Segmental Epidural Anaesthesia

SEGMENTAL EPIDURAL ANAESTHESIA FOR
INGUINAL HERNIA REPAIR

By
Dr. B.DHARMENDER REDDY
A Dissertation Submitted to
The Rajiv Gandhi University of Health Sciences Karnataka, Bangalore
in partial fulfilment
of the requirements for the degree of
DOCTOR OF MEDICINE
In
ANAESTHESIOLOGY
Under the guidance of
Dr. S. GOWRI KUMARI
Professor and HOD, ANAESTHESIOLOGY.
DEPARTMENT OF ANAESTHESIOLOGY,
MV1 MEDICAL COLLEGE AND RESEARCH HOSPITAL,
HOSKOTE, BANGALORE
APRIL 2011
RA1IV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE
DECLARATION BY THE CANDIDATE
I hereby declare that this dissertation entitled ~SEGMENTAL EPIDURAL
ANAESTHESIA FOR INGUINAL HERNIA REPAIR is a bonaIide and genuine
research work carried out by me under the guidance oI Dr. S. GOWRI KUMARI,
ProIessor and Head, Department oI Anaesthesiology, MVJ Medical College and
Research Hospital, Hoskote, Bangalore.
Dr. B.DHARMENDER REDDY,
Date: Postgraduate in Anaesthesiology,
Place: Hoskote MVJ Medical College and Research
Hospital.
Hoskote, Bangalore.
CERTIFICATE BY THE GUIDE

This is to certiIy that the dissertation entitled ~SEGMENTAL EPIDURAL
ANAESTHESIA FOR INGUINAL HERNIA REPAIR is a bonaIide research
work done by Dr. B.DHARMENDER REDDY in partial IulIilment oI the
requirement Ior the degree oI Doctor oI Medicine in Anaesthesiology.
Date: Dr. S. GOWRI KUMARI.
ProIessor and Head
Place: Hoskote Department oI Anaesthsiology,
MVJ Medical College and
Research Hospital,
Hoskote, Bangalore
ENDORSEMENT BY THE HEAD OF THE DEPARTMENT,

DIRECTOR / DEAN
This is to certiIy that the dissertation entitled ~SEGMENTAL EPIDURAL
ANAESTHESIA FOR INGUINAL HERNIA REPAIR is a bonaIide research
work done by Dr. B.DHARMENDER REDDY, under the guidance oI
Dr. S. GOWRI KUMARI, ProIessor and Head, Department oI Anaesthesiology,
MVJ Medical College and Research Hospital, Hoskote, Bangalore.
Dr. S. GOWRI KUMARI. Dr. T. RA1ESHWARI.
ProIessor and Head Dean / Director
Department oI Anaesthesiology MVJ Medical College and
MVJ Medical College and Research Hospital, Research Hospital, Hoskote
Hoskote, Bangalore. Bangalore.
Date : Date:
Place: Hoskote Place: Hoskote
COPYRIGHT
DECLARATION BY THE CANDIDATE
I hereby declare that the Rajiv Gandhi University oI Health Sciences, Karnataka, shall
have the rights to preserve, use and disseminate this dissertation in print or electronic
Iormat Ior academic/research purpose.
Date: Dr. B.DHARMENDER REDDY
Postgraduate in Anaesthesiology,
Place: Hoskote MVJ Medical College and
Research Hospital,
Hoskote, Bangalore
RA1IV GANDHI UNIVERSITY OF HEALTH SCIENCES
ACKNOWLEDGEMENT
It is most appropriate that I begin expressing my indebtedness gratitude to my beloved
parents and Iamily members Ior being supportive in all my endeavours.
It gives me great pleasure in preparing this dissertation and I take this opportunity to
thank everyone who has made this possible.
It gives me greatest pleasure to express my deep sense oI gratitude and proIound
thanks to my most revered teacher Dr. S. GOWRI KUMARI, ProIessor and HOD oI
the Department oI Anaesthesiology, MVJMC&RH, Hoskote, Bangalore, Ior her
valuable guidance, constant encouragement, constant eIIorts in Iine tuning my
practical skills, timely expert advice with prospective comments and suggestions,
which she always rendered in every step oI my work. Without her valuable guidance,
this dissertation would not have come in its present Iorm. My sincere thanks to her Ior
being my guide.
I am highly indebted and consider myselI very Iortunate to have
Dr.T.RA1ESHWARI, Dean-cum-Director and the pillar oI this MVJMC & RH, Ior
having inculcated in me a sense oI determination and courage, Ior her constant
support and invaluable guidance with her superb talent and proIessional expertise
throughout this dissertation work. I Iind no words to express my heartIelt thanks to
her.
It gives me immense pleasure to extent my sincere thanks to ProIessors

Dr. A.V. PAI, Dr.PRASAD KULKARNI and Associate ProIessor
Dr. B. NARASIMHA REDDY whose authoritative knowledge oI practical skills has
guided and inculcated in me a sense oI conIidence. I am thankIul to them Ior their
valuable teaching and guidance.
My sincere thanks are due to Assistant ProIessor Dr.NIRMALA B.C. Ior her words
oI encouragement and constant and timely support in completing my dissertation
work.
My heartIul thanks to other consultants Dr.GAYATHRI, Dr. GIRISH.K.N.,
Dr.GIRISH BABU and Dr.SHASHIDHARA Dept. OI Anaesthesiology,
MVJMC&RH, Hoskote, Bangalore, Ior their valuable guidance and constant
encouragement.
I thank management MVJ MC & RH Ior being supportive in every stage oI study.
I thank all my post graduate colleagues, members oI department oI surgery and OT
staII Ior their whole hearted cooperation.
My heartIelt thanks to all patients who have been the backbone oI this study without
whom this study would not have been complete.
Date: Dr. B.DHARMENDER REDDY
Place: Hoskote
ABSTRACT
BACKGROUND AND OB1ECTIVES: Inguinal hernia repair is one oI the most
commonly encountered surgical corrections in men worldwide. Epidural anaesthesia
is widely used Ior these surgeries. As inguinal hernia is usually seen in elderly age
group, so as to avoid or reduce the complications which could occur in the
conventional dosages this clinical study oI segmental epidural anaesthesia was
undertaken where the extent oI block is limited to only Iew segments involved in the
Iield oI surgery.
METHODS: Study was conducted on 100 patients oI ASA I and II posted Ior
elective inguinal hernia repair. Segmental epidural block was perIormed with
ing.Bupivacaine 0.5 5-6ml. Patients were observed Ior onset, duration and quality
oI analgesia. Level oI analgesia preoperatively and post operatively. Hemodynamic
stability with heart rate, systolic and diastolic blood pressure.
RESULTS: In the present study, the mean onset oI analgesia was 8.08 minutes. The
quality oI analgesia was excellent in 53 cases, good in 34 cases, Iair in 10cases and
poor in 3 cases. The mean duration oI analgesia was 167.42 minutes (120 min to 240
min). All patients were haemodynamically stable throughout the surgery. Shivering
was seen in 5 cases and sweating in 9 cases.
INTERPRETATION AND CONCLUSION: Segmental epidural block with 5-6 ml
oI 0.5 Bupivacaine is Iound to be saIe and IulIils the surgical requirement. Could be
successIully employed Ior inguinal hernia repair with limited spread oI analgesia
involving only Iew segments. Fall in blood pressure and other complications were
very minimal. This technique can be saIely used in elderly patients.
