feeling in circumscribed areas in the body (without loss of consciousness)
ANESTHETICS •Cause blockade of impulse generation or propagation by binding to sodium channels. Decreases rate of depolarization threshold potential not achieved
• Factors affecting speed of neural blockade of nerve fibers after exposure to local anesthetics are following: nerve fiber size, surface area, and degree of myelination
o Nerve fiber diameter – related to conduction velocity (large diameter = rapid conduction)
o Myelin – increase conduction velocity
o Larger doses needed to anesthetize larger nerve trunks
Mechanism of
• cause differential inhibition of sensory and motor activity (Autonomic > Sensory >>>> Motor)
Action:
• Maximum block height varies according to each sensory modality
o Sympathetic blockade (cold sensation) is 1-2 spinal segments higher than Sensory Blockade (pinprick)
o Sensory blockade to pinprick is 1-2 spinal segments higher than to touch
• Regression of blockade (“recovery”) follows in the reverse order
• Local anesthetics are acidic solutions to maintain stability. Equilibrate to pH of normal tissues on injection
Tissue pH • Carbonization (e.g. Addition of Sodium Bicarbonate): increase onset of action, decrease pain on injection, but decrease shelf life
• Activity in infected tissues (e.g. abscess): Decreased tissue pH, more ionized form of LA → decreased onset, decreased potency, and quality of anesthesia
• In vascular areas: drug is rapidly absorbed and removed → shorter duration of action
• Vasoconstricting agents (Epinephrine, Phenylephrine): decreased blood flow, reduce systemic absorption (prolong the anesthetic duration), shortens onset. & extends duration of
Vascularity
action and margin of safety in tumescent anesthesia 
• Caution in using vasoconstrictive agent in areas with single vascular source
Adverse Effects • Toxicity depends on: site of injection & speed of absorption
Local Anesthetic • CNS Toxicity (Depression): cessation of seizure activity, respiratory depression, respiratory arrest
Systemic • CNS Toxicity (Excitatory): Tinnitus, Circumoral numbness, Tongue paresthesia, Dizziness, Blurred vision, Restlessness/Confusion/Agitation, Shivering, Muscular twitching, generalized
Toxicity (LAST) convulsions
Symptom • CVS Toxicity (Depression): Hypotension, Bradycardia, Asystole
 • CVS Toxicity (Excitatory): Hypertension, Tachycardia, Arrhythmias
• Classically, Lidocaine exhibits CNS toxicity first (before CVS) Bupivacaine is cardiotoxic
• Stop injection of local anesthetic Prevention:
• Support ventilation: Prevent or correct hypercapnia, acidosis; Prevent or correct hypoxemia • Knowledge of maximum safe dose
Management
• Ensure adequate IV access • Use of vasoconstrictors
for LAST
• Control seizures • Incremental aspiration and injection of local anesthetics
Symptom
• Circulatory support: Intralipid Emulsion 20%; Manage Cardiac Instability; Cardiac • Continuous assessment of patient ‘s status [mental, neurologic, cardiovascular]
Compressions • Ultrasound guidance

Commercially Available Local Anesthetics for Local Infiltration (MIMS)

Local Anesthetics Maximum single dose (no epinephrine)  Maximum Single dose (with epinephrine) Onset of action (for infiltration) Preparation % Concentration
Lidocaine 3-4.5 mg/kg 6-7 mg/kg 1-2 mins 2% 20 mg/ml
Bupivacaine 2-2.5 mg/kg 2.5-3 mg/kg 2-10 mins 0.5% 5 mg/ml
Levobupivacaine 2 mg/kg 3 mg/kg 0.5% 5 mg/ml
Ropivacaine 3 mg/kg 3-4 mg/kg 3-15 mins 1% 10 mg/ml

