REGIONAL ANESTHESIA IN CATTLE

By
ERMIAS GEBEYEHU



A Paper Presented for the Course: Seminar on Animal Health (VST-566)



UNIVERSITY OF GONDAR
FACULTY OF VETERINARY MEDICINE

May, 2014
GONDAR

I



ACKNOWLEDGMENTS


Above all, I would like to thank the almighty GOD and his Holly mother St. Marry who gave me
strength to accomplish this seminar paper.

I forward my immense gratitude to my advisor Prof. Rajendran Natarajan for his kindness in
hospitality, constructive ideas and corrections; he had made during the course of my seminar review.

Last but not least, my gratitude and respect extend to my lovely family for their overall moral and
financial support.



II

TABLE OF CONTENTS

ACKNOWLEDGMENTS ............................................................................................................. I
TABLE OF CONTENTS ............................................................................................................. II
LIST OF ABREVIATION ......................................................................................................... III
LIST OF FIGURES .................................................................................................................... IV
LIST OF TABLES ........................................................................................................................ V
SUMMARY ................................................................................................................................. VI
1. INTRODUCTION .................................................................................................................. 1
2. LITRATURE REVIEW ON REGIONAL ANESHESIA IN CATTLE ............................ 3
2.1. Historical perspective of regional anesthesia in cattle ..................................................... 3
2.2. Local anesthetics ................................................................................................................. 4
3. REGIONAL NERVE BLOCK AND ITS TECHNIQUE IN CATTLE ........................... 7
3.1. Regional nerve block of head.7
3.1.1. Cornual nerve block........................................................................................................ 7
3.1.2. Auriculopalpebral nerve bock ........................................................................................ 8
3.1.3. Retrobulbar nerve block ................................................................................................. 9
3.1.4. Peterson nerve block in cattle....................................................................................... 10
3.2. Regional nerve bock of trunk of cattle ............................................................................ 11
3.2.1. Proximal paravertebral nerve block (Farguharsons method) ...................................... 11
3.2.2. Distal paravertebral nerve block (Magda method) ....................................................... 13
3.3. Regional nerve block of the caudal region in cattle ....................................................... 14
3.3.1. Caudal epidural anesthesia ........................................................................................... 14
3.3.2. Continuous caudal epidural anesthesia ......................................................................... 16
3.3.3. Internal pudendal nerve block ...................................................................................... 17
4. COMPLICATIONS AND SIDE EFFECTS OF REGIONAL ANESTHESIA .............. 19
4.1. Adverse reactions .............................................................................................................. 19
4.2. Over dosage ....................................................................................................................... 20
4.2.1. Treatment of over dosage toxicity of regional anesthesia ............................................ 20
5. CONCLUSIONS AND RECOMMENDATIONS ................................................................ 22
6. REFERENCES ........................................................................................................................ 24
III


LIST OF ABREVIATIONS


Cm Centimeter
CNS Central nervous system
Co1 First coccygeal vertebrae
Co2 Second coccygeal vertebrae
DOA Duration of action
Fig Figure
HCL Hydrochloride
Kg Kilogram
L1 First lumbar
L2 Second lumbar
L4 Fourth lumbar
L5 Fifth lumbar
Mg Milligram
Min Minute
Ml Milliliter
MOA Mechanism of action
S3 Third sacral
S4 Forth sacral
T13 Last thoracic vertebrae
% Percent

IV

LIST OF FIGURES


Fig.1: Needle placement for desensitizing the cornual nerve in cattle8
Fig.2: Needle placement for desensitizing the auriculopalpebral nerve in cattle9
Fig. 3: Retrobulbar needle placement through the medial canthus of the eye in cattle.11
Fig.4: Needle placement for the proximal paravertebral nerve block in cattle..13
Fig.5: Needle placement for the distal paravertebral nerve block in cattle14
Fig.6: Needle placement for caudal epidural anesthesia ..16
Fig.7: Needle placement for the internal pudendal nerve block ..18
Fig.8: Ischiorectal approach for the internal pudendal nerve block.18


V

LIST OF TABLES


Table 1: Properties of selected local anesthetic agents used in veterinary medicine5
Table 2: Summary on common local anesthetics used in veterinary clinic6
Table 3: Advantages and disadvantages of paravertebral nerve block techniques in cattle.14

VI

SUMMARY


Regional anesthesia or the nerve block is a form of anesthesia in which loss of sensation in a
region of the body is produced by application of local anesthetic agent to all the nerves supplying
that region, only a part of the body is anesthetized. Regional anesthetic techniques can be divided
into central and peripheral techniques. The central techniques include neuroaxial block. The
peripheral techniques can be further divided into plexus blocks such as brachial plexus blocks, and
single nerve blocks. The regional anesthesia can be achieved by peri neural injection as in nerve
blocks of head region, paravertebral block and epidural block by spinal injection. Many surgical
procedures can be performed safely and humanly in ruminants using a combination of physical
restraint, mild sedation and regional anesthesia. Successful regional anesthesia requires a thorough
knowledge of the anatomy of the nerve(s), including the structures they innervate, their location and
relationship to other structures such as arteries, veins and facial layers. This article describes the
approach to regional anesthesia and discusses the anatomical considerations which need to be taken
into account when performing these procedures. In regional anesthesia; anesthesiologist injects
medication near a cluster of nerves to anesthetize only the area of the body that requires surgery.
The patient may remain awake or may be given a sedative. Spinal and epidural blocks involve
interrupting sensation from the legs or abdomen by injecting local anesthetic in or near the spinal
canal.