KEY WORDS: Epidural anaesthesia; Segmental epidural anaesthesia; Hemodynamic
stability; Excellent alangesia.
LIST OF ABBREVIATIONS
Sup : Superior.
InI : InIerior.
CSE : Combined spinal epidural.
SA : Spinal anaesthesia.
EA : Epidural anaesthesia.
PNOV : Post operative nausea and vomiting.
ECG : Electro cardio graph.
MIN : Minutes.
SAB : Subarachnoid block.
TABLE OF CONTENTS
Sl.No Contents PAGE NO
1 Introduction 1
2 Objectives 4
3 Review oI Literature 34
4 Methodology 48
5 Results 57
6 Discussion 77
7 Conclusion 85
8 Summary 86
9 Bibliography 90
10 Annexures
i. ProIorma
ii. Consent Iorm
iii. Master Chart
iv. Key to Master Chart
96
98
99
103
LIST OF TABLES
S.NO.
TITLE
PAGE NO.
1
Characteristics oI ligamentum Ilavum at diIIerent
vertebral levels
7
2
Size oI epidural space at diIIerent vertebral levels
12
3
Pressures in epidural space at diIIerent vertebral levels
13
4
Age Distribution
57
5
Sex Incidence
59
6
Weight Distribution
60
7
Height Distribution
61
8
Type oI Hernia
62
9 Volume oI Drug 63
10 Quality oI Analgesia 64
11 Duration oI Analgesia 66
12 Level oI Analgesia Pre-operatively 68
13 Level oI Analgesia Post-operatively 69
14 Side EIIects 70
15
Success Rate
71
16 Mean heart rate changes 72
17 Mean blood pressure changes 74
18 Summary oI results 76
LIST OF FIGURES
S.NO TITLE PAGE NO.
1
Vertebral column
8
2
Lateral view oI Lumbar vertebrae
9
3 Median section oI Lumbar vertebrae 9
4
Fourth Lumbar vertebra ventral view
9
5 Cross section oI epidural Space 10
6 Loss oI resistance technique 14
7
Site oI action oI epidural drug
18
8
Anatomy oI inguinal canal
21
9
Structure oI bupivacaine
27
10
Epidural tray
54
11
Position oI the patient
54
12 Loss oI Resistance 55
13
Catheter insitu
55
14 Dermatomes 56
LIST OF GRAPHS
S.NO.
TITLE
PAGE NO.
1
Age Distribution
58
2
Sex Incidence
59
3
Weight Distribution
60
4
Height Distribution
61
5
Type oI Hernia
62
6
Volume oI Drug
63
7
Quality oI Analgesia
64
8
Duration oI Analgesia
67
9
Level oI Analgesia Pre-operatively
68
10
Level oI Analgesia Post-operatively
69
11
Side EIIects
70
12
Success Rate
71
13 Mean heart rate changes 73
14 Mean blood pressure changes 75
1
INTRODUCTION
"I esteem it the oIIice oI the physicians not only to restore health, but to mitigate
pain". SIR FRANCIS BACON.
"Divine is the task to relieve pain". HIPPOCRATES.
Most common symptoms Ior which a patient seeks medical advice are pain and
structural deIormity and whatever may be the basic cause they demand a relieI.
In general, relieI oI pain is one oI the most tangible roles to be played by the medical
practitioner and as such it merits careIul attention. RelieI oI pain is by Iar the most
Irequent indication oI surgical intervention.
The surgeon in his mission induces pain, which at times is more severe than the
original complaint.
Medical proIession has attempted various methods oI pain relieI Irom ancient times.
The development oI epidural analgesia and anaesthesia played a small but signiIicant
role in man`s triumph over pain, which undoubtedly is one oI the most Iascinating
chapters in the history oI medicine.
The rationale oI epidural analgesia in surgery is simple. The technique is used to
prevent aIIerent impulses Irom reaching the central nervous system and to prevent
transmission oI inappropriate eIIerent signals to the target organs such as muscle,
2
blood vessels and viscera. In doing so, epidural blockade IulIils the central aim oI
anaesthesia that is, prevention oI pain, overall control oI patient and his reIlexes and
preservation oI physical well being.
Epidural analgesia managed to escape the general decline in regional techniques when
it was given a Iresh impetus by introduction oI Touhy needle and an indwelling
epidural catheter. With these technical reIinements it became possible to maintain
analgesia continuously Ior even weeks iI necessary.
Hernia is the word derived Irom Greek words 'Herons an oIIshoot or bulge.
It is deIined by Sir Astley Cooper (1804) as 'protrusion oI any viscous or part oI the
viscous through an abnormal opening in the walls oI its containing cavity.
1
Inguinal hernia repair is one oI the most commonly encountered surgical corrections
in men representing 12.5 oI total surgical repair in Britain. In the international
classiIication oI diseases 9
th
division clinical maniIestation, the number was 9 Ior
hernias with relative value guide oI 6.
2
In providing anaesthesia Ior inguinal
herniorraphy, the technique chosen must be cost eIIective with respect to speed oI
recovery, patient comIort, and associated incremental costs.
3
Inguinal hernia repair is one oI the common treatments perIormed. Which can be
perIormed under spinal, epidural, general and inguinal Iield block.
3
Epidural anaesthesia is suitable as a sole agent Ior lower abdominal surgery and on
lower limbs. It has some deIinite advantages over spinal anaesthesia like avoidance oI
post spinal headache, minimal chances oI meningitis, and minimal chances oI nausea
and vomiting in post operative period.
4
But administration oI conventional dosage oI
local epidural anaesthetics(15ml and above) Ior surgical anaesthesia Irequently results
in multiple hemodynamic changes, including decreases in chronotropism, inotropism,
dromotropism, systemic vascular resistance, cardiac output, and myocardial oxygen
consumption.
5
The economic consequences oI these hemodynamic changes are Iar
Irom being calculated.
As inguinal hernia is usually seen in elderly age group, the above mentioned
complications will be more severe.
For a simple inguinal hernia repair, which is located at the level oI the 12th thoracic
and 1st lumbar dermatomes, an upper analgesic level oI the 8th to the 10th thoracic
dermatomes is satisIactory.
6
The practice oI the technique whereby, the block extends only to the segments
involved in the surgical Iield is said to have the Iollowing advantages.
1. Accurate limitation oI the area oI analgesia.
2. Minimal or no depression oI blood pressure.
3. Small doses oI local anaesthetics required and toxic doses are avoided.
4. Minimal incidence oI complications.
Hence to meet the above requirements the present study oI segmental epidural
anaesthesia Ior inguinal hernia repair is undertaken.
4
OB1ECTIVES
This study is undertaken to evaluate the advantages oI segmental epidural anaesthesia
Ior inguinal hernia repair.
1. To reduce the conventional dosage oI epidural anaesthesia to block only the
segments involved in the Iield oI surgery.
2. Hemodynamic eIIects.
3. To minimise the complications, which could occur in conventional dosage.
S
ANATOMY AND PHYSIOLOGY OF EPIDURAL SPACE
Epidural space is the potential space between the spinal duramater and the periosteum
and ligaments lining the vertebralcanal.
7
The duramater is made oI two layers, the endosteal and the meningeal layer. The two
layers are closely Iused within the cranium. Below the Ioramen magnum, these two
layers are separate.
The outer layer Iorms the periosteum lining the spinal canal.
The inner layer Iorms the spinal duramater. Between these two layers is the epidural
or the peridural space.
