SPINAL ANESTHESIA
IRAM SHAHZADI KHAN
BS(ANESTHESIA & CRITICAL CARE SCIENCES)
MSPH(IN PROGRESS)
ANESTHESIA LECTURER
BIHS
OBJECTIVES
Spinal Anesthesia Definition
Indication for Spinal Anesthesia
Contraindication to Spinal Anesthesia
Anatomy
MOA
Advantages of Spinal Anesthesia
OBJECTIVES
Local Anesthetic for SA
Pre-Spinal Anesthesia Consideration
Position & Procedure
Assessment of Spinal Block
Factor affecting the level of SA
Complication & Treatment
SPINAL ANESTHESIA
Spinal anesthesia, also called spinal block, subarachnoid
block, intradural block and intrathecal block, is a form of
regional anesthesiawhich is interruption of conduction of nerve
impulses by the injection of an anesthetic into the spinal canal
that reduces sensitivity to pain without loss of consciousness.
INDICATION 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.
All operations on the leg are possible, but an
amputation, though painless, may be an unpleasant
experience for an awake patient.
INDICATION FOR SPINAL ANESTHESIA
Older patients and those with systemic disease
such as chronic respiratory disease, hepatic,
renal and endocrine disorders such as diabetes.
It is suitable for managing patients with trauma
if they have been adequately resuscitated and are
not hypovolemic.
INDICATION FOR SPINAL ANESTHESIA
In obstetrics, it is ideal for manual removal of
a retained placenta (again, provided there is no
hypovolemia).
CONTRA-INDICATIONS TO SPINAL
ANESTHESIA
Absolute
Inadequate resuscitative drugs and
equipment
Coagulopathy or other bleeding
disorders
Severe hypovolemia.(Shock)
Patient refusal
CONTRA-INDICATIONS TO SPINAL
ANESTHESIA
Increased Intracranial
Pressure
Severe aortic stenosis.
Severe Mitral stenosis
CONTRA-INDICATIONS TO SPINAL
ANESTHESIA
Relative contraindication
Sepsis
Uncooperative patients.
Pre-existing neurological deficit.
Stenotic valvular heart disease.
Severe spinal deformities.
CONTRA-INDICATIONS TO SPINAL
ANESTHESIA
Lack of consent
Controversial
Prior back surgery at the site of injection.
Inability to communicate with the patients.
CONTRA-INDICATIONS TO SPINAL
ANESTHESIA
Complicated Surgery
- Prolonged Surgery
- Major Blood Loss
ANATOMY
Skin.
Subcutaneous fats.
Supraspinous ligament.
Interspinous ligament.
Ligamentum flavum.
Epidural space.
Dura.
Subarachnoid
space.
ANATOMY
The spinal cord usually ends at the
level of L1
in adults and L3 in children. Dural
puncture
above these levels is associated with
a slight
risk of damaging the spinal cord and
is best
avoided. An important landmark to
remember is
that a line joining the top of the iliac
crests
is at L4 to L4/5
MECHANISM OF ACTION
Local anesthetic solution injected into the
subarachnoid space blocks conduction of impulses
along all nerves with which it comes in contact,
although some nerves are more easily blocked than
others.
There are three classes of nerve which are blocked:
Motor
Sensory
Autonomic
MECHANISM OF ACTION
Stimulation of the motor
nerves causes muscles to contract and when they
are blocked, muscle paralysis results. Sensory
nerves transmit sensations such as touch and pain
to the spinal cord and from there to the brain,
while autonomic nerves control the calibre of
blood vessels, heart rate, gut contraction.
MECHANISM OF ACTION
Generally, autonomic and sensory fibres are
blocked before motor fibres. This has several
important consequences. For example, vasodilation
and a drop in blood pressure may occur when the
autonomic fibres are blocked.
ADVANTAGES OF SPINAL ANESTHESIA
Cost
Patient satisfaction
Respiratory disease
Patent airway
Diabetic patients.
Muscle relaxation.
Blood loss during operation is
less.
LOCAL ANESTHETICS FOR SPINAL
ANESTHESIA
Local anesthetic agents are either heavier (hyperbaric), lighter
(hypobaric),or have the same specific gravity (isobaric) as the
CSF. Hyperbaric solutions tend to spread below the level of the
injection, while isobaric solutions are not influenced in this way.
LOCAL ANESTHETICS FOR SPINAL
ANESTHESIA
• It is easier to predict the spread of spinal anesthesia when
using a hyperbaric agent. Isobaric preparations may be made
hyperbaric by the addition of dextrose. Hypobaric agents are not
generally Used.
Bupivacaine (Marcaine)
0.5 hyperbaric (heavy) bupivacaine is the best agent to use if it
is available. 0.5 plain bupivacaine is also popular.
