Spinal anesthesia:
Spinal anesthesia or sub-arachnoids
block (SAB), is a form of regional
anesthesia involving injection of a local
anesthetic into the subarachnoid space.
Should cross
Skin
Subcutaneous
Structures penetrated by the
lumbar puncture needle
muscle
Supraspinous ligament
Interspinous ligament
Ligament flavum
Epidural space
Dura ma
Arachnoids me
Sub arachnoids
Advantages of spinal anesthesia over
general anesthesia
The metabolic stress is reduced by
subarachnoid block
Reduction in blood loss.
Decreases the incidence of venous
thromboembolic complications by as much as
50%.
Pulmonary compromise appears to be less.
Advantages of spinal anesthesia Cont..
Endotracheal intubation is avoided.
Mental status can be followed.
Low cost
Short NPO time
Patient satisfaction
For diabetic patients, possible to monitor
signs of hypoglycemia
Disadvantages of Spinal Anaesthesia
Some times it is difficult to find the dural space
and occasionally, it may be impossible to obtain
CSF
High block
Being conscious might not be appropriate for
some pts (Psychological reason)
Not appropriate for prolonged surgery (pt feels
discomfort from lying on table for long periods)
Risk of meningitis
Indications
Irritable airway (bronchial asthma or allergic
bronchitis)
Anatomical abnormalities which make
endotracheal intubation very difficult,
Borderline hypertensives
Diabetes patients
Cardiac patients except those with stenotic
valvular lesions
Indications Cont..
Suitable for Obstetric patients provided that
the mother has stable hemodynamic state and
the anesthetist is familiar with the technique.
Ideal for manual removal of a retained
placenta, provided that there is no
hypovolemia
Contra indications
Failure to give consent,
Local infection or sepsis at the site of lumbar
puncture,
Bleeding disorders,
Disorders of the spine
Hypotension
Inadequate resuscitation drugs and equipment
Positions used for Spinal Anesthesia
Sitting
Lateral Decubitus
Prone
Lateral position
Place the patient on his side, right or left.
The buttocks and the shoulders should be parallel to the
edge of the table.
The anesthetist or assistance stands in front of the patient
and places one hand behind the patient's neck and the
other hand behind the patient's knees. The back is arched
to open up the intervertebral and the interlaminar spaces
fetal position
Patient should be positioned so that it takes advantage of
the baracity of the local anesthetic solution
Lateral position
Siting position
Sitting position
The patient is placed with the buttocks near the
edge of the table
Place patients feet on a stool
Have them sit up straight
Head flexed down, arms across lap or hugging
a pillow
He is instructed to arch his back like a cat or to
"push out" his back.
performance
Landmark Identification
Con
A line drowns between the highest points of
the iliac crests will cross the fourth lumbar
spine or the space between the fourth and fifth
spines.
CSF
The CSF occupies the potential space between
pia and arachinoid mater and forms the volume
of distribution for spinal anesthetic agents to
the spinal cord structures.
Formation - CSF is formed in the choroids
plexus in the brain.
150ml and absorbed by arachinoids' villi.
Spinal Anesthesia con
After administration of local anesthetic agents in
to sub arachinoid space,
Autonomic nervous out flow blocked first
followed by unmylenated C-fibers associated with
pain are blocked, thereby eliminating pain.
Lastly thick, heavily mylenated A-alpha motor
neurons are blocked last.
The degree of neuronal blockade depends on the
amount and concentration of local anaesthetic
used
Spinal Anesthesia con
Some sedation is sometimes provided to help the
patient relax and pass the time during the procedure,
But with a successful spinal anesthetic the surgery
can be performed with the patient wide awake.
Assessment of level of block
Sensory block- test for a loss of sensation
using a swab soaked in either alcohol or ether
Autonomic block-ask warming of leg.
Motor block-ask patient to raise his leg
Injected substances
Bupivacaine
- Lignocaine,
Tetracaine,
- Procaine,
Ropivacaine,
- levobupivicaine and
Cinchocaine may also be used.
Sometimes a vasoconstrictor such as
epinephrine is added to the local anaesthetic to
prolong its duration.
Injected substances Con
Opioids like morphine and Fentanyl can be combined
with local anesthetics to give a smoother effect and to
provide prolonged pain relief once the action of the
spinal local anesthetic has worn off.
Usually, the hyperbaric, is chosen, as its spread can
be effectively and predictably controlled by the
anesthesiologists, by tilting the patient.
Injected substances Con
Baricity refers to the density of a substance
compared to the density of human cerebral spinal
fluid.
Baricity is used in anaesthesia to determine the
manner in which a particular drug will spread in
the intrathecally space.
Hyperbaric solutions are made more dense by
adding dextrose to the mixture.
Selection of Baricity depends on site of surgery
Injected substances Con
Anatomical deformities of the patient's back.
This is a relative contraindication,
Neurological disease
Septicemia
Patients preference to general anesthesia
Complications:
Spinal shock (pre load with crystalloid fluids)
Cauda equina injury.
Bradicardia
Cardiac arrest.
Hypothermia.
Broken needle.
Complications
Bleeding resulting in hematoma, with or without
subsequent neurological sequelae due to compression of
the spinal nerves
Infection: Immediate within six hours of the spinal
anaesthetic manifesting as meningitis or late, at the site of
injection, in the form of pus discharge, due to improper
sterilization of the LP set.
PDPH: Post dural puncture head ache or post spinal head
ache
