Regional anesthesia

Regional anesthesia is anesthesia affecting only a specific area of the body when the patient is conscious, e.g. foot, arm, lower extremities, insensate to stimulus of surgery or other instrumentation.

1. BY DR. MUHAMMAD SAIFULLAH HOUSE OFFICER ANESTHESIA AND ICU DEPARTMENT ALLIED HOSPITAL, FAISALABAD REGIONAL ANESTHESIA

2. Regional anesthesia is anesthesia affecting only a specific area of the body when the patient is conscious, e.g. foot, arm, lower extremities, insensate to stimulus of surgery or other instrumentation. REGIONAL ANESTHESIA

3. Spinal, epidural, and caudal blocks are also known as neuraxial anesthesia. Almost all operations below the neck can be performed under neuraxial anesthesia. However, because intrathoracic , upper abdominal, and laparoscopic operations can significantly impair ventilation, general anesthesia with endotracheal intubation is also necessary. CENTRAL (NEURAXIAL) ANESTHESIA

4. ANATOMY

5. SPINAL ANESTHESIA Uses / Indications lower abdominal surgery inguinal surgery urogenital surgery rectal surgery lower extremity surgery Lumbar spinal surgery Obstetrical – C/Section Contra-indications Absolute   Severe hypovolemia Increased ICP Infection at injection site Patient refusal Coagulopathy Severe AS or MS Relative   Severe spinal deformity Sepsis Uncooperative patient Preexisting neurological deficits Demyelinating lesions Stenotic valvular heart lesions

6. DRUGS AND DOSAGE Bupivacaine Tetracaine Procaine Bupivacaine (0.75% in 8.25% Dextrose) 4-10 mg 12-14 mg 12-18 mg 90-120 min Complicatons High/Total spinal Hypotension due to sympathetic block Post dural puncture headache Bleeding Transient Neurological Syndrome

7. EPIDURAL ANESTHESIA Indications Hip and Knee Surgery Lower Extremity Vascular Surgery Lower Extremity Amputation Obstetrical – Labor & C/S Thoracic Surgery – Post-Op Pain Control Thoracic Trauma Abdominal Surgery – Post-Op Pain Control Contraindications Patient refusal for surgery Uncooperative patients Coagulopthy Skin infection at injection site Hypovolaemia Presence of neurological disorders cardiovascular disease Kyphoscoliosis

8. DRUGS AND DOSAGE Chloroprocaine (Fast) Lidocaine (Intermediate) Mepivacaine (Intermediate) Bupivacaine (Slow) Ropivacaine (Slow) Complications Accidental Dural Puncture High Epidural Local Anesthetic Toxicity Total Spinal

9. COMBINED SPINAL EPIDURAL (CSE) Suitable whenever a rapid onset of analgesia is required but the period of analgesia required exceeds that of a single spinal injection. Post operative pain relief In labouring women, the onset of analgesia is more rapid with CSE Contraindications, drugs dosages & adverse effects are the same as spinal and epidural anesthesia.

10. CAUDAL ANESTHESIA (EPIDURAL) Indications Pediatric anesthesia Anorectal surgery in adults Lower extrimity surgery A dosage of 0.5–1.0 mL /kg of 0.125–0.25% bupivacaine (or ropivacaine ) with or without epinephrine can be used Given usually after induction of GA for Intra-operative supplementation and post operative analgesia.

11. PERIPHERAL NERVE BLOCKS Indications Surgery at a specific extremity lower back pain neck pain sciatica (from a herniated disc) spinal stenosis reflex sympathetic dystrophy (a complex regional pain syndrome) shingles cancer painful peripheral vascular disease treatment of migraine headache Contraindications Uncooperative patient Bleeding diathesis Infection Local anesthetic toxicity Peripheral neuropathy

12. Somatic Blockade of the Upper Extremity Somatic Blockade of the Lower Extremity Somatic Blockade of the Trunk PERIPHERAL NERVE BLOCKS

13. INTRAVENOUS REGIONAL ANESTHESIA Indications Distal Arm or Leg Surgery Useful for Short Procedures Contra-Indications Raynaud’s Disease Sickle Cell Disease Crush Injury to the Limb Very Young may need additional Injection of local anesthetic intravenously for anesthesia of an extremity Advantages: technically simple, minimal equipment, rapid onset Disadvantages: duration limited by tolerance of tourniquet pain, toxicity