INFILTRATION • Producing loss of sensation restricted to a superficial, localized area in the body. The local anesthetic solution is injected directly into the area of terminal nerve endings
ANESTHESIA • Component of multimodal analgesia*
• Subcutaneous – IV placement, superficial skin biopsies, suturing
Indications • Submucosal - repair of lacerations
• Infiltrative – digital block
• Choice of drug: depends on the desired duration of action
• Onset of action: almost immediate for intradermal or subcutaneous administration
Drug used • Dosage of local anesthetic required depends on:
o Extent of the area to be anesthetized: Large volumes of dilute anesthetic solutions may be used for large surface areas
o Expected duration of the procedure: Epinephrine will prolong the duration of local anesthetics
Calculation of • Concentration of the medication must be known
Maximum dose of • Weight of the patient (in kg)
Local Anesthetic for • Determine if vasoconstrictor will be / will not be used
Infiltration • Determine the dose / volume of local anesthetic to be drawn
• Infiltration of local anesthetic around the border of the surgical field, leaving the operative area undisturbed
Field Block • Indication: heavily contaminated wounds, for skin abscesses, and when tissue distortion should be avoided (e.g. nose)
• Disadvantage: Increased risk for toxicity; May not be effective on areas of complex innervation

TOPICAL ANESTHESIA TUMESCENT ANESTHESIA

• drugs that cause temporary numbness by application of the medication directly to a body surface • Commonly used by plastic surgeons during liposuction
• Produce short duration of analgesia procedures.
• Preparations: creams, ointments, solutions, eye drops, gels, sprays • Involves the subcutaneous injection of large volumes of
• Lidocaine and tetracaine sprays: before endotracheal intubation, or mucosal analgesia for bronchoscopy or esophagoscopy dilute local anesthetic in combination with epinephrine and
• Lidocaine patches: for the topical treatment of postherpetic neuralgia other agents
• Local anesthetic formulations (e.g. EMLA):
o Eutectic mixture of 2.5% lidocaine base and 2.5% prilocaine base
o Used for: venipuncture, intravenous cannulation, skin grafting, dermatologic procedures, newborn circumcision.
o Penetrates intact skin, but must be applied under an occlusive bandage for 45 to 60 minutes for maximal effect
o Methods to accelerate LA transit: iontophoresis, local heating, electroporation, and a variety of forms of needleless pressure injection