The epidural space is widest in the midline posteriorly with an average oI 5mm
between ligamentum Ilavum and the posterior surIace oI the spinal dura. The depth is
slightly more, proximal to the inIerior border oI the lamina due to the obliquity oI the
vertebral lamina.
Boundaries:
8
Above: The Ioramen magnum, where the periosteal and the spinal layers oI the
dura Iuse together.
Below: The sacrococcygeal membrane.
In front: The posterior longitudinal ligament covering the posterior aspect oI
the vertebral bodies and intervertebral discs.
Behind: The anterior surIace oI the vertebral lamina and ligamentum Ilavum.
6
Laterally: The pedicles oI the vertebrae and the intervertebral Ioramina.
The epidural space is not a closed space. It communicates with the paravertebral space
through the intervertebral Ioramina. It is shallowest anteriorly where it Iuses at some
places with the posterior longitudinal ligament. It is deepest posteriorly. The depth
varies as it is obliterated by contact between the duramater and the ligamentum
Ilavum or vertebral lamina. Laterally, the space is interrupted by contact between
duramater and pedicles.
Thus the epidural space is composed oI a series oI discontinuous compartments that
become continuous when the potential space separating the compartments is opened
up by injection oI air or liquid.
According to a study dorsomedian Iibrous tissue connects the duramater and the
ligamentum Ilavum in the lumbar region Iairly Irequently.
9
Due to these
Iibrous strands, the injected Iluid distends the space laterally rather than in the
midline.
This has been conIirmed anatomically through epiduroscopy and epidurography.
These Iibrous strands are responsible Ior occasionally unilateral anaesthesia Iollowing
apparently adequate epidural technique.
Ligamentum flavum: The ligamentum Ilavum is an important landmark Ior
technical identiIication oI epidural space during the introduction oI epidural
analgesia.
7
It is made oI tough elastic Iiber disposed in a vertical direction connecting the upper
and lower bodies oI adjacent lamina. It is thinnest in the cervical region becoming
progressively thicker down the spine and is thickest in the lumbar region.
Table-1 Characteristics of ligamentum flavum at different vertebral levels
10
Site (mm) Skin to ligament (cm)
Thickness of ligament
(mm)
Cervical
1.5
3.0
Thorasic 3.0
5.0
Lumbar 3.0-8.0 5.0-6.0
Caudal 2.0-6.0 Variable
The epidural space is entered most saIely and easily in the mid lumbar region. The
lumbar spine and the interspinous ligaments are widest in the mid-lumbar
region making an easy land mark Ior insertion oI the epidural needle.
8
Fig-1 Vertebral column
9
Fig-2, 3, 4 4th Lumbar vertebra ventral aspect
10
Fig-5 Cross section of epidural space
Contents of epidural space:
1) Fat: It is a ubiquitous material in the space and is highly vascular. The
Iat competes with the nervous tissue oI the spinal roots, cord and blood vessels
within the spinal cord Ior the drug. Drugs with high lipid solubility and lipoprotein
binding characteristics tend to enter the Iat phase and remain there Ior a period oI
time, depending on their pharmacodynamics and briskness oI local blood Ilow
competing Ior uptake. .
11
2) Spinal arteries: The arteries that traverse the space arise Irom the
vertebral, ascending cervical, deep cervical, intercostals, lumbar and ileo-lumbar
arteries. They anastamose with those above and below and across the midline and
lie mainly in the lateral parts oI the epidural space
3) Epidural veins: The venous plexus oI the vertebral canal which drain the
adjacent structures and the spinal cord lie in the anterolateral parts oI the epidural
space. They Iorm a network, which runs vertically within the epidural space. It can
be subdivided into a pair oI anterior venous plexus which lie on either side oI
the posterior longitudinal ligament into which basivertebral veins empty and
a posterior venous plexus. These are valveless (Batson`s plexus) and aIIord
a connection between the pelvic veins below with the intracranial veins above. These
veins become distended during coughing and straining and also when the inIerior
venacava is obstructed by large abdominal tumors or in late pregnancy. When these
epidural veins engorge, the epidural space is markedly reduced. Aspiration tests may
not always indicate intravenous position oI a needle or catheter and subsequent
injections oI air or local anaesthetic will be carried directly to the heart. The
appropriate dose oI the drug should preclude this problem.
4) Lymphatics: The lymphatics run anteriorly Irom each intervertebral
Ioramen. They drain the dural cul-de-sacs oI the dural root sleeves and empty in
the longitudinal channels in Iront oI the vertebral column.
Connections between epidural space and paraspinal tissue space:
The epidural space is not a closed space. Many oI the tissue planes around the spinal
canal connect to Iorm an extended system oI tracks.
12
There are 58 Ioramina in all. The areolar tissue around these Ioramina varies in
density according to age. As age advances the soIt and tenuous tissue
undergoes increasing condensation to Iorm the Iibrous tissue which thickens and
blocks the intervertebral Ioramina with aging. This conIines the solutions injected into
the epidural space within the spinal canal and they escape less rapidly along the
neurovascular bundles into the paravertebral spaces. Thus dosage should be reduced.
The spread is greater in pregnant Iemales.
Size of the epidural space:
The distance across the circular peridural space is variable. It is negligible or almost
non-existent in the anterior region. It is more and readily measurable in the posterior
region, especially in the midline.
Table -2 Size of epidural space at different levels
Level Epidural space (mm) Thickness of dura (mm)
Cervical 1.0-1.5 2.0-1.5
Upper thoracic 2.5-3.0 1.0
Lower thoracic 4.0-5.0 1.0
Lumbar 5.0-6.0 0.66-0.33
13
PHYSIOLOGY
Haldt and Moloney were the Iirst to describe negative pressure in the epidural space
in 1928. This negative pressure is maximum at points oI Iirm attachments. It
is maximum in the thoracic region, less in the lumbar region and least or absent in
the sacral region.
Table 3 Pressures in the epidural space at different levels
Level Pressure (cm H
2
O)
Lower lumbar - 0.5
Upper lumbar - 1.0
Thoracic -1.0 to - 3.0 (Average -2.0)
Three theories have been put Iorth to explain the negative pressure.
1) The Cone Theory:
11
Jonzen, 1926, Eaton in 1938 and Lawrence in 1948 put Iorward this theory.
According to this theory, the needle introduced into the epidural space depresses the
dura, creating a larger space. This theory was reviewed in the studies conducted by
Aitkenhead in 1979 in experiments on dogs.
2) Transmission Theory:
11
According to Macintosh and Bryce-Smith the negative pressure in the epidural space
is caused by the transmission oI the intrapleural negative pressure
through intervertebral Ioramina to the epidural space. It varies with the depth oI
14
respiration. i.e., clinically this negative pressure will be diminished or absent iI the
patient is not relaxed or straining.
3) Flexion theory:
11
This theory states that the negative pressure is directly proportional to the Ilexion oI
the spine. Marked Ilexion at the spinal column increases the negative pressure. A rise
in negative pressure may Iavour the spread oI local anaesthetic solution in the
epidural space.
Fig-6 Loss of resistance technique
1S
Thus a good knowledge oI the anatomy oI the epidural space and nearby structures
goes a long way in proper perIormance oI the technique oI epidural block.
Identification of epidural space is by:
Negative pressure technique
Hanging drop sign.
Capillary tube method.
Manometer technique.
Disappearance of resistance techniques
Syringe technique.
Spring loaded syringe.
Balloon technique.
Brooke`s device.
Vertical tube oI Dawkins.
Local anaesthetic injected into the epidural space acts on the dorsal root ganglia and
spinal roots with their dural cuIIs in the extradural space.