LOCAL ANESTHETICS FOR SPINAL
ANESTHESIA
Bupivacaine lasts longer than most other spinal anesthetics usually 2-3
hours.
Lignocaine (Lidocaine/Xylocaine)
Best results are obtained with 5 hyperbaric (heavy) lignocaine which lasts
45-90 minutes.
Cinchocaine (Nupercaine, Dibucaine, Percaine, Sovcaine).
0.5 hyperbaric (heavy) solution is similar to bupivacaine.
Amethocaine (Tetracaine, Pantocaine, Pontocaine, Decicain,
Butethanol, Anethaine, Dikain).
A 1 solution can be prepared with dextrose, saline or water for
injection.
Mepivacaine (Scandicaine, Carbocaine, Meaverin)
A 4 hyperbaric (heavy) solution is similar to
lignocaine.
PRE-SPINAL ANESTHESIA
CONSIDERATION
PRE-OPERATIVE VISITS
Patients should be told about their anesthetic during the pre-
operative visit. It is important to explain that although spinal
anesthesia abolishes pain, they may be aware of some sensation in
the relevant area, but it will not be uncomfortable and is quite
normal. They must be reassured that, if they feel pain they will be
given a general anesthetic.
PRE-MEDICATION
Premedication is not always necessary, but if a patient is
apprehensive, a benzodiazepine such as 5-10 mg of diazepam
may be given orally 1 hour
before the operation. Other sedative or narcotic agents may also
be used. Anticholinergics such as atropine or scopolamine
(hyoscine) are unnecessary
PRE-LOADING
All patients having spinal anesthesia must have a large intravenous
cannula inserted and be given intravenous fluids immediately before
the spinal. The volume of fluid given will vary with the age of the
patient and the extent of the proposed block. A young, fit man having
a hernia repair may only need 500 mls. Older patients are not able to
compensate as efficiently as the young for spinal-
induced vasodilation and hypotension and may need 1000mls
for a similar procedure.
PRE-LOADING
If a high block is planned, at least a 1000mls should be given to all
patients. Caesarean section patients need at least 1500 mls.
The fluid should preferably be normal saline or ringer lactate. 5
dextrose is readily metabolized and so is not effective in maintaining
the blood pressure.
PROCEDURE
POSITION
Lateral ( Lt lateral Decubitus)
Sitting
- The sitting position is preferable in the obese whereas the
lateral is better for uncooperative or sedated patients.
Onset of Action
3-5 min
Duration of Action
1.5-2 hours(Depend upon drug used)
ASSESSMENT OF SPINAL BLOCK
ASSESSMENT OF SPINAL BLOCK
Sensory block is assessed by Painful stimulus(pinching the skin)
Motor block is assessed by Bromage motor scale
Autonomic block is assessed by temperature
FACTORS AFFECTING THE LEVEL OF
SPINAL ANESTHESIA
• The baricity of the local anesthetic solution
• Dosage , concentration and volume injected
• Site of injection.
• Position of the patient.
- During Injection.
- Immediately after injection.
• Patient Height.
COMPLICATIONS
Immediate complication
Hypotension and Cardiac arrest.
Total spinal block leading to respiratory
arrest.
Urinary retention.
Epidural hematoma, Bleeding.
COMPLICATIONS
Late complication
Post Spinal Headache Or Post dural puncture headache (PDPH)
Backache
Focal neurological deficit
Bacterial meningitis
TREATMENT OF HYPOTENSION
Hypotension is due to vasodilation and a functional decrease in
the effective circulating volume.
vasoconstrictor drugs
All hypotensive patients should be given OXYGEN by mask until
the blood pressure is restored.
Raising their legs thus increasing the return of venous blood to
the heart.
TREATMENT OF HYPOTENSION
Increase the speed of the intravenous infusion to maximum until
the blood pressure is restored to acceptable levels.
Pulse is slow, give atropine intravenously.
TREATMENT OF POST SPINAL
HEADACHE
Remain lying flat in bed as this relieves the pain.
They should be encouraged to drink freely or, if necessary, be given intravenous
fluids to maintain adequate hydration.
Simple analgesics such as paracetamol, aspirin or codeine may be helpful
Caffeine containing drinks such as tea, coffee or Coca-Cola are often helpful.
Prolonged or severe headaches may be treated with epidural blood patch
performed by aseptically injecting 15-20ml of the patient's own blood into the
epidural space. This then clots and seals the hole and prevents further
leakage of CSF.
TREATMENT OF POST SPINAL
HEADACHE
It used to be thought that bedrest for 24 hours following a spinal
anesthetic would help reduce the incidence of headache.
It is widely considered that pencil-point needles (Whiteacre or Sprotte)
make a smaller hole in the dura and are associated with a lower
incidence of headache than conventional cutting-edged needles
(Quincke)