CENTRAL • Performed by placing a needle between vertebrae and injecting medications into the subarachnoid space (for spinal anesthesia), or the epidural space (for epidural anesthesia)
NEURAXIAL
ANESTHESIA
• Spinal cord terminates at L3 in infants, & the lower border of L1 in adults
• Cerebrospinal fluid (CSF): located at the subarachnoid space (between pia and arachnoid mater)
Anatomy
• Epidural space extends from foramen magnum to sacral hiatus
• Sacral canal contains the terminal portion of the dural sac and ends at S2 in adults and lower in children
 • 7 cervical, 12 thoracic, 5 lumbar vertebrae and a sacrum
o Thoracic vertebrae - Spinous processes steeply angulated
o Lumbar vertebrae – more perpendicular spinous processes
• Spinal Nerves: Preganglionic sympathetic fibers originate in intermediolateral gray columns between T1 and L2
• Blood Supply:
• Posterior 1/3 – 2 posterior spinal arteries
• Anterior 2/3 – Anterior Spinal Artery (Artery of Adamkiewicz)
o Arises from aorta and enters intervertebral foramen between T7 and L4
o Ischemia within the anterior system: Anterior Spinal Artery Syndrome
• Longitudinal anterior and posterior spinal veins drain into internal vertebral plexus to the azygous system
• Correct sequence of layers traversed: Skin- subcutaneous tissue – Supraspinous ligament – Interspinous ligament – Ligamentum flavum – Dura mater – Subarachnoid mater
• surgery, obstetrics, acute postoperative pain, chronic pain relief
• consciousness needs to be maintained
• Caudal blocks are mostly performed for surgical anesthesia and analgesia in children
Indications
• Single injection (spinal, epidural): for surgeries (of known duration) to the lower abdomen, pelvic organs (e.g., prostate), and lower limbs and for cesarean deliveries
• Continuous catheter-based infusions: for prolonged surgical anesthesia, obstetric labor analgesia; For postoperative pain relief for days after major surgery (e.g., thoracic, abdominal,
lower limb)
• No metabolism in the CSF
MOA • Regression of neural blockade due to decline in the CSF drug concentration via: non-neural tissue uptake (lipid soluble LA like bupivacaine → slow vascular absorption) & vascular
absorption (increases to larger area → shorter duration of action)
• Induces blockade of sympathetic nervous system
Physiologic • Produce decreased sympathetic tone with unopposed parasympathetic tone
Effects • Blockade from spinal & epidural anesthesia result in alterations of normal homeostasis
• Blockade from spinal & epidural anesthesia result in profound sympathectomy
• cause decrease in BP, HR, & cardiac contractility
• Vasodilatory changes depend on baseline sympathetic tone & extent of the
sympathectomy
• Sympathectomy: extends for 2-6 dermatomes above the sensory block level
with spinal anesthesia; in same levels in epidural anesthesia
• Minimal change in heart rate unless sympathetic block extends to T1
• Bezold-Jarisch Reflex: profound bradycardia & circulatory collapse after
spinal anesthesia
• Measures to minimize cardiac effect of neuraxial blockade:
Physiologic
o Use appropriate dose & block height
Effects (Cardiac)
o Volume loading before induction of spinal anesthesia (barring
contraindications to fluid loading)
o Left uterine displacement in pregnant patients
o Trendelenburg position
o Manage bradycardia with Atropine
o Manage hypotension with phenylephrine
o Manage hypotension and bradycardia with ephedrine

Physiologic • Spinal anesthesia – induced hypotension → decrease regional cerebral blood flow → decrease cerebral perfusion (esp. elderly, those with preexisting hypertension)
Effects (CNS)
• Neuraxial anesthesia BLOCKS neuroendocrine response
Physiologic
• Related to inflammatory response & activation of somatic & afferent nerve fibers
Effects
• Manifested by hypertension, tachycardia, hyperglycemia, protein catabolism, depressed immune response, alteration in renal function.
(Neuroendocrine
• Substances released in response to surgical trauma: adrenocorticotropic hormone, cortisol, epinephrine, norepinephrine, vasopressin, activation of the renin-angiotensin-aldosterone
response)
system
Physiologic • Respiratory arrest rarely occurs and may be due to hypoperfusion of the respiratory centers in the brainstem.
Effects • Neuraxial blockade → paralysis of abdominal muscles (required forced exhalation) → decreased expiratory reserve volume → decreased vital capacity (seen in obese & those with
(Respiratory) severe respiratory disease)
 Physiologic
Effects (GIT)

• Minimal effect on renal blood flow

• Urinary retention due to loss of autonomic bladder control
Physiologic
• Prolonged blockade of the detrusor muscle lead to over distention & urinary retention
Effects (Renal)
o Risk factos for prolonged blockade of detrusor muscle: use of long acting local anesthesia, >50 years old, volume of fluids administered, surgical procedure
o Detrusor function is regained after resolution of S3 sensory blockade