11
Leakage by vascular absorption.
Leakage through intervertebral Ioramina.
DiIIusion through dural root sleeves.
DiIIusion through dura mater.
16
Factors aIIecting the spread oI epidural analgesia:
1. Volume of the solution:
The spread oI analgesia in the epidural space depend on the volume oI drug injected.
During his experimental study in the dogs and human cadavers by injecting coloured
solution through the sacro coccygeal membrane.
12
Larger volumes will travel Iarther and remains in situ longer than smaller volumes.
When diIIerent volume oI solution has been used vertical spread has been expressed
as a ratio obtained by dividing the volume oI solution injected by the number oI
vertical segments involved. The ratio is expressed in millilitres per segment, varies
inversely with the vertical spread, so the lower its value the greater the degree oI
spread Ior a given volume.
13
2. Speed of injection:
spread oI solution depend upon the speed oI injection.
12
With rapid injection Iluid is
dispersed widely but thinly throughout the epidural space, so that the resulting block
is extensive and is oI short duration. With the slow injection there is time Ior the
solution to pool evenly in larger amounts in any given area with the result that block
tendts to be more localised and lasts longer.
14
3. Gravity:
X-Ray studies oI the Ilow oI solution in the epidural space injected via the lumbar
route oI living subjects were Iirst carried out by Sicard and Forestier in 1921 using
lipidol. In their study they described the passage oI the heavy oil outward through the
17
intervertebral Ioramina and the inIluence oI gravity in determining the direction oI
spread.
Solution Ilow under the inIluence oI the gravity and will diIIuse cephaled in the
trendelenberg position and caudal in sitting up position .
13
4. Site of Injection:
The site oI injection is one oI the extrinsic variables in the spread oI analgesic
solution. To keep the dose to minimum, injection should be made at the level
corresponding to the middle oI the area to be blocked. The solution injected spreads
equally in cephalad and caudal direction Irom the site oI the injection provided the
solution is injected slowly.
13
5. Age:
Small volumes oI solution will travel relatively Iarther in old ages where
intervertebral Ioraminae are stenosed by calciIied processes. Exaggerated spread oI
epidural analgesia is seen in patients with atherosclerosis, the degenerative changes in
connective tissue associated with atherosclerosis produce increased permeability oI
neural coverings.
15
Marked reduction in volume is required clinically in older patients
is due to the much greater degree oI neuraxial spread and greater permeability oI the
perineurium. The dose requirement decreases as age increases.
15
The diIIusion gradient is very important when compared to volume because small
volume oI high concentration can produce wide spread block, which is due to
18
neuraxial spread which is in turn due to high concentration gradient and greater
permeability oI the perineurium.
The mechanism oI action oI epidural analgesia is complex. The site oI action oI the
drug injected in the epidural space could be summarised as per Iigure below. FIG- 7
Longitudinal spread in epidural
space
Leakage by vascular
absorbLlon
SysLemlc effecLs
Leakage Lhrough
lnLerverLebral
foramlna
araverLebral block ln
nerve Lrunks
CenLrlpeLal
subperlneural spread
Subplal spread &
upLake ln plamaLLer
18
Epidural injection
Longitudinal spread in epidural
space
Leakage Lhrough
lnLerverLebral
foramlna
araverLebral block ln
nerve Lrunks
CenLrlpeLal
subperlneural spread
Subplal spread &
upLake ln plamaLLer
dlffuslon Lhrough
duralrooL sleeves vla
arachnold vllll &
perlvascularspaces
Sub dural spread
Splnal rooL block
upLake ln epldural faL
ulffuslon ln epldural
faL
Splnal subdural space
cerebrosplnal fluld
18
ulffuslon Lhrough
splnal cord dura
Splnal subdural space
cerebrosplnal fluld
19
Epidural analgesia is not simple as spinal root or ganglion blockade, but rather oI
action on several sites aIter passing through labrynth oI diIIusion pathways as
outlined in Iigure.
Solution spread in the epidural space will depend on the volume injected. Within the
extradural space the drug will be taken up and removed by blood Ilow, or it will be
stored and perhaps spread in the extradural Iat.
In young patients with Ireely patent intervertebral Ioramina, some solutions will
passout oI the spinal canal into the paravertebral spaces and along the spinal nerves,
producing a Iorm oI paravertebral block. From these diIIusion through the epineurium
and perineurium into subperineural space will allow some degree oI centripetal spread
backward towards the neuraxis with subsequent access to the contiguous subpial
space and Irom these to the surIace oI the roots and cord.
The epidural neural blockade may aIIect various systems as described below.
1. Cardiovascular system: The possible cardiovascular inIluences may be classiIied
according to the Iollowing scheme
a) Neural b) Pharmacological
Neural:
Segmental sympathetic eIIerent blockade with resultant dilution oI resistance
and capacitance vessels.
20
Paralysis oI cardiac sympathetic Iibers Irom the upper 4 to 5 thorasic segments
with loss oI chronotropic or inotropic drive to the myocardium, resulting in
bradycardia and reduction oI ejection Iorce.
Pharmacological:
Vascular absorption oI local anaesthetic Irom the epidural space leading to high
concentration oI local anaesthetic in the circulation causes consequent distant eIIects
on smooth muscle and Iall in the cardiac output Irom beta blockade. The depressant
eIIects oI circulating local anaesthetics are P
H
dependent and are likely to be most
severe in the presence oI renal and respiratory acidosis. II the epidural solution
contained epinephrine, its absorption would lead to increase in cardiac output and Iall
in peripheral resistance.
2. Liver: Hepatic Ilow is largely dependent on mean systemic blood pressure. Under
epidural analgesia hepatic blood Ilow is signiIicantly decreased iI the systolic blood
pressure is allowed to Iall below 60-70 mm Hg.
3. Renal system: Decrease in blood pressure causes proportionate decrease in renal
blood Ilow and GFR eIIect on bladder.
4. Bladder: Lumbar and sacral epidural anaesthesia results in atonic bladder with
large volume oI residual urine, sometimes catheterisation is needed. In segmental
thoracic epidural anaesthesia lower parts oI spinal cord are leIt intact and bladder
Iunction may not be aIIected.
5. Respiratory System: Depends upon the segmental blockade. There is no eIIect on
the vital capacity, Iorced expiratory volume, FRC and gas distribution.
21
ANATOMY OF INGUINAL CANAL
a
b
Fig-8 Anatomy of inguinal canal
22
No disease oI human body, belonging to the province oI the surgeon, requires in its
treatment a better combination oI accurate anatomical knowledge with surgical skill
than hernia in all its varieties. (Sir Astley Paston Cooper, 1804)
16
The inguinal canal is 4cm long and extends Irom internal inguinal ring laterally to the
external inguinal ring medially. It lies above the inner halI oI the inguinal ligament.
17
The canal gives passage to spermatic cord in male, and the round ligament oI the
uterus in the Iemale.
18
The deep ring, an oval opening in Iascia transversalis, lies about 0.5 inches (1.3cm)
above inguinal ligament midway between the anterior superior iliac spine and the
symphysis pubis. Just medial to it is the inIerior epigastric artery. The margin oI the
ring gives attachment to the internal spermatic Iascia. The superIicial inguinal ring, is
a triangular deIect in the aponeurosis oI the external oblique muscle and lies
immediately above and medial to pubic tubercle. The margins give attachment to the
external spermatic Iascia.
