Block 20 | Module 5 | Lecture 1

Regional Anesthesia
Dr. Marco Victorio N. Fermindoza
May 9, 2018 (1:00-3:00)

LECTURE OUTLINE I. Spinal VS Epidural Anesthesia

 Collectively referred to as central neuraxial block,
I. Spinal vs. Epidural Anesthesia
pertains to local anesthetics placed around the
II. Anatomy
nerves of the central nervous system.
 Spinal Column
 Vertebra Spinal Epidural
 Ligaments Injecting local anesthetic Injecting local
 Spinal Cord solution into the CSF within anesthetic solution into
 Surface Landmarks the subarachnoid or the epidural space
III. Indications and Contraindications intrathecal space
A. Indications Limited to the lumbar region May be given at
B. Contraindications below the termination of the various levels of the
i. Absolute spinal cord neuraxis
ii. Relative - Less time to perform (faster) - Ability to produce
IV. Spinal and Epidural Anesthesia - Less discomfort segmental sensory
A. Spinal Anesthesia - Requires less anesthetic block
B. Epidural Anesthesia - More intense sensory and - Greater control over
motor block the intensity of sensory
Black- from powerpoint and motor block
Red- audio notes - Allows titration of the
Blue- from previous notes but doc mentioned them block to the duration of
INTRODUCTION surgery, control post –
REGIONAL ANESTHESIA op pain
 Reversible loss of sensation in a particular part of - Decreased risk for
the body postdural puncture
 Goals in anesthesia (also the definition of headache
anesthesia):  Spinal anesthesia is accomplished by injecting local
1) Sedation/anxiolytics/amnesia – loss of anesthetics into the CSF in the subarachnoid space.
consciousness In contrast, epidural anesthesia is achieved by
2) Analgesia – loss of pain injecting local anesthetic into the space that lies
3) Muscle relaxation within the vertebral canal but outside the dural
sac.
 Spinal and Epidural anesthesia are collectively  In comparison, SA takes less time to perform,
referred to as central neuraxial block causes less discomfort during placement, requires
 Used for surgical anesthesia and as an adjunct to less local anesthetic and produces more intense
general anesthesia sensory and motor block. In addition, correct
 Effective means for controlling obstetric and placement of needle is confirmed by flow of CSF.
postoperative pain  EA also has advantages which include a decreased
 Patients may remain completely awake during risk for posdural puncture headache, ability to
surgery but they are commonly sedated produce segmental regional block, with greater
 Skeletal muscle relaxation can be profound which control over intensity of sensory anesthesia and
can obviate the need for neuromuscular blocking motor block achieved by adjustment of anesthetic
drugs concentration.
 The placement of catheters also allows titration of
block which could provide long term management
of intraop and post op pain
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Block 20 | Module 5| Lecture 7: Regional Anesthesia by Dr. Marco Victorio Fermindoza

II. Anatomy C. Ligaments – suspend the spinal cord in the canal

Spinal Canal - extends from the foramen magnum to the - The vertebral column is stabilized by several
sacral hiatus ligaments.
A. Spinal Column - T7 to sacrum - the supraspinous ligament
- The spine consists of 33 vertebrae, 24 true, runs between the tips of the spinous
and 9 fused/fixed processes
 7 cervical - Above T7, the supraspinous ligament
 12 thoracic
continues as the ligamentum nuchae
 5 lumbar
- Interspinous ligament attaches between the
 5 fused sacral
 4 fused coccygeal spinous processes; blends posteriorly with
the supraspinous ligament & anteriorly with
the ligamentum flavum
- Ligamentum flavum - tough, wedge-shaped
ligament composed of elastin, connect the
lamina of adjacent vertebra

D. Spinal Cord

B. Vertebra
- The vertebra is the building block of the spinal
column. With the exception of C1, the
cervical, thoracic, and lumbar vertebrae
consist of a body anteriorly, two pedicles that
project posteriorly from the body, and two
laminae that connect the pedicles. These
structures form the vertebral canal, which
contains the spinal cord, spinal nerves, and
epidural space.
L1 Adults
L3 Infants
- Spinal cord terminates around the third
lumbar vertebra at birth and at the lower
border of the first lumbar vertebra in adults.
Because of the disproportionate growth of
neural tissue and vertebral canal.
- The nerve roots of the cauda equina move
relatively freely within the CSF

