Beruflich Dokumente
Kultur Dokumente
1 Regional Anesthesia
Dr. Payawal
January 6, 2014
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LEGEND:
Old trans/book notes/recording
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Objectives
1. Introduce the principles of regional anesthesia
2. Present the different techniques in regional anesthesia
3. Discuss the complications of this technique
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REGIONAL ANESTHESIA
INFILTRATION ANESTHESIA
IV
REGIONAL
ANESTHESIA
TECHNIQUE/ BIERS BLOCK)
(BIERS
LOCAL ANESTHESIA
Abdominal operation
Urologic procedure
Rectal surgery
Perineal procedure
Lower extremity procedure
Esters
SPECIFIC
DRUGS
Cocaine
(first local
anesthetic that is
used into the
clinical practice)
SIDE EFFECTS
Vasoconstrictor (in
areas where there is
bleeding),
hypertension, topical
use only
Procaine
Chlorprocaine
Tetracaine
(commonly
used)
EFFECT
Analgesia,
muscle
relaxation
and NOT
amnesia or
hypnosis
Lidocaine
Bupivacaine
For
infiltration/spinal/
epidural use
Mepivacaine
Produces a metabolite
Toluidine
Prilocaine
Causes
methemoglobinemia*
secondary to its
metabolite
Ropivacaine
Potency
o Correlates with lipid solubility
o Directly proportional; The more lipid soluble the drug
is, the more potent it is.
o Lipid solubility determines whether the molecule is
able to penetrate the nerve membrane. The more lipid
soluble the drug, the more it is able to penetrate the
nerve membrane.
o Anesthetic molecule must penetrate the nerve
membrane and bind at a partially hydrophobic site in
the Na channel.
Lipid Solubility
Potency
Lidocaine
46
Intermediate
Bupivacaine
390
High
Duration of Action
o Correlates with protein binding
o Molecules bound to plasma proteins are not
pharmacologically active.
o Albumin has lower affinity and has higher capacity
for binding while alpha1 acid glycoprotein has higher
affinity and lower capacity for binding.
o Local anesthetic with higher protein binding stays in
the protein receptor longer.
o Influenced by peripheral vascular effects
Protein Binding
Duration
Lidocaine
64
Intermediate
Bupivacaine
95
Long
Onset of Action
o Correlates with lower ionization, pKa or dissociation
constant
o Dissociation Constant is a measure of the strength of
an acid or a base.
o The pKa range of local anesthetics: 7.8 9.2
Sister of Mepivacaine,
Less cardiotoxic, For
OB analgesia
*METHEMOGLOBINEMIA
Lidocaine
DOREEN. CARMI. JAMES. HENNA. LOUIE
pKa
7.8
Onset
Quick
3
Bupivacaine
8.1
Intermediate
Correlates with Concentration
Concentration
Onset
Bupivacaine
0.5%
Quick
0.75%
Intermediate
Differential Blockade
o The ability of local anesthetics to cause a differential
inhibition of sensory and motor activity. Not all
sensations are blocked. Blockade depends on the
thickness of the nerve sheet.
o Not all sensations are blocked. Blockade depends on
the thickness of nerve sheet. A fibers should be,
theoretically, blocked by higher concentrations.
TOPICAL ANESTHESIA
Simplest
Extravascular placement of local anesthetic to the area to
be anesthetized
Dosage Requirements:
o Volume depends on the area to be anesthetized.
o More volume may be given in dilute concentrations.
o Particular attention to toxic dose of the local
anesthetic (always bear this in mind!).
Onset is almost immediate.
INFILTRATION
Examples:
obesity,
pregnancy,
increased
intraabdominal pressure, previous spine surgery,
spine deformities, age
Epidural Anesthesia
Spinal/epidural hematoma
Epidural abscess
o High Block
Dermatome
Level
T4-T5
T6-T8
Nipple Area
(T4)
Xiphoid
(T6)
T10
Umbilicus
L1
Inguinal
Ligament
L2-L3
Knee and
below
Perineum
S2-S5
Procedures
Upper abdominal surgeries
(cholecystectomy, gastrectomy)
Intestinal surgery (including
appendectomy), gynecologic
pelvic surgery, and ureter
explorations
Transurethral resection, vaginal
delivery, hip surgery
Transurethral resection without
bladder distension; thigh
surgery; lower limb
amputations
Foot surgery (Achilles tendon
repair)
Perineal surgery,
hemorrhoidectomy, anal dilation
CONTRAINDICATIONS
Absolute contraindications
Sepsis
Coagulopathies
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Benzodiazepines
Thiopental
Propofol
Equipment necessary prior performance of major
conduction blockade:
o Monitors
o Oxygen supply
o Airway Equipment
o Drugs to terminate convulsions
Cardiovascular System Toxicity
o Direct Cardiac Effects
Medications
Epinephrine, first line
Amiodarone, may be beneficial
Bretylium
RECOVERY
Score
1
2
3
4
5
6
GUIDELINES