Donald H. Lambert Boston, Massachusetts Spinal Anesthesia.
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Transcript of Donald H. Lambert Boston, Massachusetts Spinal Anesthesia.
Donald H. Lambert
Boston, Massachusetts
http://www.debunk-it.org
Spinal AnesthesiaSpinal Anesthesia
www.debunk-it.orgwww.debunk-it.org
RULE N0. 1:
YOUR ATTENDING IS ALWAYS RIGHT.
RULE NO. 2:
IF YOUR ATTENDING IS WRONG, SEE RULE NO. 1.
Spinal AnesthesiaSpinal Anesthesia Advantages v. Disadvantages Indications and Contraindications Positioning Getting ready Getting the needle in the right spot Baricity Dosing What to inject Addition of a vasoconstrictor Addition of narcotics Complications (and how to avoid them)
Advantages of Spinal AnesthesiaAdvantages of Spinal Anesthesia
Technically easy Objective end-point Rapid onset Profound sensory and motor block Low potential for systemic toxicity
Disadvantages of Spinal AnesthesiaDisadvantages of Spinal Anesthesia
Limited duration Limited sensory and motor separation “Hypotension” Potential neuro-toxicity Headache
Spinal AnesthesiaSpinal Anesthesia Advantages v. Disadvantages Indications and Contraindications Positioning Getting ready Getting the needle in the right spot Baricity Dosing What to inject Addition of a vasoconstrictor Addition of narcotics Complications (and how to avoid them)
IndicationsIndications
Any operation in the lower abdomen and below
Absolute ContraindicationsAbsolute Contraindications
Patient refusal Uncorrected hypovolemia Uncorrected coagulopathy Infection at site of injection Increased intracranial pressure
Relative ContraindicationsRelative Contraindications
Some neurologic diseases Bacteremia Deformities that preclude doing an LP easily
Spinal AnesthesiaSpinal Anesthesia Advantages v. Disadvantages Indications and Contraindications Positioning Getting ready Getting the needle in the right spot Baricity Dosing What to inject Addition of a vasoconstrictor Addition of narcotics Complications (and how to avoid them)
Positioning for the Lumbar PuncturePositioning for the Lumbar Puncture
Two choices Sitting Lateral decubitus (recumbent)
Spinal AnesthesiaSpinal Anesthesia Advantages v. Disadvantages Indications and Contraindications Positioning Getting ready Getting the needle in the right spot Baricity Dosing What to inject Addition of a vasoconstrictor Addition of narcotics Complications (and how to avoid them)
Spinal AnesthesiaSpinal Anesthesia Advantages v. Disadvantages Indications and Contraindications Positioning Getting ready Getting the needle in the right spot Baricity Dosing What to inject Addition of a vasoconstrictor Addition of narcotics Complications (and how to avoid them)
• What is the object of the game of basketball?
• Get the ball in the hoop (Red Aurbach).
• What are we trying to do with spinal anesthesia?
• Get the needle into the CSF.
Getting the needle in the right spot
Spinal AnesthesiaSpinal Anesthesia Advantages v. Disadvantages Indications and Contraindications Positioning Getting ready Getting the needle in the right spot Baricity Dosing What to inject Addition of a vasoconstrictor Addition of narcotics Complications (and how to avoid them)
BaricityBaricity The density of the local anesthetic solution in relation
to the density of the CSF More dense than CSF
hyperbaric sinks
Same density as CSF isobaric
stay where it is injected (relatively)
Less dense than CSF hypobaric
floats
Hyp
erbari
cIsob
aric
Hyp
obari
c
Spinal AnesthesiaSpinal Anesthesia Advantages v. Disadvantages Indications and Contraindications Positioning Getting ready Getting the needle in the right spot Baricity Dosing What to inject Addition of a vasoconstrictor Addition of narcotics Complications (and how to avoid them)
Spinal AnesthesiaSpinal Anesthesia
Dosing will affect Spread Duration Quality of Anesthesia
That is, the need for supplemental IV medication
The dosing in this study was 10 mg, 15 mg, and 20 mg of bupivacaine
The lowest dose limited spread
The lowest dose also resulted in more failures than the higher doses.