- Within the vertebral canal, the spinal cord is

surrounded by a series of three connective
tissue membranes (the meninges):
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Block 20 | Module 5| Lecture 7: Regional Anesthesia by Dr. Marco Victorio Fermindoza

- the pia mater is the innermost membrane - The T7-8 is identified by a line drawn between
and is intimately associated with the surface the lower limits of scapulae, often used to
of the spinal cord; guide needle placement for passage of catheter
- the second membrane, the arachnoid mater,
into the thoracic epidural space
is separated from the pia by the
subarachnoid space, which contains - The posterior iliac spine indicates the level of
cerebrospinal fluid; S2, which is the caudal limit of dural sac in most
- the thickest and most external of the adults
membranes, the dura mater, lies directly
against, but is not attached to, the arachnoid
mater
- Spinal Cord - extends the length of the
vertebral canal during fetal life, ends at L3 at
birth, and at L1-L2 by 2 years of age
o Based on the definition of the spinal
cord, it ends at L3. If the spinal needle
is injected at this imaginary line,
Tuffier's line, the spinal cord may get
hit at birth. If the patient is a neonate,
general anesthesia is performed. Since
regional and spinal anesthesia are very
dangerous for neonates. We usually
wait until the patient is 2 years old to - The most important of these landmarks is a line
be able to perform spinal anesthesia drawn between the iliac crests, which traverses
because the spinal cord ends at L1-L2. the body of the L4 vertebra which determines
the level for insertion of a needle intended to
E. Meninges
1. Dura Mater produce spinal anesthesia. This is called
> fibroelastic membrane Tuffier’s line.
> prevents displacement of an epidural
catheter into the fluid-filled subarachnoid L4-L5: widest part of the interspace
space
 The most important surface landmark is the line
2. Arachnoid membrane
> adherent to the inner surface of the dura drawn between iliac crests which generally
> major pharmacologic barrier preventing transverses the body of the L4 vertebra and is the
movement of drug from the epidural to principal landmark used to determine the level for
the subarachnoid space insertion of a needle intended to produce spinal
3. Pia anesthesia.
> innermost layer
 Subarachnoid space - lies between the pia
> highly vascular
> inner border of the subarachnoid space mater and the arachnoid and extends from S2
to the cerebral ventricles
F. Surface Landmarks If we inject local anesthetic for
- Since all of these structures are covered by our subarachnoid block, we can go as high as
skin, the Importance of anatomic landmarks the cerebral ventricles causing total spinal
could not be reiterated. They are used to anesthesia.
identify specific spinal interspaces.  The arachnoid membrane is far more delicate than
- The C7 can be appreciated as a bony knob at the dura but imparts impermeability. Because the
the lower end of the neck. dura and arachnoid are closely adherent, a spinal