Key words: Cattle, Nerve block, Regional anesthesia,



1
1. INTRODUCTION


Regional anesthesia is applying local anesthetic around the nerves supplying a specific region,
without loss of consciousness. It is brought about by blocking conduction in sensory nerve or
nerves innervating the region where an operation is to be performed. Regional analgesia can be
done by peri neural injection and spinal block (Barrie, 2001).

Many surgical procedures can be performed safely and humanly in cattle using a combination of
physical restraint, mild sedation, and regional anesthesia. Regional anesthetic techniques are
usually simple, inexpensive, and provide a reversible loss of sensation to a relatively well-
defined region of the body (Stats, 2000).

Before regional anesthesia is performed, the animal should be adequately restrained. The type of
restraint used depends on the temperament of the animal and the anesthetic technique to be used.
Sedation may be necessary, however, in some cases. The site of injection should be prepared by
clipping or shaving the hair and scrubbing and disinfecting the skin. Regional anesthesia
involves the anesthesia of an area of the body without necessarily affecting the patients level of
consciousness (Kumar, 1996).

In addition to its benefit, regional anesthesia has the risks and complications associated with use
of local anesthetics, the risks and complications of using needles and drugs in the proximity of
nerves such as neuropraxia and those risks associated with a particular technique. As with any
other anesthetic technique, choosing regional anesthesia requires a thorough assessment that
should include the patient, the surgeon, the nature of the procedure and its estimated duration as
well as the level of experience of the anesthesiologist with regional anesthesia and its
management (Susan et al., 2004).

Regional anesthesia is the first choice of anesthesia in ruminants since general anesthesia has
certain limitations, anatomical and physiological peculiarities. In ruminants, flank region is the
most common site for any laparotomy; caesarian section, rumenotomy, intestinal obstruction,
volvulus, ruminal fistula, foreign body syndrome and hernia (Lee, 2006; Kumar, 2003). This
region is innervated by the last thoracic (T13), first lumbar (L1) and second lumbar (L2) spinal
nerves (Lee, 2006).
2

During regional anesthesia of the flank region, nerves innervated to that region are blocked
through injection of local anesthetic as they emerge from the vertebral canal through the
intervertebral foramina in proximal paravertebral nerve block or more distally at free ends of the
lumbar transverse process and posterior border of the head of the last rib during distal
paravertebral nerve block (Kumar, 2003).

Paravertebral nerve block results effective analgesia in all layers of the abdominal wall. Regional
nerve blocks are temporary blocking of pathway for passage of impulses by injecting local
anesthetic solution resulting in desensitization in the region (Tucker, 2010). As compared to
other anesthetic techniques, regional anesthesia has many advantages like safe, easy in field
application, less toxicity in the body due to small quantity of the local anesthetic, produce
uniform analgesia of the site and there is normal healing in all systems in cattle (Duke and
Caulket, 2008).

Therefore the objectives of this seminar paper are:
o To review the most commonly used veterinary local anesthetic agents which plays
important role for regional nerve block in cattle
o To review the regional anesthesia technique in cattle
o To familiarize the regional anesthesia techniques among veterinarians
o To popularize the most common side effect of anesthetic agents in cattle










3
2. LITRATURE REVIEW ON REGIONAL ANESHESIA IN CATTLE


2.1. Historical perspective of regional anesthesia in cattle

The History of Veterinary anesthesia is reviewed from the time of the discovery of the anesthetic
properties of ether in birds in the 16th century to its first recorded use in humans and then in
domestic animals in 1846 (Hall and Trim, 2000).

Regional anesthesia, the art of rendering a part of the body insensible for an operation, traces its
roots to Karl Keller of Vienna, who, in 1884, demonstrated the use of topical anesthesia on the
eye. However, regional anesthesia would not have progressed much beyond topical application
and thereafter many pioneers tried new and different ways of producing regional insensibility. In
the 1940s regional anesthesia of the flank of the cattle was reported. In many ways, the history
of techniques in regional anesthesia mirrors the way in which scientific knowledge is obtained:
It is an intellectual history of ideas (OConnor, 2005).
The history of spinal anesthesia demonstrates the cyclical nature of regional anesthetic
techniques. In 1885 in the United Kingdom is credited with the introduction of conduction
anesthesia through hypodermic injection (Krommendijk et al., 1999).
In 1891, von Ziemssen, a German physician whose main medical interest was infectious disease,
reported on the feasibility of injecting drugs by means of a lumbar puncture (Noordsy and Ames,
2006).
The use of regional anesthetic techniques in animals started near the turn of the twentieth
century. In 1901, the use of regional anesthesia is intellectually challenging and incredibly
rewarding. The list of indications for regional anesthesia continues to expand as the number of
regional techniques expands or is improved upon to allow more peripheral techniques to be
performed (Shuttlworth and Smith, 2000).
Decreases in morbidity and mortality, improved postoperative pain control and decreases in
perioperative complications have been listed as potential benefits of regional anesthesia in cattle
(Katta et al., 2000 and Stevenson, 2006). In 1908, Bier introduces the IV block (Bier block) with
procaine. In 1911 Herschel performs the first percutaneous axillary block and in 1911
Kulenkampff performs the first percutaneous supraclavicular block (Hall and Trim, 2000).


