Regional & Obstetric
Anaesthesia
Department of Anaesthesia
Prince of Wales Hospital
Learning objectives
REGIONAL ANAESTHESIA
• Main types
• Indications & application
• Contraindications & adverse
effects
OBSTETRIC PATIENTS
• Special problems
Analgesia vs.
Anaesthesia
ANALGESIA is the relief of pain
AMNESIA is the loss of memory
SEDATION is relief of anxiety, but can depress consciousness
ANAESTHESIA is the reversible lack of awareness of all
sensations, not just pain
• General anaesthesia includes reversible loss of
consciousness
• Regional anaesthesia involves a limited area of the body
Main types of regional
anaesthesia
Local infiltration
Peripheral nerve blocks
• Single nerve
• Multiple
nerves
Plexus
blocks
Paravertebral block
Intravenous or Bier’s
block
Central neuraxial block
• Spinal
Local infiltration
• Involves the injection of LA into tissues near the site of
surgery
• The solution is deposited in the vicinity of larger terminal
nerve fibers
• A circumscribed area is anaesthestised
WHEN TO USE?
Primarily used for surgical
procedures involving a small area
of tissue
e.g. suturing of a small wound
tooth extraction
removal of simple
sebaceous cyst
Local infiltration
WHAT DRUGS TO
USE?
SAFETY
Volume used depends on area to be
anaesthetised
More volume can be given in dilute
concentrations
Beware of toxic doses
Addition of adrenaline can prolong duration
of action
LA additive -
Adrenaline
Typically added to LA solutions in strength of 1:50,000 to
1:200,000
Adrenaline causes vasoconstriction
Reduced blood flow at site of injection
• Decreased systemic vascular absorption
• Increased neuronal uptake of LA
• Extension of duration of block
• Decreased peak plasma concentrations of LA, therefore
reduced risk of LA toxicity
• Reduced bleeding at surgical site
LA additive -
Adrenaline
WHEN IS ADDITION OF ADRENALINE
NOT SUITABLE?
Hypertension
Coronary heart disease
Arrhythmias
CONTRAINDICATIONS
Adrenaline should not be used in LA
solutions in proximity to end arteries
e.g. fingers and toes
nose tip
ear lobules
Peripheral nerve
blocks
WHEN TO USE?
• Can be used in combination with general anaesthesia to provide
analgesia
• Can be used in isolation to avoid the risks associated with general
anaesthesia
e.g. patients with suspected difficult airway
patients at risk of respiratory depression related to GA
patients who wish to remain conscious during surgery
• Suitability depends on the context of surgery e.g. site, extent,
duration
• Important to exclude patient contraindications
e.g. coagulopathy
pre-existing neural deficits within the block distribution
active infection at injection site
Peripheral nerve
blocks
Upper limb
e.g. Digital nerve
Median nerve
Ulnar nerve
Radial nerve
Brachial
plexus
Lower limb
e.g. Femoral nerve
Popliteal nerve
Sciatic nerve
Lumbar plexus
Sacral plexus
Trunk
e.g. Inguinal nerve
Intercostal
nerve
Paraverterbal
Peripheral nerve
blocks
HOW DO WE LOCATE THE
NERVES?
Electrical stimulation
• A stimulation needle is
inserted in proximity to the
target nerve
• Watch for motor response
• The nearer the proximity the
lower the current required to
generate a motor response
Ultrasound guided
WHERE IS LA DEPOSITED?
Within the perineural sheath
Complications of peripheral
nerve blocks
SIDE EFFECT…a reversible, non-serious, unwanted effect of a
block e.g. phrenic nerve palsy after a brachial plexus block
COMPLICATION…a potentially serious, or irreversible unwanted
effect e.g. intravenous injection of LA, permanent nerve damage
after the block
Drug related
Technique related
Toxicity
Direct neural trauma
• Immediate: intravascular
Bleeding and
injection
haematoma
• Delayed: absorption from
Intravascular
vascular site
injection
• Overdose
Pneumothorax
Anaphylaxis
Anatomy is paramount to
success
e.g. Brachial plexus block
• What types of surgery would
this block be suitable for?
• What are the nerve roots that
supply the brachial plexus?
• What important structures are
located near the brachial
plexus?
• Can you deduce the side effects
and complications that may
occur after a brachial plexus
block?
Brachial plexus
Brachial plexus
Different approaches to block the
brachial plexus:
Interscalene is a common approach
Also supraclavicular and infraclavicular
approach
Interscalene block
approaches the brachial
plexus between the two
scalene muscles: scalenus
anterior and scalenus
medius
Brachial plexus
Potential side effects and complications
Phrenic nerve block: caution in patients with limited
pulmonary reserve
Horner’s syndrome from block of sympathetic trunk
Hoarseness from block of recurrent laryngeal nerve
Pneumothorax
Intravascular injection into subclavian vessels, verterbal
artery
Rarely, accidental spinal or epidural injection
IV block or Bier’s
block
• LA in injected directly into a
peripheral vein in the upper
limb below an inflated
tourniquet, which has first
been exsanguinated with an
Esmarch bandage
• Entire extremity below the
level of the tourniquet is
anaesthetised
• Duration of anaesthesia
depends upon the duration of Useful for short upper limb
tourniquet application surgery below the elbow
e.g. reduction of Colles’
• Tourniquet discomfort usually #
limits surgical duration time to FB removal
60 min.