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Block 20 | Module 5| Lecture 7: Regional Anesthesia by Dr. Marco Victorio Fermindoza
needle that penetrates the dura will generally pass
through the arachnoid membrane.
 Epidural space - contains nerve roots, fat,
lymphatic and blood vessels, areolar tissue
The epidural anesthesia is injected into the
epidural space, which is a potential space
with negative pressure. If we're inside the
epidural space, do Loss of Resistance
Syringe Test. If we are to inject the needle
and air is not sucked but CSF is leaked, this
means that we accidentally punctured the
dura and went into the subarachnoid
space.
 The posterior iliac spines indicate the level of the
S2 vertebral body which is the most common
caudal limit of the dural sac in adults.
 The dura mater is a tough fibroelastic membrane
that provides structural support and a fairly
impenetrable barrier that normally prevents
displacement of an epidural catheter into the fluid-
filled subarachnoid space.
 Loss-of-resistance technique – abrupt loss of
resistance to injection signals passage through the
ligamentum flavum into the epidural space, at
which point the contents of the syringe are
delivered.
III. Indications and Contraindications
A. Indications
Spinal Anesthesia: Epidural Anesthesia:
 for surgical procedures  abdomen and lower
involving the lower extremities
abdominal area,  frequently used to
perineum and lower supplement GA for
extremities thoracic and upper
abdominal procedures
(i.e. provide
continuous epidural
anesthesia
postoperatively)
 control of labor pain
17 | Ingles, Jaleco, Lacson
 Contraindications
Absolute:
 Patient refusal
Relative:
 Bacteremia – may lead to meningitis
 Preexisting neurologic disease
 Cardiac disease – e.g. valvular heart
disease and congestive heart failure. There
is high risk if anesthesia is done.
 Abnormal coagulation – risk for hematoma
formation if Batson plexus is injured, which
may lead to paralysis if not addressed.
 Infection at the site of planned needle
puncture
 Elevated ICP
 Bleeding diathesis
 There are few strong contraindications to
neuraxial block.
 Some of the most important ones include
patient refusal; and raised intracranial
pressure, which theoretically may predispose
to brainstem herniation.
 Relative contraindications that must be
weighed against the potential benefits include
intrinsic and idiopathic coagulopathy, such as
that occurring with administration of
Coumadin or heparin; bacteremia (might cause
epidural abscess or meningitis) and neurologic
disease.
 Neuroaxial block should also be cautiously
used in px w/ cardiac disease like mitral
stenosis, aortic stenosis which are intolerant of
acute decrease in systemic vascular resistance.
V. Spinal and Epidural Anesthesia
A. Spinal Anesthesia
 Preparation: Equipment, Drugs, Monitors
 To decrease discomfort, inclusion of an opioid
in pre-op meds. Pre-op meds can be withheld
provided that there is adequate attention to
infiltration of the skin subcutaneous tissues
with a local anesthetic solution
 Generally, patients should not be heavily
sedated because spinal and epidural
anesthesia requires patient cooperation.
1. Intravenous infusion
2. Supplemental oxygen
3. Patient positioning
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Block 20 | Module 5| Lecture 7: Regional Anesthesia by Dr. Marco Victorio Fermindoza

i. Lateral decubitus – most common

ii. Prone
iii. Sitting
4. Selection of interspaces
- Failed spinal anesthesia

Spinal Needles

Layers traversed by the Spinal Needle:

1. Skin
2. Subcutaneous tissue
3. Supraspinous ligament
4. Interspinous ligament
5. Ligamentum flavum
6. Epidural Space
7. Dura
8. Subarachnoid space