4
2.2. Local anesthetics

There are many local anesthetics that vary in their potency, toxicity, and cost. A short acting
local anesthetic procaine hydrochloride was first introduced for local and regional anesthesia but
because of adverse CNS and cardiovascular effects and apnea the use is discouraged (Skara,
2003).
Some of local anesthetics that are commonly used for regional anesthesia in veterinary use:

A. Procaine(short acting)
It has slower onset of action, and spreads less well compared to lidocaine. The unique
ability of procaine to cause dose-dependent methemoglobinemia limits its clinical
usefulness. It is not commonly use in cattle as it causes swelling around the block. By
this reason great accuracy is needed when doing specific nerve block (Rosenberg,
2002).
B. Lidocaine(intermediate action)
This is the most widely used general-purpose local anesthetic in veterinary use. It possesses
reasonably rapid onset of action, with good spreading properties, being a good all round useful
local anesthetic. Duration of action is variable (depending on uptake) but will be around 1 hour
without epinephrine, and 2 hours with epinephrine (Dan, 1993).
C. Mepivacaine(intermediate action)
This is the most widely used drug in the horse as it causes very little swelling and edema in the
area of injection, possibly as it lacks vasodilatory action. Onset of action is faster and reliability
of block greater than with procaine (Streis et al., 1991).
D. Bupivacaine(long acting)
This drug has a prolonged duration of action; up to eight hours when combined with
epinephrine. It is therefore used whenever long action is required as such in post-operative
analgesia and prolonged surgery (White, 1985).


5
Table 1: properties of selected local anesthetic agents used in veterinary medicine

Trade Name Class potency Lipid
Solu
bility
Protein
Binding
Onset of Effect

(min)
Duration
(min)

Procaine (Novocaine) Ester 1 6% Slow (30-40) 6090
Chloroprocaine
(Nesacaine)
Ester 1 1 7% Fast (10-15) 3060
Lidocaine (Xylocaine) Amide 2 3.6 65% Fast (10-20) 90200
Mepivacaine (Carbocaine) Amide 2 2 75% Fast (10-20) 120240
Bupivacaine (Marcaine) Amide 8 30 95% Intermediate
(15-30)
180600
Tetracaine (Pontocaine) Ester 8 80 80% Slow (30-40) 180600
Source: (Stoelting, 1999)


















6

Table 2: summary on some local anesthetics used in veterinary clinic


Drug

class

MOA

DOA

Effect

Adverse

Bupivacai
ne
(Marcaine
)0.5%

Local
anesthetic
agent
(amide )

Blocks nerve transmission
by blocking Na channel and
preventing excitation
conduction
Process

46 hr;
(epidural,
local
infiltration)

Reversible
prevention of
nerve
transmission;
thus motor,
sensory, and
autonomic
function is
temporarily
inhibited

CNS excitation,
seizures, respiratory
paralysis, hypotension,
hypothermia,
ventricular
arrhythmias








Lidocaine
(Xylocain
e**): 2.0%

Local
anesthetic
agent
(amide)
Blocks sodium influx and thus
prevents nerve depolarization
and conduction
90200 min;
(epidural, local
infiltration)
Blocks pain,
motor, and
sympathetic
fibers; also used
IV to treat
ventricular
arrhythmias
Hypotension due to
vasodilation;
respiratory
arrest is possible when
given epidurally;
seizures at high doses


Mepivacai
ne(Carboc
aine-V):
12%
Local
anesthetic
agent
(amide)
Blocks sodium influx and thus
prevents nerve depolarization
and conduction
120240 min;
(epidural, local
infiltration)
Blocks pain, motor
and sympathetic
fibers
Hypotension due to
vasodilation and
respiratory
arrest are possible
when given
epidurally; seizures
and cardio toxicity
with overdose

Procaine
(Novocain
e)
Local
anesthetic
(ester
linked)
Blocks sodium influx and thus
prevents nerve depolarization
and conduction
6090 min;
(local
infiltration)
Blocks pain,
motor, and
sympathetic
fibers
May cause allergic
reaction
Source: (Duke and Caulket, 2008)











7
3. REGIONAL NERVE BLOCK AND ITS TECHNIQUE IN CATTLE

Rules of performing regional or local analgesia: Clip hair and surgically prepare site, use sterile
needles, syringes and anesthetic solution, unless otherwise stated, always aspirate and check for
blood before injection. Note the location of blood vessels that lie in close proximity to target
nerves, always work out the toxic dose for the patient and stay below, base total dose
calculations on lean bodyweight, not on actual bodyweight, identify key anatomical landmarks
(Barrie, 2001).

3.1. Regional nerve block of head

3.1.1. Cornual nerve block

Cornual nerve is a sensory nerve supplying to the horn core and skin around its base. Cornual
nerve is a branch of lacrimal nerve which is a division of the ophthalmic branch of trigeminal
nerve. The cornual nerve emerges behind the orbit and ascends along frontal crest and placed
relatively superficial in the upper third covered by skin and the thin layer of frontalis muscle.
The caudal part of the nerve is having close association with the superficial temporal artery
(Stafford and Mellor, 2005).
The cornual nerve block is used for desensitizing horn core in cattle. The horn and the skin
around the base of the horn are innervated by the corneal branch of the lacrimal or
zygomatoaticotemporal nerve, which is part of the ophthalmic division of the trigeminal nerve.
The cornual nerve passes through the periorbital tissues dorsally and runs along the frontal crest
to the base of the horns (Edwards, 2001).
Indication: Analgesia of the horn core and skin around the base of the horn mainly for dehorning
process. Dehorning, or disbudding, is the process of removing or stopping the growth of
the horns of livestock (Venugoplan, 2000).
Site of block: Local anesthetic is deposited subcutaneously and relatively superficially midway
between the base of the horn and lateral canthus of the eye, at the inferiolateral border of the
frontal crest where the nerve is superficial. Lidocaine 2% is commonly used (Edwards, 2001).
Dosage: Approximately 2 to 5 ml of (1 to 3ml in calves) lidocaine in adult is deposited
subcutaneously. Complete anesthesia may take 10 minutes. Larger cattle with well-developed
8
horns require additional anesthetic infiltration along the caudal aspect of the horn, in the form of
a partial ring block, to desensitize subcutaneous branches of the second cervical nerve (Elmore,
1980).