Dermatome Surface Landmark Procedure

Anesthesia levels T4-T5 Nipple (T4) Upper abdominal surgery, Cesarean section
necessary for T6-T8 Xiphoid process (T6) Intestinal surgery (including appendectomy), Lower abdominal surgery (gynecologic, pelvic surgery, ureter)
surgical T10 Umbilicus Hip surgery, transurethral resection of the prostate (TURP), vaginal delivery
procedures L1 Inguinal ligament TURP without bladder distention, Thigh surgery, Lower extremity surgery
L2-L3 Knee Foot surgery
S2-S5 Perineum Perineal surgery (episiorrhaphy), hemorrhoidectomy, anal dilation
• Patient refusal
• Localized sepsis
Absolute
• Allergy to any of the drugs administered
contraindication
• Inability to maintain stillness during needle puncture
s
• Increased intracranial pressure (predisposing to brainstem herniation)
• Significant hypovolemia, uncorrected abnormality of coagulation, severe valvular heart disease (aortic stenosis), or obstructive cardiomyopathy
• Neurologic: myelopathy or peripheral neuropathy, spine stenosis, spine surgery, multiple sclerosis, spinal bifida
Relative • Infection
contraindication • Cardiac: aortic stenosis/ fixed cardiac output, hypovolemia
s • Hematologic: thromboprophylaxis & anticoagulation, inherited coagulopathy
• Those on antiplatelet & anticoagulation must be coordinated
• Spinal Anesthesia and Epidural Anesthesia share the same complications
• Neurologic complications: Paraplegia, cauda equina syndrome, epidural hematoma, nerve injury, post-dural puncture headache, & transient neurologic symptoms
Complications
• Cardiovascular complications: hypotension, bradycardia, cardiac arrest
• Other complications: respiratory depression, backache, infection, nausea & vomiting, urinary retention, pruritus, & shivering
• Complications Unique to Epidural Anesthesia: Intravascular injection, subdural injection

Complications Paraplegia Cauda Equina Syndrome Epidural Hematoma
Features • Due to direct needle • From direct exposure of • Bleeding within the canal
trauma to the spinal cord lumbosacral nerve roots causing ischemic
• From profound to large doses LA, or compression of the
hypotension and prolonged exposure spinal cord
ischemia (e.g. anterior through a continuous • Patient forgot to tell
spinal artery syndrome) catheter taking oral anticoagulant
after receiving neuraxial
anesthesia → did not
regain motor & sensory
function 
Symptoms • Radicular pain,
prolonged block, bladder
and bowel dysfunction
Risks • Difficult or traumatic
needle/ catheter
• Insertion; coagulopathy,
elderly, female gender
Treatment • Urgent procedure:
warrants early diagnosis
& imaging; surgery to
prevent permanent
injury
Nerve Injury Transient Neurologic Postdural Puncture
Symptoms (TNS) Headache (PDPH)
• More in epidural • Occur after • Headache after intentional
than spinal resolution of spinal or unintentional puncture
anesthesia anesthetic and is not of dural membrane
• Radicular pain or associated with • Loss of CSF through the
paresthesia during neurologic deficits dura cause traction on
procedure (Resolves after a pain-sensitive intracranial
week) structures
• bilateral or • Frontal or occipital
unilateral pain in headache that worsens on
buttocks or legs an upright position.
• Other symptoms: nausea,
vomiting, neck pain,
diplopia, tinnitus, hearing
loss, CN palsies
• Associated with • Risks: younger, female,
lidocaine and larger needle size,
mepivacaine, use of pregnancy, dural punctures
dextrose or with multiple punctures
epinephrine; dorsal
lithotomy position
• NSAIDS (first line), • Conservative: supine
opioids positioning, hydration,
caffeine, oral analgesics
• Definitive: Epidural blood
patch

Complications Hypotension Bradycardia Cardiac arrest

Features • Seen in: block height > T5; age >40 years, baseline SBP < • From mechanisms secondary to neuraxial • Occur more in spinal techniques
120mmHg, combined spinal –GA techniques, spinal sympathetic blockade • Severe bradycardia and asystole may
puncture at L2-L3 interspace, addition of phenylephrine be a consequence of hypoxemia and
with LA over sedation
Symptoms • Hypotension may be accompanied with nausea, vomiting,
dizziness, and dyspnea
Risks • baseline heart rate< 60bpm, younger than 37
years, male gender, beta-adrenergic blockade,
non-emergency status, prolonged surgery