Epidural space – negative pressure space

Subarachnoid space – positive pressure space

- 2 resistances encountered:
 Ligamentum flavum
 Dura
 Gauge 22-25
 Shape of the tips: open ended, closed tapered tip
(pencil point)
 The Whitacre and Sprotte spinal needles have a
pencil-point tip with the needle hole on the side of
the shaft. The Greene and Quincke needles have
beveled tips with cutting edges.
 Local anesthetic solution is infiltrated to anesthetize
the skin and subcutaneous tissue at the anticipated
site.
 The pencil-point needles require more force to insert
than the bevel-tip needles but provide a better
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Block 20 | Module 5| Lecture 7: Regional Anesthesia by Dr. Marco Victorio Fermindoza
tactile “feel” of the various tissues encountered as
the needle is inserted. In addition, the bevel has
been shown to cause the needle to be deflected
from the intended path as it passes through tissues
while the pencil-point needles are not deflected.
Positioning
1. Sitting- encourages flexion and facilitates recognition
of midline which may be of increased importance in
obese patients. Because lumbar CSF is elevated in
this position, the dural sac distended thus providing
a larger target for the spinal needle.
• with legs hanging over side of the bed
• Have pt hug a pillow
• Put feet up on a stool (no wheels)
• Assistant must keep the patient from swaying
• Curve back like a “C”, Halloween Cat, Shrimp,
Canon block
• For obese and pregnant patients
2. Lateral Decubitus
• Needs to be parallel to the edge of the bed
• Legs flexed up to abdomen
• Forehead flexed down towards knees
3. Jack-knife Position/Prone Position
• For ano-rectal surgery
• CSF will not drip from the hub of needle
• Use hypobaric solution
Prone position is rarely used except for perineal
procedures. It is more challenging because of the
limited flexion, contracted dural sac and the low CSF
pressure.
Approach
Midline Approach
 easier
 passes through less sensitive structures
 Less local anesthetic infiltration
1. Needle is inserted at the top margin of the
lower spinous process of the selected
interspace
2. Needle is progressively advanced in a slight
cephalad orientation
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 Once the needle tip is believed to be in the
subarachnoid space, the stylet is removed to see if
CSF appears at the needle hub.
 When redirecting a needle it is important to
withdraw the tip into the subcutaneous tissue. If
the tip remains embedded in one of the vertebral
ligaments, then attempts at redirecting the needle
will simply bend the shaft
 If the patient experiences a paresthesia, it is
important to determine whether the needle tip
has encountered a nerve root in the epidural space
or in the subarachnoid space.
 If the patient desires, light sedation is appropriate
before placement of spinal or epidural block.
 Generally, the patient should not be heavily
sedated because successful spinal and epidural
anesthesia requires patient participation to
maintain good position, evaluate block height, and
indicate to the anesthesiologist about paresthesias
if the needle contacts neural elements.
 In addition, patient cooperation is required to
properly evaluate an epidural test dose; and
sedation with as little as 1.5 mg midazolam plus 75
μg fentanyl has been shown to reduce the
reliability of patient reports of subjective
symptoms of intravenous local anesthetic
injection.
 Once the block is placed and adequate block
height assured, the patient can be sedated as
deemed appropriate.
 If CSF is not visible at the hub, then the paresthesia
probably resulted from contact with a spinal nerve
root traversing the epidural space. This is
especially true if the paresthesia occurs in the
dermatome corresponding to the nerve root that
exits the vertebral canal at the same level that the
spinal needle is inserted.
 In this case the needle has most likely deviated
from the midline and should be redirected toward
the side opposite the paresthesia. Occasionally,
pain experienced when the needle contacts bone
may be misinterpreted by the patient as a
paresthesia and the anesthesiologist should be
alert to this possibility.
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Block 20 | Module 5| Lecture 7: Regional Anesthesia by Dr. Marco Victorio Fermindoza
 The presence of CSF confirms that the needle
encountered a cauda equina nerve root in the
subarachnoid space and the needle tip is in good
position.
 CSF is gently aspirated to confirm that the needle
is still in the subarachnoid space and the local
anesthetic slowly injected (≤0.5 ml/s-1).
 After completing the injection, a small volume of
CSF is again aspirated.
 If CSF is not visible at the hub, then the paresthesia
probably resulted from contact with a spinal nerve
root traversing the epidural space. This is
especially true if the paresthesia occurs in the
dermatome corresponding to the nerve root that
exits the vertebral canal at the same level that the
spinal needle is inserted.
 In this case the needle has most likely deviated
from the midline and should be redirected toward
the side opposite the paresthesia. Occasionally,
pain experienced when the needle contacts bone
may be misinterpreted by the patient as a
paresthesia and the anesthesiologist should be
