central neuraxial blocks
TRANSCRIPT
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CENTRAL NEURAXIALBLOCKS
Dr. Anilkumar T.K.
Anaesthetist,
NMC Hospital,
Abudhabi, UAE
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VERTEBRAL ANATOMY
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SALIENT FEATURES
1. Spinal Cord ends at lower border of L1 in
adults, L3 in infants
2. Line joining the iliac crests is at L3-L4
interspace
3. Epidural Space lies between the walls of
vertebral canal & the spinal dura mater
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SPINAL BLOCK
1. Indications
2. Landmarks
3. Technique
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4. Drugs
5. Physiological Effects
6. Contraindications -
- Absolute
- Relative
7. Complications
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PHYSIOLOGICAL EFFECTS
1. Nervous system -- Differential nerve blockade- Interindividual variability of nerve root
sizes
2. Cardiovascular System -
- Hypotension- Bradycardia
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3. Respiratory System -
- Decrease in Vital Capacity- Apnea
4. Gastrointestinal System -- Constricted Gut
- Nausea/Vomiting
5. Renal System -
- Urinary Retention
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COMPLICATIONS
1. Post Dural Puncture Headache
2. Urinary Retention
3. Labyrinthine Disturbances
4. Cranial Nerve Palsy
5. Spinal Cord Trauma
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POST DURAL PUNCTURE HEADACHE
Pathophysiology of Dural Puncture -- Leakage of CSF
- Excess loss of CSF -
- intracranial hypotension
- reduction in CSF volume
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Actual Mechanism -
- Low CSF pressure - traction on the
intracranial structures in the upright
position
- Compensatory increase in blood volume -
venodilatation
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INCIDENCENeedle tip Needle gauge Incidence of PDPH
design (%)
Quincke 22 36
Quincke 25 3 –25
Quincke 26 0.3 –20
Quincke 27 1.5 –5.6
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Needle tip Needle gauge Incidence of PDPHdesign (%)
Whitacre 20 2 –5
Whitacre 22 0.63 –4
Whitacre 25 0 –14.5
Whitacre 27 0
Tuohy 16 70
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SPINAL NEEDLE TIP DESIGNS – QUINCKEN [L], SPROTTE [M] &
WHITACARE [R]
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SUSEPTIBILITY
1. Younger age compared to Elderly people
2. Obstetrics Patients
3. Females
4. Larger Spinal Needles
5. Cutting Spinal Needles
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PRESENTATION
1. Onset
2. Symptoms
- Headache
“An increase in severity of the headache
on standing is the sine qua non of post -
dural puncture headache”- Nausea & Vomiting
- Diplopia
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DIAGNOSIS
1. History -
- Dural puncture- Symptoms of a postural headache
2. Diagnostic lumbar puncture
3. MRI
4. CT myelography
5. Radionuclide myelography
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DIFFERENTIAL DIAGNOSIS
01. Viral, chemical or bacterial meningitis
02. Intracranial haemorrhage
03. Cerebral venous thrombosis
04. Intracranial tumour
05. Non-specific headache
06. Cerebral infarction
07. Sinus headache
08. Migraine
09. Drugs (e.g. caffeine, amphetamine)
10. Pre-eclampsia
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DURATION
- 72% of headaches resolve within 7 days
- 87% resolve in 6 months
- With no treatment, over 85% of post-dural
puncture headaches will resolve within 6weeks
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TREATMENT
The aim of management -
1. Replace the lost CSF
2. Seal the puncture site
3. Control the cerebral vasodilatation
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1. Psychological
2. Supportive therapy
3. Posture
4. Abdominal binder
5. Pharmacological
6. Epidural blood patch
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EPIDURAL BLOCK
- Thicker Needles
- Technique -
Space Detection -
- Loss of Resistance
- Hanging Drop
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- Single Shot or Continuous Cathetertechnique
- “Test Dose”??
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COMPLICATIONS
Intra Operatively -
1. Dural Tap
2. Total Spinal Anaesthesia
3. Shivering
4. Nausea/Vomiting
5. Urinary Retention
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Post Operatively -
1. Headache
2. Epidural Haematoma
3. Epidural Abscess
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PRECAUTIONS FORNEURAXIAL ANAESTHESIA
AND
ANALGESIA INPATIENTS TAKING
ANTICOAGULANT DRUGS
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MINIMUM DELAY BETWEEN LAST DOSEOF ANTICOGULANT DRUGS &
PLACEMENT/REMOVAL OF EPIDURALCATHETER
1. Unfractionated Heparin - 02 - 04 hrs
2. LMWH - 10 - 12 hrs
3. Aspirin - 0 day
4. Clopidogrel - >/= 07 days5. Abciximab - 2 days
6. Fondaparinux - No epidural
MINIMUM DELAY AFTER PLACEMENT/
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MINIMUM DELAY AFTER PLACEMENT/REMOVAL OF EPIDURAL CATHETER &
NEXT DOSE OF ANTICOAGULANTDRUGS
1. Unfractionated Heparin - 0.5 - 01 hr2. LMWH - 02 -12 hrs
3. Aspirin - Immediate
4. Clopidogrel - Immediate5. Abciximab - 02 - 04 hrs
6. Fondaparinux - No epidural
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CONTRAINDICATIONS TONEURAXIAL ANAESTHESIA AND
ANALGESIAPT INR > 1.5
APTT > 40 Seconds
Platelet Count < 50,000 cells/ml
- If INR is increasing, the cut-off level wouldbe INR > 1.5
- If INR is decreasing, the cut-off level
would be INR >1.2
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FASTING RECOMMENDATIONS TOREDUCE THE RISK OF PULMONARY
ASPIRATION
- Recommendations apply to healthy
patients undergoing elective procedures
- Not intended for women in labor
- The fasting periods noted apply to all ages
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Ingested Material Minimum Fasting
Period (hrs)
Clear liquids 2
Breast milk 4
Infant formula 6
Non-human milk 6
Light meal 6
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- Clear liquids include water, fruit juices
without pulp, carbonated beverages, clear
tea & black coffee
- Non-human milk is similar to solids ingastric emptying time
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- A light meal typically consists of toast &
clear liquids. Meals that Include fried or fattyfoods or meat may prolong gastric emptying
time. Both the amount & type of foods
ingested must be considered when
determining appropriate fasting period
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REFERENCES
- British Journal of Anaesthesia, 2003, Vol. 91,
No. 5, 718-729
- Miller’s Textbook of Anaesthesia, 6th Edition
- Aitkenhead Textbook of Anaesthesia,4th Edition
- Oxford Handbook of Anaesthesia, 1st Edition
- www.asahq.org- www.nda.ox.ac.uk/wfsa
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THANK YOU