Complications Respiratory Backache Infection Nausea and Vomiting Pruritus Urinary Retention Shivering
depression
Features • Dose • No • Bacterial meningitis and • due to direct • Common side effect • Local anesthetic • Seen more in
dependent association epidural abscess are rare exposure of CTZ to related to blockade of S2- epidural
and associated between • Common pathogens: emetogenic drugs intrathecal S4 nerve roots anesthesia
with addition epidural Staphylococcus (catheter (e.g. opioids), administration of weakens
of intrathecal anesthesia • related infections), S. hypotension, or GIT opioids detrusor muscle
opioids, (and and viridians (in spinal anesthesia) hyperperistalsis • Neuraxial opioids
its spread to newonset suppress
 respiratory backache • Intrathecal morphine detrusor activity
centers) up to has highest opioid- and reduce urge
• High neuraxial 6months induced risk to void
block can postpartum (compared to fentanyl
paralyze and sufentanil)
accessory
muscles of
respiration
and can impair
active
exhalation and
cough.
Risks • • systemic infection, other • • • Male, age, • Addition of
comorbidities, intrathecal fentanyl,
immunocompromised morphine meperidine;
state, prolonged catheters, forced air
obstetric patients (with • warming, warming
epidural analgesia) of IV fluids
Treatment • Chlorhexidine in an alcohol • • Naloxone, • •
base is most effective Naltrexone or
antiseptic Nalbuphine

Complications Intravascular Injection Subdural Injection

Features • Inadvertent administration of LA into epidural vein can cause LA Systemic toxicity • Subdural placement of LA
• Common in obstetric population due to engorgement of epidural vessels • Produce a higher than expected block (within 15 -30
minutes), and exaggerated sympathetic blockade
Risks • placing the patient on lateral decubitus position, administration of fluid before catheter insertion;
using single orifice catheters
TX • Aspiration of epidural catheter and incremental administration of LA is recommended (One • Symptomatic treatment
measure to avoid LAST with the use of local anesthetics)