alert to this possibility.
Paramedian Approach
 Point of insertion is 1cm lateral to the midline
 Surpasses the suprasinous and interspinous
ligament and the ligamentum flavum will be the
first resistance encountered
 The paramedian approach to the epidural and
subarachnoid spaces is useful in situations where
the patient's anatomy does not favor the midline
approach:
 inability to flex the spine or
 heavily calcified interspinous ligaments.
 This approach is probably the best approach for
the patient in the prone jackknife position.
ANESTHETIC INJECTION
 Free flow of CSF confirms correct placement
 Needle is secured by holding the hub between the
thumb and the index finger
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 Syringe is then attached and the CSF is aspirated
to reconfirm placement
 Contents delivered to the space over an 3-5sec
period
 Aspiration and reinjection is done as the
induction nears end
 If the needle tip is properly engaged in the
ligamentum flavum, it should be possible to
compress the air bubble without injecting the
saline. As the needle tip enters the epidural space,
there will be a sudden loss of resistance and the
saline will be suddenly injected.
 Once the block is placed, strict attention must be
paid to the patient's hemodynamic status
 Block height should also be assessed early by pin
prick or temperature sensation
DISTRIBUTION
These are the factors that affect distribution of the
anesthetic in spinal anesthesia:
1. Baricity
 The ratio of the density (mass/volume) of
the local anesthetic solution divided by the
density of CSF
 Predicts the direction of local anesthetic
 Hyperbaric (>1.007)
 most commonly used
 ability to achieve greater cephalad
spread
 Hypobaric (<0.997)
 generally reserved for patients
undergoing perineal procedures in
jack-knife position
 Isobaric (0.998-1.007)
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Block 20 | Module 5| Lecture 7: Regional Anesthesia by Dr. Marco Victorio Fermindoza
 Prepared in NSS
 more profound motor block and
longer duration of action
 Not influenced by patient position
 Baricity has something to do with your specific
gravity of the anesthetic as compared to the
specific gravity of the CSF. The normal specific
gravity of the CSF is 1.007. If the anesthetic is of
hyperbaric type, it has a specific gravity greater
than 1.007. If Isobaric type, specific gravity is
1.007. If hypobaric type, specific gravity is below
1.007.
 Clinical Significance: Hyperbaric anesthetic
(Mepivacaine) has tendency to gravitate towards
the dependent portion. For example, in
appendectomy, in order to achieve a full
block/sensory block up to the level of T4 (nipple
line) and we inject the local anesthesia at the level
of L3-L4. After injecting the local anesthesia, the
patient must assume the Trendelenburg position
or the Head-Down position. So that the anesthetic
gravitates cephalad.
 If hypobaric type of Mepivacaine is utilized, after
injecting the anesthetic and we want to assume
the T4 block, the patient is placed in a Head-Up
position.
 If isobaric type, after injecting the anesthetic the
patient assumes a flat-on-bed position. The
anesthetic will just spread towards the cephalad
area based on the volume given.
 What influences the baricity of an anesthesia?
If Mepivicaine is mixed with D5 water, then it
becomes hyperbaric. Isobaric if we mixed it with
plain NSS. Hypobaric, if we mixed it with sterile
water.
2. Patient position
ADJUVANTS
 Spine should be flexed by having the
patient bend at the waist and bring the
chin toward the chest, which will optimize
the interspinous space and interlaminar
foramen
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3. Dose, Volume and Concentration
 The higher the concentration, the speedier
the onset.
 The smaller the dose of the anesthetic,
decreased spread of the anesthetic.
4. Injection Site
 Epidural anesthesia can be performed
above L3-L4, since the anesthetic is just
inserted in the epidural space and not
further into the subarachnoid space. Spinal
anesthesia is strictly below L3-L4.
 One advantage of epidural anesthesia is
that it allows for Segmental blockade. For
example is when we perform mastectomy,
the block is usually at the level of thoracic
area. If you want to block T1-T10 only, you
can perform epidural anesthesia at the
level of T5. Spinal anesthesia, however,
can only block below or above the sacral
area (never segmental).
 Differential blockade is also an advantage
of epidural anesthesia. For example, in
labor analgesia, only the sensory is
blocked. This is done by reducing the
concentration of the local anesthetic
through dilution with plain NSS or sterile
water or D5 water.
5. Patient Characteristics
 Pregnant patients - lower dose needed
 Patients with acute abdomen - lower dose
needed
 Elderly patients - osteopenic spines
develop, the caliber of spaces of the
vertebra become smaller; lower doses
needed
1. Vasoconstrictors
o Increase the duration of spinal anesthesia
o Epinephrine (0.1-0.2mg) or phenylephrine
(2-5mg)
o Due to reduction in spinal cord blood flow,
which decreases loss of local anesthetic
from the perfused areas and thus
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Block 20 | Module 5| Lecture 7: Regional Anesthesia by Dr. Marco Victorio Fermindoza