19
The mid inguinal point is the midpoint oI the line between anterior superior iliac spine
and the symphysis pubis. Hence it is just medial to the midpoint oI the inguinal
ligament.
23
Boundaries of inguinal canal
19
:
1) The anterior wall oI the canal: Formed along its entire length by aponeurosis
oI the external oblique muscle. It is reinIorced in its lateral third by the origin
oI the internal oblique.
2) The posterior wall oI the canal: Formed along its entire length by Iascia
transversalis. It is reinIorced in its medial third by conjoint tendon and
reIlected part oI inguinal ligament.
3) The Iloor oI the canal: It is Iormed by grooved surIace oI the inguinal and
lacunar ligaments.
4) The rooI oI the canal: Formed by arching lowest Iibers oI the internal oblique
and transversus abdominis muscles.
Contents of inguinal canal:
18
1) Spermatic cord in males and round ligament oI uterus in Iemale.
2) Ilioinguinal, iliohypogastric and genitoIemoral nerves.
24
Protective mechanism for the development of hernia:
18
1) Canal is an oblique passage with weakest areas namely superIicial and deep
rings lying some distance apart.
2) Anterior wall is reinIorced by the Iibers oI internal oblique
3) Posterior wall is reinIorced by strong conjoint tendon.
4) On coughing and straining, the arching lowest Iibers oI the internal oblique
and transverses abdominis muscle contracts so the canal is virtually closed.
Nerve supply:
1) Ilioinguinal nerve:
20
Origin: From L1 ventral ramus
Course: It emerges Irom the lateral border oI psoas major, with or just inIerior to
iliohypogastric nerve. It passes obliquely across quadratus lumborum and the upper
part oI iliacus and enters transversus abdominis near the anterior end oI the iliac crest.
It pierces internal oblique and supplies it and then traverses the inguinal canal below
the spermatic cord. It emerges with the cord Irom the superIicial inguinal ring to
supply skin. Occasionally this nerve is completely absent, when the iliohypogastric
nerve supplies its territory.
Motor: Transeversus abdominis and internal oblique.
Sensory: Supplies sensory Iibers to transeversus abdominis and internal oblique.
Medial skin oI thigh and skin over the root oI the penis and upper part oI scrotum in
males or skin covering the mons pubis and adjoining labium majus in Iemales.
2S
2) Iliohypogastric nerve: 20
Origin: L1 ventral ramus
Course: It emerges Irom the upper lateral border oI psoas major, crosses obliquely
behind the lower renal pole, and in Iront oI quadratus lumborum. Above the iliac
crest, it enters the posterior part oI transeversus abdominis. Between transverses
abdominis and internal oblique, it divides into lateral and anterior cutaneous branches.
The lateral cutaneous branch runs through internal and external oblique above the
iliac crest and is distributed to the posterolateral gluteal skin. The anterior cutaneous
branch runs through internal oblique 2cm medial to anterior superior iliac spine, and
through external oblique aponeurosis 3cm above superIicial inguinal ring.
Motor: It supplies a small motor contribution to transeversus abdominis and internal
oblique, including conjoint tendon.
Sensory: Supplies sensory Iibres to transeversus abdominis, internal oblique and
external oblique, and innervates the posterolateral gluteal and suprapubic skin.
3) Genitofemoral nerve:
20
Origin: Ventral rami oI L1 and L2
Course: It is Iormed within the substance oI psoas major and descends obliquely
Iorwards through the muscle to emerge on the abdominal surIace near its medial
border, opposite the third or Iourth lumbar vertebrae. It descends beneath the
peritoneum on psoas major, crosses obliquely behind the ureter and divides above
inguinal ligament into genital and Iemoral branches. The genital branch, crosses the
lower part oI external iliac artery, enters the inguinal canal by the deep ring. The
Iemoral branch descends lateral to external iliac artery, then crosses deep circumIlex
26
iliac artery passes behind inguinal ligament and enters Iemoral sheath lateral to
Iemoral artery.
Motor: Cremaster muscle via genital branch oI genitoIemoral nerve.
Cutaneous:
Genital branch: skin oI scrotum in males or monspubis and labium majus in Iemales
via genital branch.
Femoral branch: Anteromedial skin oI thigh.
27
PHARMACOLOGY
Local anaesthetics are chemical compounds which are capable oI producing reversible
conduction blockade oI impulses along central and peripheral nerve pathways aIter
regional anaesthesia.
Classification:
Clinically local anaesthetic agents can be classiIied into two groups depending on the
link between the aromatic portion and the intermediate chain. The amino ester group
have an ester link and include procaine, chloroprocaine and amethocaine. The amino
amides have an amide link between the aromatic head and the intermediate chain and
include lignocaine, bupivacaine, mepivacaine, prilocaine, etidocaine and
ropivacaine
21
.
Bupivacaine Hydrochloride:
History: Bupivacaine belongs to homologous series oI mepivacaine and was
synthesized in Sweden (1957) by BoaIekenstan. First reports oI its use were made in
1963 by Televard. Since then it has been widely used in Scandinavia.
Structural Formula:
1-N-Butyl-DI-piperidine-2-carboxylicacid-2,6-dimethyl-anilide hydrochioride.
Fig-9 Structure of bupivacaine
28
The only diIIerence Irom mepivacaine is that the butyl group replaces the methyl
group in piperidine ring. Both are being used as hydrochloride salts.
Bupivacaine, Lignocaine and mepivacaine contain linkages between the aromatic
nucleus and the amino or piperidine group. They diIIer Irom procaine, which has an
ester linkage.
Physical and Chemical Properties
It is a poorly water-soluble, long acting amide local anaesthetic. It is a salt oI white,
odourless, crystalline powder with a bitter, numbing taste. It is prepared by chemical
synthesis. Its molecular weight is 324.9, Ireely soluble in water and alcohol in its
hydrochloride Iorm, with its melting point oI 258
o
c. The pKa is 8.2 and pH is 3.5.
The solution is available in the Iorm oI 0.25, 0.5 and 0.75 in isotonic sodium
solution with or without adrenaline, 1: 200,000 concentrations. A preparation
marketed speciIically Ior intrathecal use contains dextrose.
22
Mechanism of action:
Bupivacaine, like other local anaesthetics prevents the generation and the conduction
oI the nerve impulse. Their primary site oI action is the cell membrane. Conduction
block can be demonstrated in squid giant axons Irom which the axoplasm has been
removed.
Local anaesthetics block conduction by decreasing or preventing the large transient
increase in the permeability oI excitable membranes to Na that normally is produced
by a slight depolarization oI the membrane. This action oI local anaesthetics is due to
their direct interaction with voltage-gated Na channels. As the anaesthetic action
29
progressively develops in a nerve, the threshold Ior electrical excitability gradually
increases the rate oI rise oI the action potential declines, impulse conduction slows,
and the saIety Iactor Ior conduction decreases. These Iactors decrease the probability
oI propagation oI the action potential, and nerve conduction eventually Iails
23
.
Pharmacokinetics of Bupivacaine:
Bupivacaine is rapidly absorbed Irom the site oI injection, the rate oI rise in plasma
concentration and the peak plasma concentration depending on the particular local
anaesthetic technique being used. There is also some inter individual variation, and
peak systemic concentrations may occur between 5 and 30 min aIter administration.
1. Absorption:
The site oI injection, dose, age oI the patient and addition oI a vasoconstrictor
determine systemic absorption oI bupivacaine. The maximum blood level oI
bupivacaine is related to the total dose oI the drug administered Irom any particular
site.
