SPINAL ANESTHESIA (SUBARACHNOID BLOCK, INTRATHECAL BLOCK)
-It is the most commonly used anesthetic technique.
-It can be utilized for all open gynecology and obstetrics surgeries and surgeries of lower limb
and pelvis.
😍Procedure😍:-
- Given in lateral, sitting and also prone position.
- Approach➡ may be midline (most commonly used), lateral (paramedian) and
lumbosacral (Taylor).
- After cleaning and draping, lumbar puncture is done in desired space (usually L3-4) and
the local anesthetic drug is injected after confirming the free flow of CSF.
X-Site of Action of Local Anesthetic ➡ mainly acts on spinal nerves and dorsal ganglia.
💉Drugs used for Spinal Anesthesia💉
[Link] anesthetics⬇
● Lignocaine: Concentration used is 5%.The drug used for spinal is hyperbaric(or heavy),
the solution is made hyperbaric by addition of 7.5% dextrose.
● Bupivacaine: most commonly used,the concentration used is 0.5% and it is made
hyperbaric by addition of 8% dextrose.
● Ropivacaine and levobupivacaine.
● Chloroprocaine.
● tetracaine.
[Link]: A small dose of fentanyl (20-25 mcg) is usually added to the local anesthetic.
3.a2-Agonists: Clonidine and d
exmedetomidine can prolong the duration of spinal block
anesthesia.
[Link]: epinephrine, phenylephrine.
[Link]: by increasing the concentration of acetylcholine can prolong the analgesic
effect of spinal.
[Link] drugs like➡ midazolam, k etamine, tramadol or NSAIDS.
📌 Spinal Needles 📌
Dura cutting: Standard Quincke-Babcock, Greene and Pitkin needle are examples. These
needles cause more damage to dural fibers the incidence of postspinal headache is high.
Dura separating: These have pencil tip point end. types➡ Whitacre and Sportte. these needles
only separates the dural fibers,➡ so damage to dural fibers and incidence
of postspinal headache is less.
Factors Affecting the Height (Level) of Block:-
● Dosage of drugs.
● Baricity of the agent ➡ hyperbaric, hypobaric or isobaric.
● Position of the patient.
● Site of injection.
● CSF volume➡ inverse relation with level of block (⬇CSF volume lead to ⬆ level of
block and vars versa)
● Pregnancy.
● Age (⬆ age associated with ⬆ level of block)
● Epidural after spinal anesthesia.
Factors Affecting the Duration of Block:-
● Dose.
● Increased concentration.
● Pharmacological profile of drug like protein binding, metabolism.
● Added vasoconstrictors.
😥Complocations of spinal anesthesia😥
#-intraoperative:-
● Hypotension (most common complication)
● Treatment(Tx) ➡ prophylactic with preloading 1-1.5 liters of crystalloid.
● Curative ➡ head low position (trendelenburg position) to ⬆ venous returns (15-20° has
not ⬆ the level of block).it's a very vital part of management of spinal hypotension.
● Fluids➡ crystalloids or colloids.
● Vasopressors (sympathomimetic) like ephedrine (it's preferred), methoxamine,
phenylephrine, metaraminol and epinephrine.
● Inotropes (dopamine, dobutamine)
● Oxygen inhalation to prevent hypoxia from hypotension.
● Bradycardia ➡ Tx: i.v atropine
● Dyspnea: due to lower intercostal paralysis,➡Tx:oxygenation and assurance.
● High spinal/ total spinal ➡ Tx: depending on the level of block. Severe forms require
atropine and Vasopressor.
● Respiratory paralysis (apnea) usually due to hypotension.. So treat it and maintain +ve
pressure ventilation.. If it's because of a high spinal, the patient requires intubation.
● Nausea and vomiting ➡ due to hypotension that causes central hypoxia. Tx: treat the
cause and give antiemetics.
● Difficulty in phonation: This is because of high spinal extending up to cervical level.➡Tx:
IPPV
● Shivering: o2 consumption can ⬆ by 4-5 times during shivering, Therefore the patient
must receive oxygen,cover the patient (warming) and give him antishivering drug like
pethidine or tramadol.