increases the duration of exposure to local 2 types of nerves

anesthetic  Myelinated – resistant to local anesthetic
2. Opiods and other analgesic agents  Non-myelinated – drenched with local anesthetic
before blocking the myelinated fibers
o Enhance surgical anesthesia and provide
postoperative analgesia
 Spinal anesthesia interrupts sensory, motor, and
o Fentanyl (25ug) for short surgical
sympathetic nervous system innervation. Local
procedures
anesthetic solutions injected into the subarachnoid
o Morphine (0.1- 0.5mg) effective for
space produce a conduction block of small-diameter,
~24hours
unmyelinated (sympathetic) fibers BEFORE
SYMPATHETIC BLOCK
interrupting conduction in larger myelinated (sensory
Preganglionic and motor) fibers. The sympathetic nervous system
sympathetic blockade block typically exceeds the somatic sensory block by
two dermatomes. This estimate may be conservative,
Arteriolar and venous with sympathetic nervous system block sometimes
dilatation
exceeding somatic sensory block by as many as six
dermatomes, which explains why systemic
Increased vascular
capacitance hypotension may accompany even low sensory levels
of spinal anesthesia
 Spinal anesthesia has little, if any, effect on resting
Pooling of Blood
alveolar ventilation (i.e., analysis of arterial blood gases
unchanged), but high levels of motor anesthesia that
Decreased Venous produce paralysis of abdominal and intercostal
Return muscles can decrease the ability to cough and expel
secretions. Additionally, patients may complain of
Decreased Cardiac difficulty breathing (dyspnea) despite adequate
Output
ventilation because of inadequate sensation of
SEQUENCE OF NEURAL BLOCKADE breathing from loss of proprioception in the abdominal
1. Pain and thoracic muscles
2. Temperature
3. Sensation Spinal Anesthesia Complications
4. Proprioception  Hypotension
5. Touch  Directly proportional to the degree of
6. Pressure sensation sympathetic blockade
7. Motor paralysis  The thoracic and the lumbar areas are
predominantly sympathetic. While the
PHYSIOLOGY: cervical and sacral areas are
 Sympathetic predominantly parasympathetic. Local
- derived from thoracolumbar anesthesia is injected at the level of L3-L4,
- causes hypertension hence, there is sympathetic blockade.
What will happen? There will be
 Parasympathetic vasodilatation of blood vessels most
- derived from craniosacral
especially in the venous system (there is
- innervated by vagus nerve & sacrum plexus
resultant pooling of blood) -- decrease
- causes hypotension