SPINAL ANESTHESIA
Sensory Nerve • Temperature (Cold) → Temperature (Hot) → Pain → Touch → Deep Pressure → Proprioception
Block Sequence • Sensory blockade: 1-2 segments below sympathetic blockade (ex. Sensory blockade is anticipated at T6 with loss of temperature sensation up to T4)
Factors • Drug factors (dose, volume, concentration), patient factors, procedural factors.
affecting drug • Dose: most reliable determinant of local anesthesia spread of isobaric & hypobaric solutions.
height: Drug • Opioids: enhance spread of local anesthetics
factors
Factors • Baricity: density of local anesthetic solution in relation to CSF
affecting drug • Hyperbaric local anesthetics are influenced by baricity
height: Baricity
• Advanced age: older patient decreased CSF volume, increased specific gravity; nerve roots more sensitive to LA
• CSF volume: influences peak block height & regression
Factors
• Increased abdominal pressure: decreased CSF volume, increased LA spread, seen in obese patients
affecting drug
• Pregnancy: change in lumbar lordosis; smaller subarachnoid space due to the engorgement of venous plexus
height: patient
• Extremes of height: related to vertebral column length; spread of hyperbaric LA in spina may be affected in kyphosis
factors
• Extremes of weight
• Gender
• Patient position: spread of LA within 20-25 mins of injection; optimize baricity of local anesthetics
Factors
o Trendelenberg position + flexion of hips → favor cephalad spread
affecting drug
o Sitting for 30 mins after injection of hyperbaric solution → “saddle block” (S2-S5)
height:
o Block height more extensive in hypobric solutions when given in sitting position
Procedural
• Needle type & orientation of orifice
factors
• Level of injection:
 o Isobaric solutions: higher block height when given in cephalad injections
o Hyperbaric solutions: no effect
• Epidural injection after spinal: increase block height
• Injection rate
• Barbotage: effects not consistent
• Dose, intrinsic property of local anesthetics, use of additives
• Spinal additives:
o Exert direct analgesic effect on spinal nerve roots
o Prolong duration of sensory & motor blockade
o Reduce dose of local anesthetics
o Motor block sparing, faster recovery
Spinal Opiates Vasoconstrictors Alpha-2 agonists
• Direct spinal cord dorsal horn opioid receptor activation • E.g. Epinephrine and phenylephrine • E.g. Clonidine, Dexmedetomidine, Epinephrine
• Cerebral opioid receptor activation after CSF transport • Prolong motor and sensory blockade • Act on alpha-2 adrenergic receptors on the dorsal
Factors
• Peripheral and central systemic effects horn of the spinal cord
affecting block • Clonidine and Dexmedetomidine prolong motor-
Onset of Duration of Epinephrine Phenylephrine
duration Opioids Uses
action action sensory blockade and improve analgesia
Hydrophilic: Slow Long Analgesia; • Alpha-1 adrenergic • (used with Lidocaine and o Dexmedetomidine is more alpha-2 selective
morphine postoperative mediated Tetracaine)
(diamorphine, analgesia vasoconstriction reduce • associated with
meperidine) systemic local anesthetic Transient Neurologic
Lipophilic: Rapid Short Labor uptake Symptom
Fentanyl, analgesia, • alpha-2 mediated effect
Sufentanyl cesarean enhance analgesia
delivery
• Ideally, the patient is awake
• Position: sitting vs lateral decubitus
o Lateral Decubitus: allows administration of sedatives if needed; Position should optimize spread of the local anesthetic
o Sitting Position: Identification of midline is easier; Hypotension is more common; Landmark: Iliac crests
o Tuffier’s Line – identified by drawing a line to connect the superior aspect of the posterior iliac crests. Reference to L4 vertebra body
• Projection and Puncture: median vs paramedian
o Spinal cord ends at L1-L2 in adults
o Puncture sites for Spinal Anesthesia: L2-L3, L3-L4, L4-L5 interspace
o End point: drainage of CSF
o Process:
Technique ▪ Local anesthesia is infiltrated on the skin
▪ The spinal needle is inserted through the skin, subcutaneous tissue, supraspinous ligament to the interspinous ligament
▪ A click or pop is appreciated when the needle traverses the ligamentum flavum and dura.
• CSF should appear in the hub after the stylet is removed.
• CSF should be free flowing. If there is no CSF: Rotate the needle at 90-degree increments, Advance the needle, or Remove the needle and reinsert
▪ When CSF is freely obtained, the anesthetic is injected (at 0.2ml/sec)
▪ After injection, reconfirm needle location by aspirating CSF and injecting it back into the subarachnoid space.
o Paramedian Approach:
▪ Useful in setting of diffuse calcification of the interspinous ligament (e.g. elderly patient)
▪ spinal needle is inserted 10 –15degrees off the sagittal plane
▪ technique does not pass through supraspinous and interspinous ligaments. (but still traverses ligamentum flavum and dura)
Other Featured • 12 hours: timing of last dose of low molecular weight heparin SQ for safe administration of spinal anesthesia

Neuraxial / Spinal Anesthesia: Special Techniques

CONTINUOUS SPINAL ANESTHESIA
• Allows for incremental dosing and predictable titration of the block
• Useful in controlling blood pressure (pregnant, in patients with severe aortic stenosis); and for
prolonged cases (instead of combined spinal- epidural)
• Need to insert microcatheters (which are implicated in cauda equina syndrome)
UNILATERAL/SELECTIVE SPINAL BLOCK
• Use of small doses of anesthetic, and optimizing patient positioning and drug baricity
• E.g. A patient for Right leg surgery is given hyperbaric LA while on a RLDP position. The RLDP
position is maintained after LA injection → LA spreads on dependent areas → unilateral block of
Right leg.
 Neuraxial / Spinal Anesthesia: Monitoring of Block Modified Bromage Scale
• Monitor Onset, extent and quality of sensory and • 0 = no motor block
motor blockade • 1 = inability to raise extended leg; able to move knees & feet
• Monitor sympathetic blockade (HR, BP) • 2 = inability to raise extended leg & move knee; able to move feet
• 3 = complete block of motor limb
Nerve fibers Check for: Use:
C-fibers Cold sensation Ice, alcohol
A-delta fibers Pinprick Needle (not to pierce skin)
*Ensure block to cold or pinprick is 2-3 segments above the level of surgical stimulus; ensure motor blockade