2. Distribution:
This can be described by a two compartment model. The rapid distribution (phase A)
is believed to be related to uptake by rapid equilibrating tissue (i.e., tissues that have
high vascular perIusion). The slow distribution (phase B) is mainly a Iunction oI
distribution to slowly equilibrating tissue, biotransIormation and excretion oI the
compound.
30
More highly perIused organs show higher concentrations oI the drug. Bupivacaine is
rapidly extracted by lung tissue. Though skeletal muscle does not show particular
aIIinity Ior bupivacaine it is the largest reservoir oI the drug.
Distribution characteristics of Bupivacaine.
1. T1/2 A (min) 2.7
2. T1/2 B (min) 28
3. Volume oI distribution at steady state (ltrs) 72.
4. Clearance (ltrs/min) 0.47.
3. Biotransformation and excretion:
Bupivacaine undergoes enzymatic degradation primarily in the liver. The excretion
occurs via the kidney. Renal perIusion and Iactors aIIecting urinary P
H
aIIect its
excretion. Less than 5 percent oI unchanged drug is excreted via the kidney through
urine. The major portion oI injected agent appears in urine in the Iorm oI 2, 6,
pipecolyloxylidine (PPx) which is an N-dealkylated metabolite oI bupivacaine. Renal
clearance oI this drug is related inversely to its protein binding capacity and pH oI
urine.
Dosage:
The dosage varies upon the area to be anaesthetised.
1. The vascularity oI the tissue
2. The number oI segments to be blocked
3. The individual tolerance
4. Site oI injection
31
In recommended doses, bupivacaine produces complete sensory block, but the motor
block depends on the concentration.
1) 0.25 incomplete motor blockade
2) 0.5 motor blockade is produced but muscle relaxation may be inadequate Ior
surgery.
3) 0.75 causes complete motor blockade.
Maximal dose is 2mg/kg body weight (25-30 ml 0.5 solution) and the strength used
is 0.125 - 0.75.
24, 25
Advantages:
1. More powerIul drug.
2. Prolonged duration, 4-5 times that oI lignocaine or mepivacaine.
Toxicity of Bupivacaine:
It is relatively Iree oI side eIIects iI administered in an appropriate dosage. It is more
cardiotoxic than lignocaine and this is made worse by hypoxia, hypercapnia and by
pregnancy.
1. Central nervous system toxicity:
CNS is more susceptible to bupivacaine. The initial symptom involves Ieeling oI light
headedness and dizziness Iollowed by visual and auditory disturbance. Disorientation
perioral numbness and occasional Ieeling oI drowsiness may occur. Objective signs
are usually excitatory in nature which includes shivering, muscular twitching and
tremors; initially involving muscles oI the Iace and part oI extremities. At still higher
32
doses cardiovascular or respiratory arrest may occur. Acidosis increases the risk oI
CNS toxicity Irom bupivacaine, since an elevation oI PaCO2 enhances cerebral blood
Ilow, so that more anaesthetic is delivered rapidly to the brain.
2. Cardiovascular system toxicity:
Bupivacaine depresses rapid phases oI depolarization (Vmax) in purkinge Iibres and
ventricular musculature to a greater extent than lignocaine. It also decreases the rate
oI recovery Irom a dependent block than that oI lignocaine. This leads to incomplete
restoration oI Vmax between action potential at high rates, in contrast to complete
recovery by lignocaine. This explains why lignocaine has antiarrhythmic property
while bupivacaine has arrhythmogenic potential. High level oI bupivacaine prolongs
conduction time through various parts oI heart and extremely high concentration will
depress spontaneous pacemaker activity, resulting in bradycardia and arrest. Cardiac
resuscitation is more diIIicult Iollowing bupivacaine induced cardiovascular collapse
and hypoxia along with acidosis which markedly potentiates cardiac toxicity.
Bretylium but not lignocaine could raise the ventricular tachycardiac threshold that
was lowered by bupivacaine.
3. Respiratory system:
Respiratory depression may be caused iI excessive plasma level is reached which in
turn results in depression oI medullary respiratory center. Respiratory depression may
also be caused by paralysis oI respiratory muscles as may occur in high spinal or total
spinal anaesthesia.
33
4. Autonomic nervous system:
Myelinated preganglionic beta Iibres have a Iaster conduction time and are more
sensitive to the action oI local anaesthetic including bupivacaine. Involvement oI
preganglionic sympathetic Iibres is the cause oI widespread vasodilatation and
consequent hypotension that occurs in epidural and paravertebral block. When used
Ior conduction blockade all local anaesthetic particularly bupivacaine produces higher
incidence oI sensory blockade than motor Iibres.
Adverse effects and precautions
The saIety and eIIectiveness oI local anaesthetic depend upon proper dosage, correct
technique, adequate precautions and readiness Ior emergencies. The lowest dosages
that produce eIIective anaesthesia should be used, to avoid high plasma levels and
serious systemic side eIIects. Injection oI repeated doses oI bupivacaine may cause
signiIicant increase in blood levels with each dose, due to accumulation oI the drug or
its metabolites or due to slow degradation. Tolerance varies with the general condition
oI the patient. Debilitated elderly patients and acutely ill patients should be given
reduced doses commensurate with age and physical condition.
34
REVIEW OF LITRETURE
Corning has been credited with being the Iirst to use epidural analgesia in 1885.
26
In 1901 Jean Enthuse Sicard and Fernand Cathelin independently introduced cocaine
through the sacral hiatus, becoming the Iirst practitioners oI caudal epidural analgesia.
They popularised this caudal approach Ior epidural analgesia.
27
Arthur Lawen successIully used caudal anaesthesia with large volumes oI procaine Ior
pelvic surgery.
28
AIter the Iavourable reports oI Sicard and Cathelin, TuIIier attempted epidural analgesia
by lumbar approach. But his lack oI success and natural diIIiculties oI locating a narrow
space oI 2-4 mm width at a depth oI 20 times that amount discouraged all Iurther
attempts Ior many years.
In 1906 Forestier independently described the interspinous approach to the peridural
space utilizing a loss oI resistance technique and thus, is considered as the co-originator
oI the method oI locating the peridural space with Sicard, who in 1906 demonstrated the
Ieasibility oI the interspinous approach to the epidural space.
28
In 1921 Fidel Pages, a Spanish military surgeon devised a technique to introduce
epidural procaine at all the levels oI neuraxis. His method was to use a blunt needle and
then Ieel and hear the entry oI the needle through the ligamentum Ilavum. He had
produced a segmental anaesthesia through epidural injections, avoiding some oI the side
3S
eIIects oI complete neuraxial block, which occurred aIter high subarachnoid
administration oI local anaesthetics. He published an article 'Anaesthesia Metamerica
in which he described satisIactory anaesthesia Ior abdominal surgery obtained by
utilising the interspinous approach to the peridural space.
27, 28
In 1926 Janzen Iirst described existence oI negative pressure in the epidural space.
29
A catheter passed through a needle into epidural space was Iirst used in obstetrics by
Aburel in 1931.
In 1931 Achille Mario Dogliotti described epidural injections oI local anaesthetics,
apparently without prior knowledge oI the work oI Pages. In 1933 in his article 'A new
method of block anaesthesia has mentioned about anatomy, physiology and
identiIication oI epidural space by loss oI resistance technique by using a continuous
pressure on the plunger oI a saline Iilled syringe as the needle advanced through the
ligamentous structures. Subsequently this method became known to be as Dogliotti
method.
