Ultrasound for obstetric neuraxial anesthetic procedures ...
Predicting Difficult Neuraxial Blockade
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Transcript of Predicting Difficult Neuraxial Blockade
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PREDICTING DIFFICULT NEURAXIAL BLOCK
Dr Divesh Arora
Consultant Anesthesiologist
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INTRODUCTION
Anticipated technical difficulty can influence the anesthesiologist’s decision to perform neuraxial block.
Multiple attempts at needle placement might lead to:*•Patient discomfort•Higher incidence of spinal hematoma•PDPH•Trauma to neural structures*Horlocker TT et al. A retrospective review of 4767 consecutive spinal anesthetics:CNS complications. Anesth Analg 1997;84:578-84
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• Limited work has been carried out to predict difficult neuraxial block
• Scoring system to predict difficult neuraxial block ?
• Reliability of the predictive factors and scoring systems
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FACTORS PREDICTIVE OF DIFFICULT NEURAXIAL
BLOCK• Age• Sex• Weight• BMI• Body habitus• Spinal bony landmarks• Spinal bony deformity• Previous spine surgery• Radiological characteristics of vertebrae
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PATIENT CHARACTERISTICS
• Age: degenerative changes, osteophytes
• Sex: Osteoarthritis and lordosis more prevalent in females
• BMI:Distribution of fat
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Body Habitus*
• Normal
• Thin
• Muscular
• Obese*Sprung et al. Predicting the difficult neuraxial block: A
prospective study. Anesth Analg 1999;89:384-9.
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Spinal Bony Landmarks*
• Grade I: Spinous processes visible
• Grade II: Spinous processes not visible but palpable
• Grade III: Spinous processes not visible and not palpable
• Grade IV: No Landmarks*Chien I et al. Spinal process landmark as a predicting factor
for difficult epidural block. Kaohsiung J Med Sci Nov 2003;19(11):563-8
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SPINAL BONY DEFORMITY
LORDOSIS SCOLIOSIS
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KYPHOSIS ANKYLOSING SPONDYLITIS
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Previous Spine surgery
• Post operatively anatomical as well as degenerative changes occur in spine
• Limited spread of LA due to adhesions
• X Ray spine is of value
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Radiological Characteristics of
Vertebrae
• Presence / Absence of osteophytes
• Ligament Calcification
• Narrow Intervertebral spaces
• Spinal bony deformity
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• Identification of the entry point
• Skin crease serves as a landmark
• Approximate depth of epidural / subarachnoid space
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DIFFICULTY SCORE FOR NEURAXIAL BLOCK *
0 1 2 3
Age(yr) 20-40 41-60 >60 ---
BMI(Kg/m2) <22 22-27 27-34 >34
Spinal Bony Landmarks
Clear Unclear --- ---
Spinal Bony Deformity
No Yes --- ---
Radiology Of Vertebrae
Easy Difficult --- ---
*Atallah et al. Development of a difficulty score for spinal anesthesia. Br J Anaesth 2004;92:354-60
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TECHNICAL DIFFICULTY
• Each new skin puncture is counted as a new attempt
• Redirection of needle in the ligaments
• Change of intervertebral space
• Time required for the completion of procedure
• Patient Discomfort
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RELEVANT STUDIES
Sprung et al. Predicting the difficult neuraxial block: A prospective study. Anesth Analg 1999;89:384-9.
• BMI weakly related
• Quality of landmarks correlates best
• Patient characteristics not associated with difficulty
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Filho et al. Predictors of successful neuraxial block: A prospective study. Eur J Anaesthesiology 2002 June;19(6):447-51
• Anatomical landmarks, Patient positioning, Experience of Anesthetist are independent predictors of success.
• Patient characteristics are minor predictors.
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Chien I et al. Spinal process landmark as a predicting factor for difficult epidural block. Kaohsiung J Med Sci Nov 2003;19(11):563-8
• Spinal landmark grading system is valuable.
• Deformed spinal anatomy and body habitus correlates with the number of attempts required.
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OUR EXPERIENCE
• High volume joint replacement unit
• CSE is the mainstay anesthesia technique
• X Ray lumbosacral spine is routinely done
• Prospective study on this topic is being conducted by our unit
• Detailed analysis is yet to be completed
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• Age: younger the better
• Sex: more difficult in females
• BMI: Distribution of fat is more important
• Spinal bony landmarks palpation in conjunction with radiological characteristics of spine correlates with technical difficulty
• Deformity of spine increases the number of attempts
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How To Make Difficult Neuraxial Block Successful
As the quality of anatomical landmarks cannot be changed special attention should be given to the following:
• Explanation of the procedure to the patient
• Proper patient positioning• Experience of anesthesia provider• Paramedian or taylors approach
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USE OF C ARM
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USE OF USG
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CONCLUSION
Examination of patients back for the:
• Quality of landmarks
• Spinal deformity
And radiology of spine are the most reliable methods of determining the ease or potential difficulty in performing the neuraxial block
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