Spinal AnesthesiaSpinal Anesthesia Advantages v. Disadvantages Indications and Contraindications Positioning Getting ready Getting the needle in the right spot Baricity Dosing What to inject Addition of a vasoconstrictor Addition of narcotics Complications (and how to avoid them)
Spinal Anesthesia AgentsSpinal Anesthesia AgentsAgent Conc. (%) Dose Gluc. Duration
Proc. 10 100-200 30-90Chlorop. 2 40-120 30-90Lido. 1.5 – 5 30-100 7.5 30-90Mep. 4 40-80 9 30-90Prilo. ? ? ? ?Ropiv. ? ? ? ?Dibu. 0.06-0.5 2.5-12 5 75-150Bupiv. 0.25-.75 5-22.5 8.25 75-150Tetra. 0.25-1 5-20 5 75-150
.
Dosing GuidelinesDosing Guidelines Based on the spinal canal
model (and many years of doing this) Hyperbaric solutions
extend into the thoracic region
Isobaric solution remain in the lumbar region
Hyperbaric
Isobaric I give hyperbaric
solutions for operations above the L1 dermatome and isobaric solutions for those below
Dosing GuidelinesDosing Guidelines
Hernia operations and those operations whose innervation is by nerves above L1 HYPERBARIC
Those operations whose innervation is by nerves below L1 (pretty much all lower extremity operation including hip operations) ISOBARIC
CHOOSING A LOCAL ANESTHETIC FOR CHOOSING A LOCAL ANESTHETIC FOR SPINAL ANESTHESIASPINAL ANESTHESIA
BASE DECISION ON THE BASE DECISION ON THE DURATIONDURATION OF OF THE OPERATIONTHE OPERATION
DURATION AGENT
< 1.5 HRS PROCAINE (LIDOCAINE,?CHLOROPROCAINE,?ROPIVACAINE)
> 1.5 HRS BUPIVACAINE(TETRACAINE)
CHOOSING A LOCAL ANESTHETIC FOR CHOOSING A LOCAL ANESTHETIC FOR SPINAL ANESTHESIASPINAL ANESTHESIA
GIVE ENOUGH TO PROVIDE GIVE ENOUGH TO PROVIDE ADEQUATEADEQUATE ANESTHESIAANESTHESIA
BARICITY PROC. LIDO. BUPIV. TETRA.ISOBARIC 80 mg 60 mg 15 mg 15 mgHYPERBARIC 80 mg 60 mg 15 mg 15 mg
? CHLOROPRACAINE, ? ROPIVACAINE
Isobaric Spinal AnesthesiaIsobaric Spinal Anesthesia Epidural Bupivacaine for spinal anesthesia is an “off label
use” of this agent It says right on the bottle: “Not for spinal anesthesia” What is the value or wisdom behind using that agent? It works great and I have used it since the 1980’s. I know of no reports of complications associated with using it. Litigation for the off-labeled use of a drug has not appeared in the
ASA closed claims database. Who would know?
Unless you wrote on your anesthesia record, “I used the bupivacaine that is not for spinal anesthesia.”
Spinal AnesthesiaSpinal Anesthesia Advantages v. Disadvantages Indications and Contraindications Positioning Getting ready Getting the needle in the right spot Baricity Dosing What to inject Addition of a vasoconstrictor Addition of narcotics Complications (and how to avoid them)
Spinal AnesthesiaSpinal Anesthesia Advantages v. Disadvantages Indications and Contraindications Positioning Getting ready Getting the needle in the right spot Baricity Dosing What to inject Addition of a vasoconstrictor Addition of narcotics Complications (and how to avoid them)
Narcotic work here in the substantia gelatinosa
Local anesthetics work here in the nerve roots
Spinal AnesthesiaSpinal Anesthesia
Addition of narcotics Fentanyl (15-25 ug lasts a few hours) Sufentanil (10 - 20 ug lasts a few hours) Morphine (100 - 200 ug lasts 12-24 hours) Side effects (increase with increasing dose)
Nausea and vomiting Itching Respiratory depression
Spinal AnesthesiaSpinal Anesthesia Advantages v. Disadvantages Indications and Contraindications Positioning Getting ready Getting the needle in the right spot Baricity Dosing What to inject Addition of a vasoconstrictor Addition of narcotics Complications (and how to avoid them)
Spinal AnesthesiaSpinal Anesthesia
Complications Cardiac arrest Hypotension Headache Nerve injury
Eisenach, James C. Regional Anesthesia: Vintage Bordeaux (and Napa Valley)
Anesthesiology 1997;87:467-469
Editorial on Auroy’s study:“Spinal anesthesia appears in this study
to be more dangerous than other regional anesthesia techniques.” “The risk of cardiac arrest is five- to six fold