Fig. 1: Needle placement for desensitizing the cornual nerve in cattle (Edwards, 2001).

Technique of corneal block: Insert a 2.5 cm, 20 gauge needle into the upper third of the temporal
ridge, immediately behind the ridge and about 2.5 cm below the base of the horn, to a depth of
0.7 to 1.0 cm. The nerve may be palpable, between the frontalis and temporal muscles, about
half way from the lateral canthus of the eye to a point about 3cm below the lateral base of the
horn (Misty et al., 2008). In large bulls the needle should be inserted to about 2.5 cm deep. Draw
back on the plunger to check that the needle is not placed intravascularly. Inject 5 to 10 ml
lidocaine 2% hydrochloride (Scott et al., 1993). A blink response should be noted during
administration; drooping of the upper eyelid is a good early sign of correct anesthesia. Failure
may occur if the anesthetic solution is injected too deeply, into the temporal muscle aponeurosis.
Note: In large individuals with well developed horns make a second injection about 1 cm caudal
to the first injection, to block the posterior division of the nerve (Sharma, 2005).

3.1.2. Auriculopalpebral nerve bock

Anatomy: The eyelids are innervated by the auriculopalpebral nerve. The nerve is a motor
branch of facial nerve supplying to the orbicularis occuli muscle of the eye lid and therefore the
block produces akinesia only. It is mostly used in large animals for examination of eye, in
blepharospasm and for removal of foreign bodies. The nerve runs from the base of the ear along
the facial crest, past and ventral of the eye giving of its branchs on the way. Auriculopalpebral
nerve supplies to the orbicularis occuli muscles it is the one of the branches of facial nerve and
motor to eyelid and auricular muscle (Stafford and Mellor, 2005).
Indications: Surgical affection related to eyelid (entropion, ectropion and prolapse of 3rd
eyelid), to avoid the blinking reflex of the eye lid to examine and treat the eye, to relieve the
9
spasm of the eye lids following injury, to use in conjunction with Petersons block, during
surgical treatment of squamous cell carcinoma of eye removal of foreign body from cornea and
subconjunctival injections (Sakarda, 2006).
Site of block: Anesthesia of the eyelid is accomplished by performing a line block of the eyelid
or by blocking the auriculopalpebral branch of the facial nerve. The site is directly at appoint
midway between the imaginary line drown from the lateral canthus of the eye and the temporal
fossa (Navarre and Numbing, 2006).
Technique: Regional analgesia techniques are necessary for surgery of the eye and its associated
structures. In bovine a 20 -or 22- gauge,3-5 cm long needle is inserted subcutaneously at a point
midway between the imaginary line drown from the lateral canthus of the eye and the temporal
fossa and inject 3-5 ml of 2% Lidocaine is injected subfacialy (Sakarda ,2003).

Fig.2: Needle placement for desensitizing the auriculopalpebral nerve in cattle (Sakarda, 2003).

3.1.3. Retrobulbar nerve block

This block provides kinesis of the extraocular muscles by blocking cranial nerves II, III, and VI,
by preventing movement of the globe. It is indicated for enucleating of the eye or for surgery of
the cornea. The needle placement for retrobulbar injection is the midway between medial and
lateral canthus of eye or the upper and lower eyelids (Scott et al., 1993).
Technique:

I. Four-point retrobulbar nerve block

The four-point retrobulbar block is technically easier and can be done more rapidly as compared
with the Peterson eye block. In this technique, an 18 gauge, 9-cm long needle is introduced
through the skin on the dorsal, lateral, ventral and medial aspects of the eye, at 12, 3, 6, and 9
oclock positions, respectively. Introduction of the needle through the conjunctiva should be
avoided to reduce the occurrence of ocular contamination. The needle is directed behind the
10
globe using the bony orbit as a guide. When the needle is introduced into retrobulbar sheath, the
eye will move slightly with the tug of the needle. The surgeons finger is used to deflect the
globe to protect it from the point of the needle. After this location is reached and aspiration is
performed to assure that the needle is not in a vessel, 5-10 milliliters of lidocaine (2%) is
deposited at each site. Mydriasis indicates a successful block (Sharma, 2005).
II. The single retrobulbar block:
It is an alternative to the four-point retrobulbar block. In this technique, the 9-cm long 18-gauge
needle is bent into a circle. The needle is inserted immediately ventral to the dorsal orbital rim
and directed such that the needle impacts into the bone of the orbit. Then the needle is advanced
as it is rotated ventrally in a progressive manner such that the needle remains in close proximity
to the bone. After the needle is inserted to the caudal aspect of the eye, 20 ml of 2% lidocaine
HCL is administered after aspiration to ensure that the needle is not positioned in a vessel or
other fluid structure. Successful deposition of lidocaine causes mild apoptosis of the globe
(Riebold et al., 1982).

Fig.3: Retrobulbar needle placement through the medial canthus of the eye in cattle (Riebold et
al., 1982).