Bier’s block
HOW DOES IT WORK?
• If LA is injected into the venous circulation with distal occlusion,
the nerves that travel with blood vessels will become
anaesthetised as the drug diffuses into the extravascular space
• Ischaemia and compression of the peripheral nerves at the level
of the inflated cuff may also contribute
• Typically short acting and less toxic local anaesthetics are used
e.g. lignocaine or prilocaine
• Adrenaline is not added to the LA solution
CONTRAINDICATIONS
• If tourniquet cannot be applied safely e.g. sickle cell disease
• Allergy to prilocaine or lignocaine
OBSTETRIC
ANAESTHESIA
The most common anaesthesia
technique for Caesarean section is a
regional technique
Increased use of regional anaesthesia
has reduced maternal deaths from
anaesthesia
Regional anaesthesia is safer than
general anaesthesia in obstetric
patients
Indications for Spinal
Anaesthesia
• All but the most urgent Caesarean
sections
• If no contraindications
Principals of Spinal
anaesthesia
Drugs are deposited
directly into the
cerebrospinal fluid that
bathes the entire spinal cord
Single injection of LA
combined with an opioid
Requires deliberate puncture
of the dura mater using a
spinal needle through which
drugs are injected
Blocks sensory transmission
and is often accompanied by
a dense motor block
Spinal anaesthesia: pros
& cons
ADVANTAGES
Fast
Reliable
Dense block
Avoids GA
DISADVANTAGES
Hypotension
Limited duration
Headache
Spinal needles
REDUCED
RISK OF
HEADACHE
with:
• Small
gauge
needle
(25g)
• Pencil point
needle
Principals of Epidural
anaesthesia
Injection of local anaesthetic
(LA) solution into the epidural
space via a catheter
Drugs injected into the epidural
space will diffuse up and down
and penetrate the dura
Epidural drugs can block
sensory and motor
transmission
Quality of block enhanced by
addition of opioids into LA
solution
How to locate the epidural
space?
Spinal vs Epidural
Spinal Epidural
Through dura (CSF) Outside dura (NO CSF)
Small needle (pencil point) Large needle (Tuohy)
Endpoint: free flow CSF Endpoint: Loss of resistance
(air/saline)
Single shot Continuous infusion via
catheter
Rapid onset Slow onset
Small dose (high concentration, Large dose (low concentration,
low volume) high volume)
Surgical anaesthesia Surgical anaesthesia AND
analgesia
Combined Spinal and Epidural
technique
Can be used to provide labour analgesia and
anaesthesia for Caesarean section
Unsuitability for neuraxial
technique
Unsuitable
• Coagulopathy
• Thrombocytopenia
• Local infection
• Severe sepsis
• Anatomic abnormality
• Concurrent disease
e.g.
raised ICP
severe cardiac
disease
• Lack of expertise
• Lack of resources
• Patient refusal
Unsuccessful neuraxial
technique
Multiple failed
attempts
• Operator experience
• Obesity
• Difficult spine anatomy
e.g.
Scoliosis
Previous spine
surgery
• Moving /uncooperative
patient
Complications of neuraxial
anaesthesia
• Failure/inadequate block
• High block
• LA toxicity
• Hypotension
• Post dural puncture headache
• Nerve damage
• Haematoma
• Infection
Why is Obstetric GA
considered less safe?
Obstetric general
anaesthesia carries
many potential life
threatening
complications
Obstetric Airway Difficulties
General anaesthesia induces loss of consciousness & loss of
normal tissue tone
• Loss of protective aspiration reflexes
• Upper airway obstruction
• Loss of spontaneous respiratory effort
Airway manipulation
• Head tilt-chin lift-jaw thrust
• Facemask ventilation
• Intubation
PREGNANCY EXACERBATES DIFFICULTIES
• Weight gain and oedema
• Pre-existing obstetric disease e.g. pre-eclampsia
• Increased oxygen demand & reduced oxygen reserve
• Delayed gastric emptying and reflux
Consequences of difficult
airway
Difficult intubation is 8 times more common (1:300
cases)
Delayed or unsuccessful airway management
Inadequate gas exchange + higher aspiration risk
Maternal hypoxia
Aspiration pneumonitis
Primary respiratory arrest
Progression to cardiac arrest
Maternal death
Rapid Hypoxia &
Aspiration
• Increased oxygen consumption by 20%
• Maternal consumption
• Fetal consumption
• Decreased oxygen reserve
• Physiological changes of pregnancy
• Reduced FRC by 20%
• Delayed gastric emptying and relaxed LOS
• Increased even with adequate fasting
• Premedication is important e.g. antacids, Na citrate
Modified General
Anaesthesia
• Rapid sequence induction
• Suxamethonium
• Cricoid pressure
• Protect airway with endotracheal
tube
Aortocaval
compression
Left lateral uterine displacement
Fig 5.1, Positioning for Pregnant Patient
(Wilkins 2009)
Lecture Summary
Understand the principals of regional
anaesthesia
• When this may be indicated
• Different types of techniques
• Potential risks and benefits
• Potential complications
Special considerations for obstetric anaesthesia
• Regional anaesthesia is the safest technique
• Use of rapid sequence induction for modified
general anaesthesia
• Avoid aortocaval compression for all maternal
patients