27
A.Gutierrez oI Argentina developed the hanging drop sign, which is still being used by
some anaesthesiologists to identiIy the epidural space.
30
In 1936 B.Odom oI New Orleans published 285 cases oI lumbar epidural anaesthesia
and introduced the concept oI test dose to detect intrathecal injection.
31
36
William Lemmon used a 17-gauge, malleable, silver needle that was connected through
a hole in the operating table to rubber tubing and a syringe. Injections could then be
made at intervals to maintain the block Ior several hours.
32
Edward Tuohy in 1945 used a ureteral catheter threaded through a large Huber-tipped
spinal needle to provide continuous anaesthesia.
33
Later in 1949 this was modiIied to
give continuous epidural analgesia by Martinez Curbelo.
34
A Iresh impetus was given
by the introduction oI Tuohy`s needle Ior epidural analgesia.
The marked increase in the use oI epidural analgesia Iollowed the introduction oI
reliable, relatively non-toxic and Iast acting local anaesthetics.
Philip Bromage and John Bonica perIormed several studies on epidural dose-response
relationships and the hemodynamic changes that Iollowed initiation oI the block. Whose
text books on the subject have made them thus the world`s authority oI epidural
space.
35,36
In 1951 Rudin D.O. working upon live dogs Iound that it is possible to recover in
CSF up to 10percent oI local analgesic drug placed in the epidural space and behaves
as a true spinal analgesic acting either on nerve roots or dorsal root ganglia and that
the drug spreads Irom the epidural space through the intervertebral Ioramina and
produces block at the paravertebral space.
37
In 1966 Ekblon and Widman during 640 extradural lumbar blocks gave on an average
1.29/- 0.03 mg/kg body weight oI local anaesthetic without the appearance oI any
appreciable side eIIects.
37
In 1972 a study on the relation oI age and length oI vertebral column and volume oI
solution Ior lumbar epidural anaesthesia was done by Dr. Mandappa. Approximately
up to age oI 60 years the relationship between dose in volume to length oI vertebral
column could be established. For higher age group a volume to age relationship is
observed which could be due to narrowing oI the inter vertebral Ioramina limiting the
Ilow oI injected Iluid away into paravertebral space and also atherosclerosis oI blood
vessels which limits absorption oI injected Iluid. The procedure oI approximating
length oI the vertebral column, age oI the patient has greatly reduced the
complications. Further it is interesting to note that older age group requires only about
halI the volume oI drug required Ior younger age group Ior same operation. Sticking
to this regime, many protect the aged patients Irom complications.
In 1972, Philip R.Bromage Studied the incidence oI missed, unblocked segments
during continuous epidural analgesia Ior relieI oI pain in labour and vaginal delivery
in 433 patients. Six diIIerent local anaesthetic agents were tested: the carbonated salts
oI lignocaine and prilocaine, and the hydrochloride salts oI lignocaine, prilocaine,
bupivacaine and amethocaine. The incidence oI painIul or unblocked segments ranged
Irom 1 per cent with carbonated lignocaine, to 12.8 per cent with amethocaine
hydrochloride, and it was Iour times higher with lignocaine hydrochloride than with
carbonated lignocaine.
38
38
In 1974 P. R. Bromage studied lower limb reIlex changes in segmental epidural
analgesia where sensory changes and lower limb reIlexes were observed in 35 patients
receiving segmental epidural analgesia in the mid-thoracic region. Sensory blockade
was conIined to the thoracic and upper lumbar segments. The lower limb reIlexes
changed to an "upper motor neurone" pattern, with the onset and development oI
segmental blockade. With regression oI analgesia the reIlexes returned to normal in
the reverse order. The signiIicance oI these Iindings is discussed in relation to the
anatomy oI descending spinal pathways, and to the pattern oI penetration oI local
anaesthetics into the substance oI the spinal cord.
39
In1975 Maltau JM, gave selective lumbar epidural anaesthesia with 0.25 or 0.5
bupivacaine without adrenaline in doses oI 5 ml to 8 ml in 35 patients and monitored
the Ioetal heart rate changes. In 33 parturients the FHR changes observed were
insigniIicant. In one case a period oI marked bradycardia was seen. One parturient
developed acute hypotension with a synchronous Ioetal bradycardia while lying in the
supine position. He concluded that continuous lumbar epidural anaesthesia with low
dose bupivacaine without adrenaline does not precipitate Ioetal bradycardia during the
Iirst stage when care is taken to avoid maternal hypotension.
40
In 1977, Hollman A, Jouppila R, Pihlajaniemi R, Karvonen P and Sjostedt conducted
a study oI segmental (T10-T12) epidural analgesia in 418 parturient, using 4-6 ml
dose oI 0.5 bupivacaine with or without adrenaline. Seventy percent oI parturients
were primi paras and 30 had history or signs oI possible uteroplacental
insuIIiciency. The analgesia during the opening phase was oI good quality in 89 oI
primiparas and 84 oI multi. The onset oI analgesia was rapid (3-5min) and duration
39
was on average 2 hr. Slight but rapidly correctable hypotension occurred in 16.5,
and in 2 cases the hypotension led to more serious complications. There was no
maternal or neonatal mortalities.
41
In 1978 Jouppila R, Pihlajaniemi R, Hollman A and Jouppila P conducted a study
Segmental epidural analgesia and postpartum sequel`. Where the incidence oI the
postpartum sequel oI headache, backache, pain in the legs and diIIiculties in
micturition, was studied in 219 normal vaginal deliveries aIter segmental epidural
analgesia at the level oI T10-T12 Ior pain relieI during the Iirst stage oI labour. The
results showed that segmental epidural analgesia did not increase the occurrence oI
postpartum sequel either in primiparous or in multiparous parturients.
42
In 1979 Jouppila R, Jouppila P, Karinen JM and Hollman studied the eIIect oI low-
dose continuous segmental epidural analgesia given during the Iirst stage oI labour on
the progress oI labour, the Irequency oI Ioetal malpositions and the rate oI vacuum
extractions was studied in 100 parturients (epidural group). The results were
compared with 100 parturients given none or conventional analgesia (control group).
The results showed that in the primiparous epidural group the progress oI labour was
slower than in the control group. AIter the block, however, the subsequent course oI
the labour was oI equal duration in both groups. The duration oI the second stage oI
labour did not diIIer signiIicantly between the groups. The diIIerences in Ioetal
malpositions at delivery were statistically insigniIicant. Nor did the rate oI vacuum
extractions, 8 in the primiparous and 0 in the multiparous epidural group, diIIer
statistically Irom the corresponding rate in the control groups. The results signiIy a
normal progress and outcome oI labour aIter low-dose segmental epidural analgesia.
43
40
In 1979 Willdeck-Lund G, Lindmark G and Nilsson BA, conducted segmental
epidural block Ior vaginal delivery to 242 women. OI these, 178 with a spontaneous
start oI labour and vaginal delivery were studied with respect to the eIIect oI epidural
block with bupivacaine-adrenaline on the course oI labour and the condition oI the
inIant in women with normal uterine activity and women with primary uterine inertia
treated with oxytocin inIusion. On an average, the 178 women had already had a
longer course oI labour beIore the block was applied than women in control groups.
The block per se had only a slight eIIect on the Iirst stage oI labour, but the eIIect on
the second stage was more obvious, leading to outlet extraction in 50 oI the
primiparous women, compared to 12 oI the controls.