3.1.4. Peterson nerve block in cattle

Indication: To abolish eye ball movement as well as the blinking reflex of the eye lids. It is used
for enucleating of the eye or for surgery of the cornea, and when properly performed causes
analgesia of the cornea, Mydriasis and apoptosis (Edwards, 2001).
It involves less risk in damaging surrounding anatomic structure around the eye globe, and less
volume requirement reducing potential for systemic toxicity and expense. Oculomotor, trochlear,
abducent, and three branches of the trigeminal nerve which are responsible for sensory and
motor function of all structures of the eye except the eyelid, are desensitized in 10 15 minutes
11
following injection. Adequate restraint of the head is necessary when performing this procedure
(Sharma, 2005).
Site of injection: The point of injection is the notches formed by the supraorbital process
cranially, the zygomatic arch ventrally, and the coronoid process of the mandible caudally.
Approximately 15 ml of 2% lidocaine is injected (Sakarda, 2006).
Technique of Peterson nerve block: After performing a small local skin block over the intended
site of puncture a 3.8-cm long 14 gauge needle is inserted through the skin as a cannula for
introduction of an 18-gauge 9-cm long needle for the nerve block. The cannula is inserted caudal
to the junction of the supraorbital process and zygomatic arch and is introduced through the skin.
Then, the 18-gauge, 9-cmlong needle is introduced through the cannula needle and is directed in
a horizontal and slightly dorsal direction until the coronoid process is encountered (Getty, 1995).
The needle is walked off the rostral aspect of the coronoid process and advanced in a
ventromedial direction along the caudal aspect of the orbit until the needle encounters the bony
plate encasing the foramen orbitorotundum. Once the needle is advanced to the foramen, it is
advised that the needle be drawn back a few millimeters to reduce the risk of intrameningeal
injection. After aspirating to assure the needle is not in the internal maxillary artery, 10-15
milliliters of lidocaine (2%) is deposited, with an additional 5 milliliters of lidocaine deposited
as the needle is slowly withdrawn. Mydriasis indicates a successful block (Misty, 2008).
3.2. Regional nerve bock of trunk of cattle

Indications: It is commonly used for such procedures as surgery of the digestive tract
(abomasopexy, omentopexy, rumenotomy, volvulus, and so forth), cesarean section,
ovariectomy and liver and kidney biopsy. The most commonly used techniques are proximal
paravertebral block (farguharsonsmethod), distal paravertebral block (Magda technique). The
first two are most commonly used techniques (Paulb and Jeennings, 1984).

3.2.1. Proximal paravertebral nerve block (Farguharsons method)

The proximal paravertebral nerve block desensitizes the dorsal and ventral nerve roots of the last
thoracic (T13) and first and second lumbar (L1 and L2) spinal nerves as they emerge from the
intervertebral foramina (Kumar, 2003).Approach to the Site of proximal paravertebral nerve
12
block: For T13, just cranial to the transverse process of L1; for L1, just cranial to the transverse
process of L2; For L2, just cranial to the transverse process of L3 (Roe, 1986).

Technique:
To perform proximal paravertebral block ,Proper needle placement of anesthetic, the skin at the
cranial edges of the transverse processes of L1, L2, and L3, and at a point 2.5 to 5 cm of the
dorsal midline can desensitized by injecting 2 to 3 ml 2% lignocaine using an 18- gauge 2.5-cm
needle is necessary. A 14-gauge 2.5-cm needle is used as a cannula or guide needle to minimize
skin resistance during insertion of an 18-gauge 10- to 15-cm spinal needle. Approximately 5 ml
of regional anesthetic may be placed through the cannula to anesthetize further the tract for
needle placement (Cakala, 2009).
To desensitize T13, the cannula needle is placed through the skin at the anterior edge of the
transverse process of L1 at approximately 4 to 5 cm lateral to the dorsal midline. The 18-gauge
10- to 15-cm spinal needle is passed ventrally until it contacts the transverse process of L1 to
desensitize L1 and L2; the needle is inserted just caudal to the transverse processes of L1 and L2
(Venugopalan, 2000). The needle is walked off of the caudal edges of the transverse processes of
L1 and L2, at a depth similar to the injection site for T13, and advanced approximately 1 cm to
pass slightly ventral to the process and into the inter-transverse ligament. For rumenotomy
blocking T13, L1 and L2 nerve is sufficient. For caesarean section L3 nerve should be blocked
(Noordsy and Ames, 2006).

Fig.4: Needle placement for the proximal paravertebral nerve block in cattle.
L1, first lumbar vertebra; L5, fifth lumber vertebra; R13, last rib; T13, last thoracic vertebra
(Noordsy and Ames , 2006).



13
3.2.2. Distal paravertebral nerve block (Magda method)

Site of nerve block: In this technique the needle enters ventral to the tips of the transverse of
the L1, L2 and L4 lumbar vertebrae. The distal paravertebral nerve block desensitizes the dorsal
and ventral rami of the spinal nerves T13, L1, and L2 at the distal ends of the transverse
Processes of L1, L2, and L4, respectively. 10 ml 2% Lignocaine is injected to desensitize the
region (Susan et al., 2004).
Technique: An 18-gauge 3.5- to 5.5-cm needle is inserted ventral to the transverse process
lumbar vertebrae and local anesthetic is infused in a fan-shaped pattern. The needle can then be
removed completely and reinserted or redirected dorsally, in a caudal direction, where 2 to 3 ml
of anesthetic agent is again infused in a fan-shaped pattern. This procedure is repeated for the
transverse processes of the second and forth lumbar vertebrae (Venugoplan, 2000).

Fig.5: Needle placement for the distal paravertebral nerve block in cattle (Skarda, 2006).













