Nikad!! Never!! Nikad!!

Continue advancing or injecting

through a needle (or catheter) ako pacijent complains snaan
bol. Moe da izazove oteenje nerava ili kimene modine.
Test dose.Give 4 ml of 1.5% lidocaine with epinephrine through the catheter, observing
the maternal heart rate in between contractions (from the pulse oximeter or EG!.
Watch for signs of intravascular(. "ovecan#e srcane fre$venci#e %a &' (") na$on
#edne minute mo%e da u$a%e na intravascular in#ection. palpitations, jumpy heart
and hypetension!
or subarachnoid injection
Raise the level with 3 ml boluses to achieve a !" level
(usual dose #$% ml). Never give more than 3 ml in one
minute.
AVOID HYOT!"#IO" $$
DO%&'!"T$ (intervals* + 1. ,ital signs, -. .ualit/ and level of the bloc$, and, &. 012. (lood
pressure and patient status should be followed b/ the anesthesiologist for the first &' minutes
after an/ bolus in#ection. 2emember that a high bloc$ from a subdural in#ection, and resulting
h/potension and respirator/ depression, can occur up to 1.5 hours after an epidural in#ection or
top+up.!
Stage Description Spinal Dermatomes
Stage I pocetak labor do 10 cm cervical dilation T10 !1 "Sympathetic
#ibers$
Stage II 10 cm cervical dilatation do rodjenja bebe S %& S' "(udendal nerves,
somatic$
Stage III Delivery o# the (lacenta T10 !1 "Sympathetic
#ibers$
Kompletan anestezioloki pribor mora da bude dostupan.
Poslednjih 4 sta bez davanja opioida---petidin
Pre stavljanja katetera mora da se ustanovi faza porodjaja,srana radnja
fetusa i arterijski pritisak porodilje
Anesteziolo mora da bude prethodno upoznat sa kompletnom medi!inskom
istorijom majke,da objasni detalje anestezije
Anesteziolo mora tano a odredi volumen,kon!entra!iju i tip anestetika pre
zapoinjanja anestezije
". #$ infusion
%) Insertion o# epidural as above
*) %irst dose iven b& anaesthetist - The standard dose is 1+ml o# 0)1,
-upivicaine "*ml 0)+, -upivicaine made up to 1+ml .ith /ormal saline$ 0
1entanyl +0ug) This does act as both initial dose and test dose) 2nalgesia should
be apparent .ithin 1 & %0 minutes, although the sensation o# contraction should
still be present)
') The mid.i#e measures maternal -( and pulse every #ive minutes #or t.enty
minutes and monitors the #oetal heart continuously #or thirty minutes) The
anaesthetist stays .ith the mother during this time and is available to administer
#luid 03& 4phedrine * & 5 mg boluses as re6uired should systolic -( #all belo.
100m7g or by greater than %0,)
+) 2#ter t'ent& minutes, the anaesthetist assesses the components o# the block8
1) s&mpatheti! tople noge
%) motor & ability to raise legs o## the bed against resistance
*) sensor& redukovana osetljivost na ethyl chloride) 2n upper level o# T9&10 is
usually ade6uate)
(ei der 3osierung rechnet man %wischen 1 + 1,5 ml pro %u bloc$ierendes 4egment,
wobei die 5usbreitung relativ gleichm67ig ober+ und unterhalb der atheterspit%e erfolgt.
8bri%gani anesteti$ i%a%va9e privremenu,rever%ibilnu si()ati*+u,sen-ornu i (otornu
blo$adu. (lo$ada sprovo:en#a impulsa prvo nasta#e u tan#im,a %atim u debl#im nervnim
vla$nima,pa su ta$o prvo %ahva9ena simpati;$a,%atim sen%orna i na $ra#u motorna
vla$na.
2astvori lo$alnog anesteti$a man#e $oncentraci#e dovode do sen%orne blo$ade,$o#a se
po#a;ava i produ<ava pove9an#em do%e,do$ rastvori ve9e $oncentraci#e br<e ispol#ava#u
de#stvo i uspostavl#a#u i motornu blo$adu
,e9 posle . do / (in od davan#a anesteti$a,nasta#e lagano ubla<avan#e poro:a#nih
bolova,u% prate9u simpati;$u blo$adu sa gubit$om ose9a#a %a te()eraturu i
hi)oalge-ijo(.
"rogresivno dola%i do gubit$a ose9a#a %a bol i lagani dodir,a a$o se $oncentraci#a
anesteti$a pove9a,ra%vi#a se gubita$ ose9a#a %a grub dodir i motorna blo$ada.