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Block 20 | Module 5| Lecture 7: Regional Anesthesia by Dr. Marco Victorio Fermindoza
venous return-- thereby creating decrease
in preload as well as cardiac output –
vasodilatation will also decrease peripheral
resistance – Hypotension
 Bradycardia
 If block reaches T2, T3
 Unopposed vagal stimulation
 Post spinal headache
 6-48 hours following dural puncture
 Fronto-occipital type of headache which is
very painful.
 Continued leak of CSF through a hole in
the dura mater > Decrease CSF pressure >
Traction on meningeal vessels & nerves
 Epidural needles are usually large bore
needles (gauge 18). When the needle is
pushed further than the epidural space,
the dura may be accidentally punctured
causing CSF to leak towards the epidural
space. There will be a resultant decrease in
intracranial pressure. When the patient
stands up, there will be traction of the
meninges. One of the purposes of CSF is
(galangoy-langoy ang brain). When there
is decreased intracranial pressure, the
Hypotension Treatment
brain "sags" and is impinged by the nearby
structures causing headache.
 Multiple injections can also cause Post-
Puncture headache. When there is
difficulty of finding the epidural space,
there is a tendency of repeated puncturing
creating multiple small injections which
will eventually cause leakage of CSF into
the epidural space.
High Spinal Anesthesia Treatment
 Loss of CSF causes downward displacement of the
brain and resultant stretch on sensitive supporting
structures. Pain also results from distention of the
blood vessels, which must compensate for the loss
of CSF because of the fixed volume of the skull.
 Nausea
 hypotension or unopposed vagal
stimulation
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 Low blood pressure may also result to
nausea and vomiting
 Urinary Retention
 Bladder - sacral block results in atonic
bladder
 Bladder atony results to difficulty of
urinating. This is why when under regional
anesthesia, catheterization is done.
 Excessive administration of IV fluids should
be avoided during minor surgery with
spinal anesthesia
 Backache
 Back ache from the trauma during the
procedure.
 From multiple attempts at correct
advancement of spinal needle or ligament
strain in an uncomfortable position of
patient.
 Neurologic sequelae
 Direct trauma to a spinal nerve or
intraneural injection
 Hypoventilation
 C3-C5 - ascending intercostal muscle
paralysis
 IV fluid pre-loading at 10-20cc/kg
 Head-down position 5-10 degrees
 Sympathomimetics
 Ephedrine (5-10mg IV)
 Colloids or additional crystalloids
 Prior to giving anaesthesia, check for the hydration
status of the pt and rehydrate of necessary.
 Blockade above T4 - interrupts cardiac sympathetic
fibers leading to bradycardia, decrease cardiac
output, hypotension
Why do we need to block up to the level to
T4 when the procedure will be done is only
at the level of T10?
It has something to do with the
peritoneum which envelopes the internal
organs in the peritoneal cavity. Once
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Block 20 | Module 5| Lecture 7: Regional Anesthesia by Dr. Marco Victorio Fermindoza
incision is done at this area and block is
only at the level of T10, the patient may
feel pain since the peritoneum extends up
to the level to T6.
Why not above T4?
Once the anesthesia reach the level above
T4 (in cases of prolonged Trendelenburg
position), there will be bradycardia
because T1-T4 contains the Cardio-
accelerator fibers which gets blocked when
anesthetics reach these levels.
When it reaches the cervical area, this is
High spinal anesthesia
Treatment: Vasoconstrictors, Atropine and
place the patient in flat-in-bed position.
Hoarseness of voice may result from the
anesthetic reaching the level of the
laryngeal nerve.
Treatment: Oxygen supplementation 5-6L
via nasal prong or >6L via face mask or we
can ventilate the patient via the anesthesia
machine to increase O2 saturation. Or if
the patient is not responsive, intubation
may be done.
Sedate the patient if restless. If blood
pressure is low, vasoconstrictors may be
given. When heart rate is decreased,
atropine or epinephrine may be
administered.
When anesthetic reach the level of the
ventricles, patient may be brain dead.
Treatment: intubation is recommended.
This is now called Total Spinal Anesthesia.
This is what we avoid.
 Total spinal anesthesia is the term applied to
excessive sensory and motor anesthesia associated
with loss of consciousness. There is ischemic
paralysis of medullary ventilator centers causing
apnea.
Treatment:
• Ventilatory support
• Circulatory Support (sympathomimetic drugs)
• Head-down position
17 | Ingles, Jaleco, Lacson
Spinal Headache Treatment
• Bed rest
• Oral analgesics
• Hydration
• Caffeine sodium benzoate 500mg IV or caffeine
containing beverages
• Epidural blood patch
B. Epidural Anesthesia
 Results from injection of local anesthetics into the
epidural space.
 The major site of action of local anesthetics
placed in the epidural space appears to be the
SPINAL NERVE ROOTS.
 Anesthesia occurs more slowly than with spinal
anesthesia and develops in a segmental manner
 Block is not as dense as spinal anesthesia
 Anesthesia may also result from the extension to
the subdural area of the local anesthetic
INDICATIONS
 Analgesia
 Anesthesia (with variable blocks)
 Labor and delivery
 Prolonged post-op pain relief
 All indications for spinal anesthesia
ADVANTAGES
• Maintain continuous anesthesia after placement of
catheters – suitable for prolonged procedures
• Post operative analgesia
TECHNIQUES
 LUMBAR and LOW THORACIC EPIDURAL
 Both midline and paramedian approaches
are used
 Midline approach is more popular due to:
o Simpler anatomy and easier
orientation
o Passage of needle through less
sensitive structures
 THORACIC EPIDURAL
 Uses generally, a paramedian approach