14

Table 3: Advantages and disadvantages of paravertebral nerve block techniques in cattle

Techniques Advantages Disadvantages

Proximal
Paravertebral
Block

Small dose of analgesic,
Wide and uniform area of analgesia and
muscle relaxation,
Minimal intra-abdominal pressure
Increased intestinal tone and motility
Absence of local analgesic from the
operative wound margins

Technical difficulty
Arching up of the spine due to
paralysis of the back muscles.
Risk of penetrating vital
structures such as the aorta and
thoracic longitudinal vein on the
left side and the caudal Vena
cava on the right side.

Distal
Paravertebral
Block

The use of more routine size needles, no risk
of penetrating a major blood vessel.
Lack of scoliosis minimal weakness in the
pelvic limb and Ataxia.

Larger doses of
anesthetic are needed.
Variation in efficiency
exists, particularly if
the nerves vary in their
anatomical pathway.
Source: (Lee, 2006)

3.3. Regional nerve block of the caudal region in cattle

3.3.1. Caudal epidural anesthesia

When the anesthesia is injected within the canal but outside the durra matter, it is called epidural
anesthesia. In epidural anesthesia there is desensitization of the first sensory nerves followed by
sacral, parasympathetic, sympathetic and motor nerves (Krames, 2000).
Depending on the site of injection epidural anesthesia can be caudal epidural anesthesia,
lumbosacral epidural anesthesia and lumbar segmental epidural anesthesia. Out of these
techniques the most commonly followed is the caudal epidural anesthesia (Oconnor, 2005).
It mostly produces the desensitization of sacral region, tail, anus, vulva perineum, and caudal
aspect of the femoral region. It doesnt affect the motor response of hind limb. In this the needle
enters the spinal canal but doesnt penetrate menings and the injected solution penetrates along
15
the canal outside the durra matter. Caudal epidural anesthesia is an easy and inexpensive method
of analgesia that is commonly used in cattle (Navarre and Numbing, 2006).
Indications: Prolapsed of vagina, uterus and rectum, treatment of parturient paresis, rectovaginal
fistula operation, repair of perianal fistula, correction of atresia ani, prevention of straining,
amputation of rectum and tail. The site is in the fossa between the last sacral vertebra and the
first coccygeal vertebra or between the first and second coccygeal vertebrae. We commonly use
2% lidocaine HCL (approximately 1 ml/kg), bupivacaine HCL with adrenaline@ 0.01ml/kg and
xylaxine HCL 0.02 0.04 mg/kg+ 0.5 % lignocaine (Mark and Papi, 2007).

Technique: If possible the hair should be clipped and the skin scrubbed and disinfected. Standing
alongside the cow, the tail should be moved up and down to locate the fossa between the last
sacral vertebra and the first coccygeal vertebra or between the first and second coccygeal
vertebrae (Misty et al, 2008 ), an 18-gauge 3.8-cm needle, with no syringe attached, is directed
perpendicular to the skin surface, then the needle is pushed down till it contacts the floor the
vertebral canal, fit the syringe and withdraw the piston slightly to check the presence of blood .If
blood is present, the meddle is taken out, blood clot cleaned and reinserted, lignocaine solution
3-5 ml is injected. If the needle is in correct position there is practically no resistance felt during
injection. If resistance felt, slightly adjust the needle and then inject. Onset of effect is seen,
within few minutes, by flaccidity of the tail. Repeated injection may be used for longer action
(Rawal et al., 2009).



Fig.6. Needle placement for caudal epidural anesthesia (A) and for continuous caudal epidural
anesthesia (B) located between the first and second coccygeal vertebrae (Rawal et al., 2009).
16
The advantages of caudal epidural anesthesia are rapid recovery, simple and inexpensive, little
effect on organ systems and good muscle relaxation and postoperative analgesia. In addition to
its advantage it has some complications such as permanently paralyzed tail, loss of motor control
of hind limb (ataxia) and infection resulting in draining tracts at the site (Horlocker et al., 2009).
Continuous caudal epidural anesthesia is used in cattle with chronic rectal and vaginal prolapse
that experience continuous straining after the initial epidural. This procedure is performed by
placing a catheter into the epidural (Navarre and Numbing, 2006).
3.3.2. Continuous caudal epidural anesthesia

Indication: Continuous caudal epidural anesthesia is used in cattle with chronic rectal and
vaginal Prolapse that experience continuous straining after the initial epidural (Noordsy and
Ames, 2006).
Anesthetic of choice: More recently, a 2-agonists and opioids either alone or in combination
with local anesthetic solutions have been used for epidural anesthesia. Epidural administration of
the a2-agonist xylazine hydrochloride (0.05 mg/kg) diluted in 5 to 12 ml of sterile saline or
xylazine hydrochloride (0.3 mg/kg) added to 5 ml of 2% lidocaine hydrochloride combinations
offer similar anesthesia to lidocaine. Although the duration of anesthesia is prolonged (45
hours) using these combinations, systemic effects (sedation, salivation, and ataxia) may also
occur (Hall and Trim, 2000).

Technique of Continuous caudal epidural anesthesia:
This procedure is performed by placing a catheter into the epidural space for intermittent
administration of local anesthetic. A 17-gauge 5-cm spinal needle (touchy needle) with stylet in
place is inserted into the epidural space at Co1 to Co2 with the bevel directed craniad. The stylet
is removed, and 2 ml of local anesthetic is injected to determine if the needle is in the epidural
space. A catheter is inserted into the needle and advanced cranially for 2 to 4 cm beyond the
needle tip. The needle is then withdrawn while the catheter remains in place. An adapter is
placed on the end of the catheter and the catheter secured to the skin on the dorsum. Local
anesthetic solution may then be administered as needed (Rawal et al, 2009).