● Restlessness, anxiety and apprehension:➡ Tx: sedate and assure the patient.
● Local anesthetic toxicity. ➡Treat the symptoms.
● Local anesthetic anaphylaxis.
● Cardiac arrest. ➡CPR.
● Broken needle ➡ portable x-rays and call neurosurgeon.
● Pain during injection ➡ Tx by local infiltration.
● Bloody tap: Bleeding after spinal usually occurs due to puncture of epidural vein.
#-postoperative:-
1. Urinary retention: Blockade of sacral parasympathetic fibers (S2, 3, 4). ➡Tx by
catheterization.
2. Neurological complications:
- Post-spinal headache
- Paralysis of cranial nerves (all cranial nerve except 1st, 9th and 10th)
- Meningitis ➡Tx by i.v antibiotics
- Transient neurological symptoms (most often seen with lignocaine)
- Cauda equina syndrome⚠ its neurotoxicity caused by local anesthetics usually
seen with lignocaine. Clinical features: Retention of urine, incontinence of feces,
loss of sexual function and loss of sensation in perineal region.➡ Due to:
Vacuolation of nerve fibers. Most of cases recover spontaneously.
- Paraplegia: due to➡ epidural hematoma, epidural abscess,
arachnoiditis(inflammation of arachnoid) and spinal cord ischemia.
3. Pruritus: is the most common side effect of intrathecal opioids. It can be treated with
opioid antagonists.
4. Backache.
Post-spinal headache
● It is a low pressure headache due to leakage of CSF from a dural hole created by the
spinal needle.
● Decreased intracranial pressure leading to ➡ traction of pain sensitive structures like
dura,vessels and tentorium ➡ producing pain.
● The CSF loss is about 10ml/hr.
● It's an occipital headache, present at any time between 12-72hr postoperative.
● Headache may be associated with nausea, vomiting, dizziness, tinnitus, diplopia, neck
stiffness, pain or even seizures.
● The typical symptomatology of post spinal headache is that the patient will complain of
😥
pain in sitting and standing position while pain gets relieved in lying down.
● Etiological factors :
- Needle size.
- Type of the needle (dura seperating is safe).
- High altitudes.
- Patient history of headache.
- Inadequate hydration.
- Pregnancy.
- Incidence less by paramedian approach and low glucose concentration of the
🎀 Treatment🎀
drug.
Preventive:
- Use of small gauge and dura separating needles.
- Adequate hydration so that CSF production exceeds loss.
- Avoiding spinal in patients with a history of headache.
Curative:
🌸
● 1st Line: ➡is conservative and it includes:
🌸
- Ask the patient to lie supine in a slight Trendelenburg position.
🌸
- Analgesics.
🌸
- Intravenous fluids (15 mL/kg/hr) or oral fluids 3 liters/day.
- Oral or intravenous caffeine: 500 mg of caffeine in 1 liter of ringer lactate inhibits the
vasospasm cycle in cerebral vessels.
● 2nd Line: include abdominal binders, desmopressin (retains fluid), inhalation of
5-6%CO2 in oxygen (CO2 by cerebral vasodilation will promote CSF production)
● 3rd Line: it's the definitive method of treatment➡ It includes an autologous Epidural
blood patch (10-20 mL of the patient's own blood is given in the same space in which the
spinal was given).
NOTE 😁
Queckenstedt's test is employed to differentiate between high pressure and low pressure
headache. In this test applying pressure on jugular veins increases the headache
in meningitis while relieving post-spinal headache.
SPINAL ANESTHESIA IN CHILDREN
- Should be given in lower space (L4-5).
- Due to more CSF volume ( 4 mL/kg vs. 2 mL/kg for adults) dose of local anesthetic required is
more and duration of block is less.
- Use of narcotics is contraindicated.
- Chances of systemic toxicity are high.
SADDLE BLOCK
- It is the spinal given in sitting position and the patient remains seated for 5-10 minutes till
the drug get fixed.
- Only sacral segments are blocked.
- Utilized only for perineal surgeries.
- The advantages:
1. Hemodynamic fluctuations are minimal.
2. No possibility of high spinal.