greater than with other regional anesthetic techniques ”
Cardiac Arrest Still OccurringCardiac Arrest Still Occurring
Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors
1988 2004
Number of Claims 900 5,047
Number of Arrests 14 (1.5%) 68 (1.3%)
Mean Age 36 42
ASA Physical Status I - II I - II
Caplan, R A; et al. Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors. Anesthesiology 1988;68:5-11
Caplan, R A; et al. Injuries Associated with Regional Anesthesia in the 1980s and 1990s: A Closed Claims Analysis. Anesthesiology. 2004;101:143-152
Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors
Local Anesthetic Tetracaine
Dose 6 - 14 mg
Maximum Level T4
Time of Arrest 12 - 78 minutes
Caplan, R A; et al. Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors. Anesthesiology 1988;68:5-11
Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors
Caplan, R A; et al. Anesthesiology 1988;68:5-11 and Mackey, D C, et al. Anesthesiology 1989;70:866-868
Factors Predisposing to Asystole High level Loss of Cardiac Sympathetic Stimulation Unopposed Vagal Tone Decreased Venous Return
Empty Left Ventricle Activation of Intracardiac Reflexes
? So-called Bezold-Jarisch Reflex ? So-called Vaso-vagal Syncope
Cardiac arrest during spinal anesthesia
How can this be prevented and/or treated? Maintain venous return at all cost Use epinephrine at the first sign of cardiac arrest
Keats, A. S. Anesthesia mortality--a new mechanism.Anesthesiology 1988;68:2-4.
Author Year Spinal Epidural GeneralAromaa 1997 0.04 0 N/AAuroy 1997 6.4 0.98 N/ABiboulet 2001 6.5 0 0.8Auroy 2002 2.7 0 N/ASprung 2003 1.5* N/A 5.5Kopp 2005 2.9 0.9 29 cases
* ”Regional Anesthesia”
Cardiac Arrest Associated with AnesthesiaCardiac Arrest Associated with Anesthesia(per 10,000)(per 10,000)
There appears to be two mechanisms for cardiac arrest during spinal anesthesia
Spinal factors Vaso-depressor syncope
Factors other than the spinal Blood loss Cardiac events Orthopedic manipulations
Cardiac Arrest Associated with AnesthesiaCardiac Arrest Associated with Anesthesia
Spinal AnesthesiaSpinal Anesthesia
Complications Cardiac arrest Hypotension Headache Nerve injury
Spinal Anesthesia ComplicationsSpinal Anesthesia Complications
Hypotension (happens!)
Incidence and risk factors for side effects ofspinal anesthesia in 952 patients
Hypotension in 314 (33%)
Bradycardia in 125 (13%)
Nausea in 175 (18%)
Vomiting in 65 (7%)
Dysrhythmia in 20 (2%)
Carpenter, RL, et al. Anesthesiology 1992;76:906
Reduction of side effects during spinalanesthesia
Minimize peak block height
Perform lumbar puncture at or below L3-L4
Avoid vasoconstrictors
Avoid procaine
Carpenter, RL, et al. Anesthesiology 1992;76:906
Spinal AnesthesiaSpinal Anesthesia
Complications Cardiac arrest Hypotension Headache Nerve injury
The Two Components The Two Components of Spinal Headacheof Spinal Headache
There must have been a lumbar puncture
The headache is related to posture Worst when standing or
sitting Gone or improved with
recumbence
Effect of Age on the Incidence Effect of Age on the Incidence of Spinal Headacheof Spinal Headache
Vandam and Dripps JAMA 1956;161:586-591
0
2
4
6
8
10
12
14
16P
erce
nt H
eada
che
10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89
Age
Effect of Needle Gauge on the Effect of Needle Gauge on the Incidence of Spinal HeadacheIncidence of Spinal Headache
Vandam and Dripps JAMA 1956;161:586-591
02468
1012141618
Per
cent
Hea
dach
e
16 19 20 22 24
Needle Gauge
Spinal AnesthesiaSpinal Anesthesia
Complications Cardiac arrest Hypotension Headache Nerve injury
Two types Permanent
Cauda equina syndrome Adhesive arachnoiditis
Non-permanent Transient radicular irritation
Nerve Injury with Spinal AnesthesiaNerve Injury with Spinal Anesthesia
Lidocaine spinal anesthesia was associated with 14.4 per 10,000 neurologic complications compared to 2.2 per 10,000 for bupivacaine spinal anesthesia.