17
3.3.3. Internal pudendal nerve block

Anatomy: The internal pudendal nerve consists of fibers originating from the ventral branches of
the third and fourth sacral nerves (S3 and S4) and the pelvic splanchnic nerves (Constantinescu,
2001).
Indications: To facilitate relaxation of the bulls penis without causing locomotors impairment,
the internal pudendal nerve block can be used in the standing bull for penile relaxation and
analgesia distal to the sigmoid flexure and examination of the penis, in the standing female the
internal pudendal nerve block can be used to relieve straining caused by chronic vaginal prolapse
and this may also be used for surgical procedures of the penis, such as repair of prolapses,
removal of perianal tumors, removal of penile papillomas or warts, and other minor surgeries of
the penis and prepuce (Elmore, 1980).
Technique or procedure:
The procedure for bilateral internal pudendal nerve block was first described by Larson. This
procedure involves desensitizing the internal pudendal nerve and the anastomotic branch of the
middle hemorrhoidal nerve using an ischiorectal approach (Larson, 2001).
The skin at the ischiorectal fossa on either side of the spine is clipped, disinfected, and
desensitized with approximately 20 ml 2% lidocaine. A 14-gauge 1.25-cm needle is inserted
through the desensitized skin at the ischiorectal fossa to serve as a cannula. An 18-gauge 10-cm
spinal needle is then directed through the cannula to the pudendal nerve. The operators left hand
is placed into the rectum to the level of the wrist and the fingers directed laterally and ventrally
to identify the lesser sacroisciatic foramen. The lesser sciatic foramen is first identified by rectal
palpation as a soft depression in the sacroisciatic ligament (Scott et al., 1993).
The internal pudendal nerve can be readily identified lying on the ligament immediately cranial
and dorsal to the foramen and approximately one fingers width dorsal to the pudendal artery
passing through the foramen. The internal pudendal artery can be readily palpated a fingers
width ventral to the nerve. The spinal needle is held in the operators right hand and introduced
through the cannula in the ischiorectal fossa. The spinal needle is directed medial to the
sacroisciatic ligament and directed cranioventrally (Edwards, 2001).
18
The needle is not felt until it has been introduced approximately 5 to 7 cm and can then be
repositioned to the nerve. Once at the pudendal nerve, 20 ml lidocaine is deposited at the nerve.
The needle is then partially withdrawn and redirected 2 to 3 cm more caudodorsally where an
additional 10 ml of local anesthetic is deposited at the cranial aspect of the foramen to
desensitize the muscular branches and the middle hemorrhoidal nerve. The needle is then
removed and the sites of deposition are massaged to aid in dispersal of the local anesthetic. This
procedure is then repeated on the opposite side of the pelvis. Relaxation of the penis varies and
may take as long as 30 to 40 minutes for full effect. The duration of the internal pudendal nerve
block lasts from 2 to 4 hours (Larson, 2001).

Fig.7: Needle placement for the internal pudendal nerve block. (A) Internal pudendal nerve.
(B) Caudal rectal nerve. (C) Internal pudendal artery. (D) Sacroisciatic ligament
(Constantinescu, 2001).


Fig. 8: Ischiorectal approach for the internal pudendal nerve block. The injection site for the
internal pudendal nerve block in cattle is at the point in the ischiorectal fossa that is most deeply
depressed with the surgeons finger (Larson, 2001).





19
4. COMPLICATIONS AND SIDE EFFECTS OF REGIONAL ANESTHESIA

4.1. Adverse reactions

Systemic: Adverse experiences following the administration of lidocaine are similar in nature
to those observed with other amide local anesthetic agents. These adverse experiences are, in
general, dose-related and may result from high plasma levels caused by excessive dosage, rapid
absorption or inadvertent intravascular injection, or may result from a hypersensitivity,
idiosyncrasy or diminished tolerance on the part of the patient. Serious adverse experiences are
generally systemic in nature. The following types are the most commonly reported adverse
reactions (Lanza, 1996).Central Nervous System: CNS manifestations are excitatory and/or
depressant and may be characterized by lightheadedness, nervousness, apprehension, euphoria,
confusion, dizziness, drowsiness, tinnitus, blurred or double vision, vomiting, sensations of heat,
cold or numbness, twitching, tremors, convulsions, unconsciousness, respiratory depression and
arrest (Katta et al., 2000). The excitatory manifestations may be very brief or may not occur at
all, in which case the first manifestation of toxicity may be drowsiness merging into
unconsciousness and respiratory arrest. Drowsiness following the administration of lidocaine is
usually an early sign of a high blood level of the drug and may occur as a consequence of rapid
absorption (Cox et al., 2003).Cardiovascular System: Cardiovascular manifestations are
usually depressant and are characterized by bradycardia, hypotension, and cardiovascular
collapse, which may lead to cardiac arrest (Mather and Chang, 2001).
Allergic: Allergic reactions are characterized by cutaneous lesions, urticaria, edema or
anaphylactic reactions. Allergic reactions may occur as a result of sensitivity to local anesthetic
agents in multiple dose vials (Katta et al., 2000). Allergic reactions as a result of sensitivity to
lidocaine are extremely rare and, if they occur, should be managed by conventional means. The
detection of sensitivity by skin testing is of doubtful value (Milne, 2002).
Neurologic: The incidences of adverse reactions associated with the use of local anesthetics
may be related to the total dose of local anesthetic administered and are also dependent upon the
particular drug used, the route of administration and the physical status of the patient. In the
practice of caudal or lumbar epidural block, occasional unintentional penetration of the
20
subarachnoid space by the catheter may occur (Rosenberg, 2002). Subsequent adverse effects
may depend partially on the amount of drug administered subduraly. These may include spinal
block of varying magnitude, hypotension secondary to spinal block, loss of bladder and bowel
control, and loss of perineal sensation and sexual function (Katta et al., 2000). Persistent motor,
sensory and/or autonomic (sphincter control) deficit of some lower spinal segments with slow
recovery (several months) or incomplete recovery have been reported in rare instances when
caudal or lumbar epidural block has been attempted (Mather and Chang, 2001).
4.2. Over dosage