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Block 20 | Module 5| Lecture 7: Regional Anesthesia by Dr. Marco Victorio Fermindoza
Layers Traversed by Epidural Needle
1. Skin
2. Subcutaneous tissue
3. Supraspinous ligament
4. Interspinous process
5. Ligamentum flavum
IDENTIFICATION OF THE EPIDURAL SPACE
 LOSS OF RESISTANCE TECHNIQUE
 A syringe containing air/ saline or both is
attached to the needle
 needle is slowly advanced while assessing
resistance
 An abrupt loss of resistance to injection
signals passage through the ligamentum
flavum and into the epidural space
 HANGING DROP TECHNIQUE
 a small drop of saline is placed at the hub
of the epidural needle
 the drop is retracted into the needle by the  pH is responsible for onset
negative pressure in the epidural space
ADMINISTRATION
 SINGLE SHOT EPIDURAL
 Simplicity, more uniform than through
indwelling catheter
 Administration of a test dose of local
anesthetic solution assessed after 3mins
 injection of local anesthetic solution over a
1 to 3 min period
 CONTINUOUS EPIDURAL ANESTHESIA
 A catheter is advanced 3-5cm beyond the
tip of the needle positioned in the epidural
space
 epidural needle is withdrawn over the
catheter
 CAUDAL ANESTHESIA
 Performed in either prone or lateral
position
 Sacral hiatus is located 5cm from the tip of
coccyx
 Failure rate is as high as 10% in adults
 Easier in children
17 | Ingles, Jaleco, Lacson
Things to remember with epidural placement
 Thread the catheter 3-5 cm
 Remove the needle while keeping positive
pressure in the catheter
 Check position
 Secure catheter
 Test done
 Aspirate for blood or CSF
 Paramedian insertion usually results in
higher blood vessel puncture
 1.5% lidocaine with epinephrine
 lipid solubility is related to potency
 protein binding for duration of action
ADJUVANTS
 EPINEPHRINE
 Decreases vascular absorption
 maintains effective anesthetic
concentrations
 OPIOIDS
 to enhance surgical anesthesia and to
control post operative pain
 Lipid solubitilty
 Morphine - hydrophilic, spreads
rostrally within the CSF
 Fentanyl - lipophilic, rapidly
absorbed and exhibits less rostral
spread.
 SODIUM BICARBONATE
 Because local anesthetics are weak bases,
they exist largely in the ionic form
 adding sodium bicarbonate favors the non-
ionized form of local anesthetic and favors
faster onset of anesthesia
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Block 20 | Module 5| Lecture 7: Regional Anesthesia by Dr. Marco Victorio Fermindoza
SIDE EFFECTS
1. Backache
 needle trauma, local anesthetic irritation, and
ligamentous strain secondary to muscle
relaxation
2. Postdural Puncture Headache
 loss of CSF through the meningeal needle hole
resulting in decreased buoyant support for the
brain. In the upright position the brain sags in
the cranial vault putting traction on pain-
sensitive structures
3. Hearing loss
4. Systemic Toxicity
 does not occur with spinal anesthesia because
the drug doses used are too low to cause toxic
reactions even if injected intravenously. Both
CNS and cardiovascular toxicity may occur
during epidural anesthesia
5. Total Spinal
 occurs when local anesthetic spreads high
enough to block the entire spinal cord
6. Neurologic Injury
 Transient Neurologic Injury defined as pain,
dysesthesia, or both in the legs or buttocks
after spinal anesthesia
7. Spinal Hematoma
 Coagulation defects are the principal risk
factor for epidural hematoma.
ADDITIONAL NOTES
COMBINED SPINAL-EPIDURAL ANESTHESIA
 Combined spinal-epidural anesthesia is a
technique in which a spinal anesthetic and an
epidural catheter are placed concurrently. This
approach combines the rapid onset and intense
sensory anesthesia of a spinal anesthetic with the
ability to supplement and extend the duration of
the block afforded by an epidural catheter
 The technique is commonly used in obstetric
anesthesia
Technique
 Combined spinal-epidural anesthesia is most
commonly performed by placing a needle in the
epidural space, followed by passage of a small
17 | Ingles, Jaleco, Lacson
spinal needle into the subarachnoid space through
the lumen of the epidural needle. After injection of
the local anesthetic solution, the spinal needle is
removed and a catheter is threaded into the
epidural space through the epidural needle.
 Although standard spinal and epidural equipment
may be used, there are commercially available
needles specifically designed for combined spinal-
epidural anesthesia.
 An undocumented concern associated with
combined spinal-epidural anesthesia is that the
meningeal puncture site may permit high
concentrations of subsequently administered
epidural local anesthetics to enter the
subarachnoid space or facilitate passage of the
epidural catheter through the dura.
COMBINED EPIDURAL-GENERAL ANESTHESIA
 Advantages of epidural block during general
anesthesia include less need for opioids, pain-free
emergence from anesthesia, and block of the
stress response that is nearly complete for most
surgical procedures performed below the
umbilicus.
 Various modifications of the combined epidural-
general anesthetic are used, but if the
administration of general anesthesia is not altered
by limiting the use of volatile anesthetics and
opioids, there is little advantage to the technique.
 Combined epidural-general anesthesia requires
strict attention to fluid management and blood
pressure. Sympathomimetics with α-adrenergic
activity, such as phenylephrine, dopamine, or
epinephrine, can be used to counteract the
consequences of afterload reduction, especially in
patients at risk for stroke or myocardial ischemia.
 Excessive intravenous fluid administration to treat
hypotension is discouraged because it is often not
effective and can lead to intravascular fluid
overload as the block recedes.
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Block 20 | Module 5| Lecture 7: Regional Anesthesia by Dr. Marco Victorio Fermindoza

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