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Regional Anaesthesia

Organisation of the Body

QuestionAnswer
What do you need for spinal anaesthesia A narrow, hollow syringe a drug
Biers Block Tying a band around the upper arm removes all the blood from the limb Anaesthetic can then be injected to produced a rapid numbing of the limb that does not spread around the body If this did spread e.g. blood flow restored, the heart would stop
What structures does spinal anaesthesia have to pass through Skin Fat Interspinous ligament Ligamentum flavum Epidural space Dura
Where is a spinal anaesthetic injected into? Below the spinal cord in the lumbar cerebrospinal fluid This eliminates the chance of damaging the spinal cord, although individual nerves maybe affected
Numbers of vertebrae and spinal nerves 7 cervical vertebrae 8 cervical spinal nerves 12 Thoracic vertebrae and spinal nerves 5 lumbar vertebrae and spinal nerves 5 sacral nerves
Where does the spinal cord end Between L1/L2 in an adult It initially reaches the end of the spine but regresses during development
Cauda Equina The nerves that come out the bottom of the spinal cord This is where the needle is inserted into If a nerve is hit a patient may experience pain/discomfort
Positioning of spinal injection L4 is level with the top of the pelvis, so can be used to identify the correct injection site The patient should be flexed forward to allow access to the dura membranes which are usually covered by bone
Role of dermatomes in anaesthetic By identifying which nerve innervates the area of the body we want to numb, we can identify what area of the spinal cord we need to direct the anaesthetic to
Drugs used in spinal anaesthesia Usually Bupivacaine 0.5% with glucose 6% to make it heavier than CSF This means it will flow downhill, so by angling the patient you can control with area of the spine you numb
Volume of drug used in spinal anaesthesia Small - 2-3ml
Site of spinal anaesthesia Into the lumbar CSF which bathes the cauda equina in the region L2-L5
Time course of spinal anaesthesia Rapid onset - 5-15 mins May instantly produce effects Lasts 1- 2 hours
Effect of spinal anaesthesia Lock all nerves and modalities below the level of the injection, typically T10 downwards Small nerves (temperature and pin prick sensations) are blocked before larger nerves (voluntary motor) Spread depends on posture
Adverse effects of spinal anaesthesia Hypertension - sympathetic constrictor nerves to blood vessels are blocked - 100% of cases Bradycardia-slowing of the heart if sympathetic block reaches T1-T4 - 20% Headache-1% with fine point needles (leakage of CSF) Nerve damage, meningitis, deafness
Uses of spinal anaesthesia Pain relief and muscle paralysis during surgery - used alongside general anaesthesia
Where is an epidural performed Needle in the epidural space Can be accessed via the sacral hiatus Contains fatty tissue and blood vessels - bleeding may occur when the needle is inserted
Drugs used in epidurals Bupivacaine 0.5% - lasts longer Lidocaine 2% and adrenaline (prevents blood vessel dilating and carrying the anaesthetic around the body) - works quicker
Volume of drug used in epidurals Large - 20ml The epidural space is voluminous and you want to fill this up
Site of epidural Usually the lumbar epidural space but can be in the thoracic (must be careful not to affect nerves suppling heart/lung) and caudal areas
Time course of epidurals Slow onset - 10-30 mins Lasts up to 6 hours
Effects of epidurals Block of all nerves and modalities in a band around the body at the levels reached by the injection Typically T10-S1 for a lumbar epidural Spread depends on posture
Adverse effects of epidurals Hypotension, bradycardia, shivering If the dura is not punctured headache and total spinal do not occur (occur if injected in CSF) Nerve damage and infection are rare
Uses of epidurals Commonly used in labour for childbirth as a form of analgesia with bupivacaine 0.125-0.25% The Tuohy technique and using a catheter allows infusion or top ups for prolonged use Very useful in pain relief and muscle paralysis in surgery
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