Acute emergencies from local anesthetics are generally related to high plasma levels
encountered during therapeutic use of local anesthetics (Misty et al., 2008).

Underventilation or apnea due to unintentional subarachnoid injection of local anesthetic
solution may produce these same signs and also lead to cardiac arrest if ventilatory support is not
instituted. Increasing the volume and concentration of lidocaine hydrochloride injection may
result in a more profound fall in blood pressure when used in epidural anesthesia (Mark and
Papi, 2007).
Although the incidence of side effects with lidocaine is quite low, caution should be exercised
when employing large volumes and concentrations, since the incidence of side effects is directly
proportional to the total dose of local anesthetic agent injected. Delay in proper management of
dose-related toxicity, underventilation from any cause and/or altered sensitivity may lead to the
development of acidosis, cardiac arrest and, possibly, death (Cox et al., 2003).

4.2.1. Treatment of over dosage toxicity of regional anesthesia

Atropine may be used to reverse bradycardia and hypotension. Doxapram may be used to
reverse respiratory depression. Alpha-2 receptor antagonists such as yohimbine, tolazoline and
atipamezole are specific antagonists to xylazine. At the first sign of underventilation or apnea,
oxygen should be administered (Payne et al., 1998).
If cardiac arrest should occur standard cardiopulmonary resuscitative measures should be
instituted. Dialysis is of negligible value in the treatment of acute over dosage with lidocaine In
21
case of accidental overdose leading to respiratory failure, cold water douches and artificial
respiration are indicated (Katta et al.,2000).















22
5. CONCLUSIONS AND RECOMMENDATIONS

In General regional anesthesia techniques are safe and effective methods for providing
anesthesia for common surgical procedures and painful conditions in cattle. These techniques are
inexpensive and easy to perform and offer safe alternative to general anesthesia in some cases.
Regional anesthetic techniques are easily employed in practice with knowledge of anatomy and
careful dose calculation, the various blocks can be carried out with good success.
For the majority of the techniques discussed, specialist equipment is not necessary, as they
require only items commonly found in practice. The use of regional anesthetic techniques can
greatly increase patient comfort both during anesthesia and in recovery. Regional anesthesia
techniques are usually selected to be carried out quickly, easily, cheaply and with inexpensive
equipment, the most suitable technique that can be easily followed under field conditions and to
be generally safe for the animals involved. Since the mid-1990s, many advances have been made
in the field of animal pain research but much remains to be done. It is necessary a full analysis of
matters that should be considered when deciding whether or not, and how, to undertake
particular painful husbandry procedures is increasing. This suggests that alternative approaches
must be considered.
In over all, the techniques of regional anesthesia require every anesthesiologist to properly apply
the method. The cornual nerve block is used for desensitizing horn core in cattle for dehorning
.Auriculopalpebral nerve bock is mostly used in large animals for examination of eye, in
blepharospasm and for removal of foreign bodies. Retrobulbar block is used for enucleation of
the eye or for surgery of the cornea. paravertebral nerve block used for rumenotomy Caudal
epidural anesthesia mostly used for prolapsed of vagina, uterus and rectum, treatment of
parturient paresis, rectovaginal fistula operation, repair of perianal fistula, correction of Artesia
ani, prevention of straining, amputation of rectum and tail. Continuous caudal epidural
anesthesia is used in cattle with chronic rectal and vaginal prolapse that experience continuous
straining. Internal pudendal nerve block can be used in the standing bull for penile relaxation
and analgesia distal to the sigmoid flexure and examination of the penis, in the standing female
the internal pudendal nerve block can be used to relieve straining caused by chronic vaginal
prolapse and this may also be used for surgical procedures of the penis, such as repair of
prolapses, removal of perianal tumors, removal of penile papillomas or warts, and other minor
surgeries of the penis and prepuce.
23
Based on the above conclusions the following recommendations are forwarded:
Regional anesthesia injection for nerve block should be employed only by clinicians
who are well versed in diagnosis and management of dose-related toxicity and other
acute emergencies that might arise from the block.
The clinicians must ensure the immediate availability of oxygen, other resuscitative
drugs, cardiopulmonary equipment, and the personnel needed for proper management of
toxic reactions and related emergencies that might arise from the block.
The safety and effectiveness of the anesthetic agent should maintain through proper
dosage, correct technique, adequate precautions, and readiness for emergencies.
Standard textbooks should be consulted for specific techniques and precautions for
various regional anesthetic procedures.
The aseptic precautions are to be strictly adopted for nerve blocks.
Always use as low anesthetic as possible, as low concentration as possible and as low
gauge needle as possible for infiltration.
The selection of anesthetic should be based on the need. For short procedures Procaine
HCL, medium procedures Lignocaine HCL and long procedures Bupivacaine HCL are
ideal.
Local anesthetics may be used in the field of pain management especially continuous
epidural administration.










24
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