spinal anaesthesia


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1 : welcome
2 : Spinal Anaesthesia Dr angshuman rudra pal
3 : Introduction  spinal anaesthesia or sub-arachnoid block (SAB), is a form of regional anaesthesiainvolving injection of a local anaesthetic into the subarachnoid space, generally through a fine needle, usually 9 cm long (3.5 inches).
4 : History First used at turn of twentieth century. Intrathecal use of cocaine was first described by Bier in 1898. Procaine synthesized in 1904 Enthusiastic clinicians: Morton……promoted high spinal anaesthesia. Koster…….total spinal. Kennedy……grave spinal cord paralysis. Touted for the T/t of medical conditions (pulmonary edema).
5 : Anatomy of vertebral column vertebral bones:33 7 cervical 12 thoracic 5 lumber 5 fused sacral 4 fused coccygeal . 4 curvature:: Thoracic & sacral kyphotic Cervical & lumbar lordotic
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7 :
8 : Contents of spinal canal Spinal cord. Meninges. Fatty tissue. Venous plexus.
9 : spinal cord Extent Spinal nerves: 31 pair Cauda equina Filum terminale
10 :
11 : Blood supply of spinal cord
12 : menninges 1.Duramater 2.Arachnoidmater 3.piamater
13 :
14 : CSF Formation circulation Absorption Volume Rate of secretion Sp. Gravity Ph Pressure Composition: Protein: 20 to 40 mg/100 ml Glucose :45 to 80 mg/100 ml Chloride: 720 to 750 mg/100 ml
15 : CSF circulation
16 : Menchanism Of Action Site of action Sensitivity of nerve fibre Sesory blockade (A-beta ,A- delta , C fibre) Motor block ( A-alfa , A-gama ) Autonomic blockade (preganglionic C fibre) Differential blockade High block Physiologic response Testing of block
17 : Cardiovascular manifestation 1. Hypotension a. venodilatation b. decreased cardiac output due to 1. decreased venous return 2. Bradycardia…….1. Brainbridge reflex 2. cardioaccelator fiber c. decreased catecholamine release. d. supine hypotension syndrome. e. Direct absorption of drug into circulation.
18 : Pulmonary manifestation Tidal volume : unchanged. Minute ventilation : unchanged. Arterial O2 conc. : maintained. Vital capacity : redused. COPD patient : risky.
19 : Gastrointestinal manifestation Nausea & vomiting 1. Hypotension 2. Bile in stomach 3. Abdominal structure handling 4. Psychological. Hyperperistalsis. Good for laparoscopy.
20 : Liver : Renal : autoregulation ( 55 mmHg ). Urinary retention : Genital : Engorged penis. Endocrinal : Stress response inhibited. Thermoregulatory : shivering ( vasodilatation)
21 : Important dermatological segments Nipple : T4 Xiphisternum :T6 Umblicus : T10 Inguinal ligament : L1 Perinium :S1 to S4
22 : dermatomes
23 : Level of block required for common surgeries Cesarean section : upto T6 Prostate : upto T 10 Testicular surgery : upto T10 Hernia : upto T10 Appendix : upto T8 Hyterectomies : upto T6 Perineal surgery : Sacral segments.
24 : Technique Pertinent anatomy must be kept in mind. 4 p’s… Preparation Position Projection Puncture
25 : preparation Assesment , explanation , consent , examination of the patient. Commencing intravenous infusion. Establishing monitoring of patient. Ensuring that operating table tilts. Checking anaesthetic machine. Ensuring that a defibrillator is available. Equipments Drugs
26 : Equipments Reusable or disposable spinal trays
27 : Spinal needle Dura cutting: Quincke-babcock Dura separating: whitcre & sporte
28 : Spinal needle 16 to 30 g size
29 : Drug selection 1. Local Anaesthetic: Lignocaine 5% in 7.5% dextrose onset, fixation, drawback, caution . Bupivacaine (Sensoricaine) 0.5% in 8% dextrose (10 to 12.5 mg for CS ). .
30 : drugs
31 : Other local anaesthetics Tetracaine 1% in 5% dextrose. Procaine 10% in 5% dextrose. ( Oldest , brief , high fq nausea , less back pain). Ropivacaine. Mepivacaine. Levobupivacaine
32 : Opioids Morphine : Diamorphine: Fentanyl : dose…10 to 25 micrigram. Sufentanyl : Pethidine : local anaesthetic property.
33 : Spinal anaesthetic additives Epinephrine Phenylephrine Clonidine Neostigmine
34 : Sitting Position Low lumbar or perineal sx Obesity , scoliosis… Stool , pillow. Assist. Manipulated.
35 : Lateral decubitus Most common. Less dependent. Easy sedation. Back parallel. Thigh flexed.
36 : Prone position Jackknief modification. Rectal , perineal , lumbar procedure. Paramedian approach. Aspirate CSF.
37 :
38 : Aseptic field prepared. Identification of space level Surface landmarks C7 : very prominent & easily palpable. T7 : inferior angle of scapula. L4 –L5 interspace : highest point on illiac crest. A wheal is made Site of injection.
39 :
40 :
41 : Projection & Puncture Tissue resistance. Bone contacted. Redirect. Loss of resistance. Needle rotated. Withdrawn Free flow of CSF. Midline approach
42 : Paramedian Approach Arthritis , kyphoscoliosis , prior lumbar sx. Wheal. Little resistance. 15 to 25 degree angle.
43 : Lumbosacral approach Taylor. L5- S1 space. PSIS. Cephalomedial direction
44 : Factors affecting height block Most important: Baricity of anaesthetic solution (incl. temp). Position of pt.during & after injection. Drug dosage Site of injection
45 : Other factors Age Cerebrospinal fluid Curvature of spine Drug volume Intraabdominal prsessure Needle direction. Patient height Pregnancy.
46 : Factors not affecting height block Gender Weight. Needle bevel direction Added vasoconstrictors Barbotage.
47 : Factors affecting duration of block Dose. Concentration Pharmacological profile of drug ….PPB,metabolism Type of drug Added vasoconstrictors
48 : Advantages of SA over GA Cheaper. Less risk of pulmonary aspiration. No complication …bronchospasm , laryngospasm , P. O. atelectasis , hypoxia. Minimal disturbance of body chemistry. Less bleeding. Cardiovascular response to intubation avoided. Systemic sideeffects of GA drug not seen.
49 : to be continued………

 

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