=a$on indentifi$aci#e )rocesusa s)inosusa *etvrtog lu(balnog )r0ljena,pre$o $oga

prela%i lini#a $o#a spa#a obe crista+e iliaca+e superior,i odgovara#u9eg me:upr>l#ens$og
prostora(?-+?& i ?&+?4!,$o<a i pot$o<no t$ivo infiltru#u se lo$alnim anesteti$om,$a$o bi
intervenci#a prote$la be%bolno
8vesti @uoh/ iglu sa vrhom o$renutim $rani#alno do ligamentum flavum,i%vaditi mandren i
sa n#om spo#iti bri%galicu sa fi%iolo>$um rastvorom
8 to$u latentne fa-e )rvog )oro1ajnog doba ra%vi#a se tipi;an visceralni bol umerene
#a;ine u obli$u neprestanih gr;eva,$o#i dose<e do @+11 i @+1- dermatoma.a$o porod#a#
napredu#e do a$tivne fa%e prvog poro:a#nog doba(dilataci#a cervi$sa &+4 cm!,uterusne
$ontra$ci#e posta#u sve #a;e,pa samim tim i bol,$o#i ve9ina porodil#a opisu#e $ao o>tar i
gr;evit.An ta$o:e obuhvata dermatome @+11 i@+1-,ali se >iri i na dermatome @+1'
i?1."ro#e$ci#a ovih dermatoma u le:nom delu, anatoms$i se po$lapa sa gorn#om
polovinom sa$ralne $osti i posledn#a tri lumbalna pr>l#ena(?+5,?+4,?&!.
"ri +raju )rvog )oro1ajnog doba i u drugo( )oro1ajno( dobu bol posta#e o>tri#i i >iri
se $a perineumu,don#im delovima sa$ruma,anusu,a ;esto i butinama.ao i drugi bolovi
i%a%vani stimulaci#om povr>nih somats$ih stru$tura,perinealni bol #e o>tar,dobro
lo$ali%ovan,a prenose ga nervi plecsus+a pudendus+a.,e9ina porodil#a se tada <ali na
nepre$idne
Dati inicijalnu do-u 2
bupivacain ',-5% 5+B ml fra$cionirano,
Inter(itentna +ontinuirana(!A32
bupivacain ',-5% 5+B ml,
ponoviti do%e posle C' do D' min
Visina sen-ornog blo+a $o#a treba da bude do @1' pr>l#ena,procen#u#e se
neosetl#ivo>9u pup$a na hladno ili boc$an#e insulins$om iglom,a stepen motornog blo$a
(romage+ s$alom
o (rthostati! h&potension
)anaement :be;bediti adekvatnu hidrataciju i nadoknadu te<nosti
Zabeleiti svaku promenu veu za 20% od bazalne
H4)oten-ija& smanjenje po<etne vrednosti srednjeg arterijskog pritiska ;a *0,,;ahteva
terapijski tretman)
%O'5I%ATIO"#2
6. Decreased fetal heart rate.
782
@urn the patient on her side.
A- b/ mas$.
(olus with E, lactated ringerFs solution (use caution if the patient is h/pertensive!.
Ephedrine 5+1' mg.
=otif/ A( team, notif/ anesthesia fellow or attending.
9. H4)otension
4/stolic (" G1''mm 1g s/stolic or a decrease of -'%, whichever results in the higher (".
782
E, 2ingers bolus.
Ephedrine 5+1'mg E,.
Greater left uterine displacement.
?eg elevation if needed.
Ef 12 slows ma/ need gl/cop/rollate or atropine.
:. High s)inal.
4/mptoms*
Hea$ arms, wea$ head+lift, difficult/ swallowing, shortness of breath, decreasing A- 4at
782
Ax/gen b/ mas$, control the airwa/ + intubate if necessar/ using thiopental 1'' mg and
succin/lcholine 1-' mg. Ionfirm the position of the endotracheal tube b/ auscultation of the chest
and epigastrium, b/ pulse oximetr/, and b/ capnograph/.
)onitor vital signs.
4upport ("+fluids, ephedrine, gl/cop/rollate.
(eware of the increased li$elihood of h/potension and brad/cardia if general anesthesia is
administered in the presence of a high spinal bloc$.
.. Intravascular injection.
3iagnosis*
2inging in the ears.
3i%%iness
Iircum+oral numbness.
2estlessness, anxiet/.
@ach/cardia (if epinephrine used!.
4ei%ures
7;2
4@A" in#ectingJ
.Get help statJ
.1ave nurse set up suction and '-.
.Apen bottom drawer of epidural cart + have resuscitation eKuipment read/J
Ef the patient sei%es, protect the airwa/, appl/ additional left uterine displacement,
ventilate, and rapidl/ administer thiopental 1'' mg. and succin/lcholine 1-' mg, with
cricoid pressure, and intubate. @urn the patient into the left lateral position. )easure
vital signsL if the patient is h/potensive, avoid additional thiopental.
Don<t )rocrastinate.
Alwa4s err on the side of treating too earl4.
Ef in doubt, give pressors, paral/%e, intubate, and maintain ox/genation. 2emember that a
h/poxic, acidotic patient is more difficult to rescuscitate. (egin 5I?4 immediatel/ M /ou can
alwa/s discontinue it if the patient recovers Kuic$l/.
N %entral=nervous2
+ Excitation*
O Iircumoral numbness +++u$ocenost lica
O @ongue paresthesia+++pareste%i#a #e%i$a
O 3i%%iness++++vrtoglavica
O (lurred vision++++%amagl#en pogled
O @innitus+++%u#an#e
O 2estlessness+++nemir
O IonfusionP5gitation+++++
O )uscular twitchings+++podrhtavan#e misica
O 4ei%ures tonic clonic++++ tonic clonicni napadi
+ 3epression*
O ?oss of conscience
O 2espirator/ arrest
O 3eath
N %ardio=vascular2
+ Earl/Pmild*
O 1/pertension
O @ach/cardia
+ 4evere*
O 5,+3issociation
O (rad/cardia
O )/ocardial ischemia
O 1/potension
O Iardiac arrest
(lood concentration