Auroy Y. et al. Major complications of regional anesthesia in France: The SOS Regional Anesthesia Hotline Service. Anesthesiology 2002; 97: 1274-80
Permanent Nerve Injury with Spinal Permanent Nerve Injury with Spinal AnesthesiaAnesthesia
In the cases [of cauda equina syndrome and paraparesis] after subarachnoid block, hyperbaric 5% lidocaine was used in eight cases, bupivacaine 0.5% in 11 cases, and in one case a mixture of both drugs was used.
Moen V. et al: Anesthesiology 2004; 101: 950-9
Permanent Nerve Injury with Spinal Permanent Nerve Injury with Spinal AnesthesiaAnesthesia
Spinal is somewhat more dangerous in causing cardiac arrest and major nerve injury than epidural or general
Epidural has a neurological injury rate similar to spinal but the injuries are different Epidural are associated with hematoma and
compressive nerve injury (? owing to volume) Spinals are associated with local anesthetic toxicity
Major Complication of Spinal AnesthesiaMajor Complication of Spinal Anesthesia
Neurologic injury associated with paresthesia or pain on injection is believed to be traumatic.
Neurologic injury not associate with paresthesia or pain on injection is believed to be due to local anesthetic toxicity.
Permanent Nerve Injury with Spinal Permanent Nerve Injury with Spinal AnesthesiaAnesthesia
Eisenach, James C. Regional Anesthesia: Vintage Bordeaux (and Napa Valley)
Anesthesiology 1997;87:467-469
Editorial on Auroy’s study:“Spinal anesthesia appears in this study to be
more dangerous than other regional anesthesia techniques.”“Neurologic injury is two- to threefold greater with spinal than with other regional anesthetic techniques.”
Nerve Injury Still OccurringNerve Injury Still Occurring
Minor complications Transient neurologic symptoms (TNS) a.k.a. transient
radicular irritation (TRI)
Non-permanent Nerve Injury with Non-permanent Nerve Injury with Spinal AnesthesiaSpinal Anesthesia
Most frequent with lidocaine (10-34% incidence) More frequent with lithotomy position and knee
arthroscopy VAS pain score averages 6 out of 10 Many rate the pain worse than their incision Can last up to three days Least frequent with bupivacaine
TNS/TRI
Non-permanent Nerve Injury with Non-permanent Nerve Injury with Spinal AnesthesiaSpinal Anesthesia
The best alternative to lidocaine appears to be bupivacaine.
Lasts too long
Other shorter acting substitutes have not caught on. Procaine, mepivacaine, prilocaine, ropivacaine
TNS/TRI
Non-permanent Nerve Injury with Non-permanent Nerve Injury with Spinal AnesthesiaSpinal Anesthesia
Chloroprocaine (off label) is being rediscovered as a short acting spinal anesthetic.
Series of ten articles by Dan Kopacz et al. in the last year (see Anesth Analg 2004 and 2005)
Comparable to lidocaine. No TNS
TNS/TRI
Non-permanent Nerve Injury with Non-permanent Nerve Injury with Spinal AnesthesiaSpinal Anesthesia
The spinal anesthetic profile of 40 mg chloroprocaine compares favorably with the same dose of spinal lidocaine
Lidocaine was associated with mild to moderate TNS in 7 of 8 subjects
No subject complained of TNS with chloroprocaine
Yoos JR, Kopacz DJ:. Anesth Analg 2005; 100: 566-72
TNS/TRI
Non-permanent Nerve Injury with Non-permanent Nerve Injury with Spinal AnesthesiaSpinal Anesthesia
Spinal AnesthesiaSpinal Anesthesia Advantages v. Disadvantages Indications and Contraindications Positioning Getting ready Getting the needle in the right spot Baricity Dosing What to inject Addition of a vasoconstrictor Addition of narcotics Complications (and how to avoid them)
Unanswered questions are better Unanswered questions are better than unquestioned answers!than unquestioned answers!
Questions?Questions?
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