EPIDURAL ANESTHESIA
• epidural space extends from foramen magnum to sacral hiatus
o contains nerve roots, fat, areolar tissue, lymphatics, and blood vessels
Anatomy
o lies between the ligamentum flavum and dura
• Compared to Spinal Anesthesia, Epidural block may be performed at any level of the vertebral column to provide segmental analgesia
Factors • Volume and total mass of injectate: 1-2mL of LA solution required to block per segment; correlate with LAST
affecting block • Additives: influence quality, onset and duration of anesthesia and analgesia
height: Drug
Factors
Factors • Elderly (decreased requirement): due to decreased leakage of LA through intervertebral foramina, and compliance of epidural space
affecting block • Pregnancy (decreased requirement): Due to engorgement of epidural veins from increased IAP
height: Patient • Continuous positive airway pressure: increase height of thoracic block
factors • Weight: no correlation to block height

Factors Level of injection Patient Position:

Affecting Block Insertion Site Direction of LA spread Position Effect on epidural spread
Height: Upper cervical Caudal Lateral Decubitus Faster onset, preferential spread to dependent areas
Procedure Midthoracic Cephalad = caudal Supine & Sitting No effect
Factors Low thoracic Cephalad Head down tilt Increased in pregnancy
Lumbar Cephalad > caudal
• Epidural anesthesia (EA) has similar pharmacology with Spinal anesthesia
• LA for epidural use are preservative-free
• TNS seen (with lidocaine) is uncommon with epidural anesthesia.
• Motor blockade seen at high concentrations and larger doses of LA
• Higher concentrations of LA result to longer block duration
Pharmacology
• Additives:
o Epinephrine reduce vascular absorption of LA.
o Phenylephrine is less used in EA.
o Opioids enhance the analgesic effects of LA like intrathecal opioids
o Epidural Alpha 2-agonists prolong motor and sensory block
• Patient preparation and asepsis is the same as spinal anesthesia
• appropriate level for epidural puncture and catheter insertion is determined
Technique
• Equipment: Uses a Tuohy needle with a graded shaft. It has a flexible catheter with single or multiple orifices.
• Position: Sitting or lateral decubitus position. The patient is ideally awake during the procedure.
• Vertebral levels are noted using surface landmarks
Vertebral Level Surface landmark
C7 Vertebra prominens
Technique:
T3 Root of the scapular spine
Steps
T7 Vertebral body Inferior angle of the scapula
L4-L5 Intercristal line
S2 Posterior superior iliac spine
 • The needle is inserted after infiltration with local anesthesia on the puncture site.
o Midline Approach – for low thoracic and lumbar punctures
o Paramedian – for high thoracic region (steeper spinous processes, narrower spaces)
• Tuohy needle (with stylet attached) is advanced in a controlled fashion through the supraspinous ligament and interspinous ligament. The stylet is replaced by a syringe (containing air
or saline)
• Needle is advanced further using the loss of resistance technique (to air or saline) * to identify the epidural space. Intermittent (air)* or constant pressure (saline)* is applied to the
syringe by the dominant hand while the needle is advanced by the nondominant hand.
• Ligamentum flavum is identified as a tougher structure with increased resistance. After traversing the ligamentum flavum, the pressure applied to the syringe will allow air (or saline) to
enter the epidural space without resistance.
• The distance from the skin to epidural space is noted. The epidural catheter is threaded 4-6cm in the space.

• caudal space is the sacral portion of the epidural space

• Involves needle penetration of the sacrococcygeal ligament covering the sacral hiatus (groove above the coccyx between the sacral cornua)
CAUDAL
• Need to supplement with general anesthesia if used for surgical anesthesia (e.g. procedures below the diaphragm)
ANESTHESIA
• Used for postoperative analgesia in pediatric patients
• Landmarks: posterior superior iliac spines and sacral hiatus

• Procedures that inhibit conduction in fibers of the peripheral nervous system

PERIPHERAL
• Minor nerve block: involving single nerve entities i.e. ulnar or radial nerve
NERVE BLOCK
• Major nerve blocks: involve the blockade of two or more distinct nerves or a nerve plexus or, blockade of very large nerves at more proximal sites (i.e., the femoral and sciatic nerves)
Anatomy • blocks are easier understood when correlated with the brachial plexus, lumbosacral plexus, and sensory innervation of the thorax and abdomen.
• Reduced physical stress (vs central neuraxial anesthesia)
• Avoids airway manipulation complications associated with endotracheal intubation (vs. GA)
Advantages
• Indwelling catheters can prolong block and analgesia
• Provides surgical anesthesia and postoperative analgesia
• decreased with imaging and improvement of equipment (e.g. ultrasound)
Complications
• Local anesthetic toxicity, Neurologic injury, Inadvertent neuraxial block, Intravascular injection of local anesthetics

UPPER LIMB BLOCKS • Brachial plexus blockade for upper limb surgery is the most common major peripheral nerve block technique
• …
Nerve Block Shoulder Arm Elbow Forearm Hand
Interscalene ✓ *Not recommended as anesthetic for closed
reduction & pinning of distal radius & ulna
Supraclavicular ✓ ✓ ✓ ✓
Infraclavicular ✓ ✓ ✓ ✓
Axillary block X ✓ ✓ ✓
Blocks at elbow Hand, wrist sx
Wrist block Wrist, finger sx

LOWER LIMB BLOCKS

Nerve block Hip Femur Knee Leg Foot

Femoral Analgesia in hip sx ✓ ✓
Obturator (prevent adduction of ✓
thigh in bladder surgery
Saphenous Medial aspect (ex. Vein With sciatic block
stripping)
Sciatic ✓ Foot ankle
Ankle Distal foot & toe

TRUNCAL BLOCKS • Used for postoperative analgesia after thoracic and abdominal procedures.
 Truncal blocks Indications
Field blocks Superficial thoracic surgery, breast surgery
Proximal intercostal nerve blocks Mastectomy, breast reconstruction, thoracotomy, VATS
Paravertebral blocks
Transversus abdominis plane block Laparotomy, appendectomy, laparoscopic surgery, abdominioplasty, cesarean delivery, alternative to epidural for abdominal wall operations
Ilioinguinal-iliohypogastric block Inguinal hernia repair & other inguinal surgery
Rectus sheath block Umbilical hernia repair & other umbilical surgery
IV REGIONAL • intravenous administration of a local anesthetic into a tourniquet-occluded limb.
ANESTHESIA - BIER’S • local anesthetic diffuses from the peripheral vascular bed to nonvascular tissue (e.g. axons and nerve endings)
BLOCK • Safety and the efficacy depend on: interruption of blood flow to involved limb & gradual release of the occluding tourniquet
Drug used • Lidocaine & prilocaine
• Drugs with a high cardiotoxic potential (e.g. Bupivacaine)
Contraindications
• Local Anesthetics with epinephrine additive
• Easy to administer, with low failure rates
• Rapid onset and recovery
Advantages
• Patient is awake during the procedure
• Predictable extent of anesthesia
• Use only for short procedures
• Tourniquet pain in 20-30minutes
Disadvantages • May compromise vascular supply to extremity
• Postoperative pain after rapid recovery
• Systemic absorption of local anesthetics (Seizures reported with lidocaine doses as low as 1.4 mg/kg; Cardiovascular collapse)