44
In 1979 Gal D, Choudhry R, Ung KA, Abadir A and Tancer ML conducted a study to
evaluate segmental epidural analgesia . Bupivacaine (0.25 per cent) was used during
the Iirst stage oI labor and Ior the second stage, either 3 per cent - Chloroprocaine
delivered through the catheter (Group I) or 1 per cent Lidocaine as a perineal inIiltrate
(Group II) was used. There were 124 Iull term patients oI whom, 36 were nulliparous
and 88 were multiparous. The eIIects oI segmental epidural analgesia on maternal
blood pressure, pain relieI, preservation oI lower limb motor power, duration and
progress oI labor, and Ioetal outcome were evaluated. Pain relieI during the Iirst stage
oI labor was satisIactory in 114 (92 per cent) oI the patients. There were no signiIicant
changes in maternal blood pressure, motor power in lower limbs, eIIiciency oI uterine
contractions and internal rotation oI the presenting part when analgesia was eIIective.
The use oI 2-Chloroprocaine Ior second stage pain relieI required low Iorceps
delivery in 84 (91 per cent) patients, as compared to 14 (44 per cent) patients that had
1 per cent Lidocaine local inIiltration. Foetal outcome, was excellent in all cases.
45
41
In 1982,Pentti Jouppila, RiittaJouppila, Arno Hollman and Antero Koivula measured
intervillous blood Ilow using a Xe
133
clearance technique during the Iirst stage oI
labour in 9 parturients with severe preeclampsia beIore and aIter lumbar epidural
analgesia. Analgesia was produced with 10 ml oI 0.25 bupivacaine. AIter the lumbar
epidural block the intervillous blood Ilow signiIicantly improved, suggesting that
epidural analgesia is the obstetric analgesic method oI choice in cases oI severe
preeclampsia.
46
In 1983 Kanto J, Erkkola R, Mansikka M and Arimaa L, Studied the eIIect and
saIety oI segmental epidural analgesia (SEA) in three groups oI parturients totalling
250. In 50 primigravidae, the analgesic eIIect was good in 90, moderate in 8, and
poor in only 2. The SEA did not lead to more malpositions than were present in the
nonepidural groups. Nevertheless, the rate oI instrumental deliveries was
approximately three times higher in the SEA groups than in nonepidural groups.
47
In 1993 Anthony C. Webster, J. D. McKishnie, J. T. Watson and W. Donald Reid
evaluated lumbar epidural anaesthesia (LEA) to assess its technical Ieasibility,
eIIectiveness and incidence oI complications in inIants. Using a standard loss oI
resistance technique and a 4.0 cm 20 G epidural needle. Epidural analgesia was
achieved in all 16 cases with bupivacaine 025 with and without 1:200,000
epinephrine, 0.75 ml/ kg Ior the Iirst two cases, and subsequently 1.0 ml/ kg. In 15
patients, good operating conditions were achieved with epidural analgesia alone.
Inhalational anaesthesia supplementation was necessary in three cases. In the Iirst two
patients, the level oI analgesia (T
8
) was insuIIicient to control the response to traction
on the hernial sac. In one inIant, analgesic to T
4
, whose surgery was inadvertently
42
delayed Ior Iour hours, inhalation anaesthesia was needed to control restlessness
rather than pain. Ten inIants were analgesic to T2, Iour to T4, two to T9 and two to
T9. No adverse hemodynamic eIIects were seen. And there were no postoperative
complications. They concluded that lumbar epidural anaesthesia was technically easy,
and provided good operating conditions Ior most neonates in this study.
48
In 1993 Peutrell JM and Hughes DG, in order to avoid complications oI high doses oI
local anaesthetics, injected the local anaesthetics at appropriate segmental level
through epidural catheter in awake ex-premature babies who were undergoing
inguinal herniotomies. The anaesthesia was excellent in six babies. Two babies cried
brieIly with peritoneal or spermatic cord traction. One other baby needed
supplementation with nitrous oxide in oxygen in order to complete the surgery. The
majority oI babies slept throughout surgery. There was no reported postoperative
complications.
49
Studies conducted by Dr.M.H.Rao, ProI. Dept. OI Anaesthesiology, Thirupathi and
Dr.Phani Thota, Head Dept. OI Anaesthesiology KMC Mangalore in 1995 on
segmental dose requirement oI epidural lignocaine and the eIIects on age, height,
body weight and body surIace area. In their study a negative correlation is seen
between the age and segmental dose requirement oI epidural lignocaine in adults.
Correlated moderately with height and body weight but correlated best with body
surIace area. Dose required to block each segment in males was about 22.3
mg/segment and in Iemales about 19.7 mg/segment.
50
43
In 1995 William M. Splinter, Juan Bass and Lydia Komocar conducted a study where
they compared the eIIect oI local anaesthesia with that oI caudal anaesthesia on
postoperative care oI children undergoing inguinal hernia repair. This was a
randomized, single-blind investigation oI 202 children aged 113 yr. Anaesthesia was
induced with N
2
O/O
2
and halothane or propoIol and maintained with
N
2
O/O
2
/halothane. Local anaesthesia included ilioinguinal and iliohypogastric nerve
block plus subcutaneous injection by the surgeon oI up to 0.3 ml/kg bupivacaine
0.25 with 5 g/kg adrenaline. The dose Ior caudal anaesthesia was 1 ml/kg up to
20 ml bupivacaine 0.2 with 5 g/kg adrenaline. Postoperative pain was assessed in
the anaesthesia recovery room. The postoperative pain scores and opioid usage were
similar; however, the local anaesthesia group required more acetaminophen in the day
care surgical unit. The local anaesthesia patients had a shorter recovery room stay.
The postoperative stay was prolonged in the caudal anaesthesia group. They conclude
that Local anaesthesia and caudal anaesthesia have similar eIIects on postoperative
care with only slight diIIerences.
51
In 1996 Cedric Prys-Roberts and Andrew M.S.Black stated that segmental epidural
block with local anaesthetic is Iar more satisIactory when placed at correct vertebral
level and in more than 90 patients undergoing lower abdominal surgeries where
block required is between T10-L2 the volume oI local anaesthetic required is 5ml.
Duration oI block with Bupivacaine 5ml (0.5) is limited to 3-4 hours, whereas
continuous inIusion, with 0.25(3-7ml/hr) aIter bolus dose oI 5ml maintains
satisIactory analgesia Ior a variable period oI time.
52
44
In 2000 Della Rocca G, Giampalmo M, Giorni C, Di Marco PA, Monaco S, Romboli
D, Gossetti F, Negro P, Carboni M and Pietropaoli P conducted a study comparing
diIIerent anaesthetising techniques Ior inguinal hernia repair, where 405 patients
undergoing inguinal hernioplasty were studied. Four diIIerent anaesthetic techniques
were used: (i) surgical Iield inIiltration (SFI) with 0.5 carbonated lidocaine
0.125 bupivacaine (193 pts.) in which monitored anaesthesia care was administered
with propoIol (3 to 4 mg/kg/h) when necessary; (ii) epidural anaesthesia with 2
lidocaine Ientanyl 100 mcg (137 pts.); (iii) general anesthesia with isoIlurane and
Ientanyl in N2O:O2 (48 pts.); and (iv) intrathecal anaesthesia with 1 hyperbaric
bupivacaine 1-2 ml (25 pts.). Intra- and postoperative complications, intraoperative
sedation, postoperative supplemental drugs Ior analgesia and postoperative length oI
hospital stay were recorded. Intraoperative hypotension/bradycardia were observed in
4 patients (2) in the SFI group and in 6 patients (4) in the epidural group. Sedation
was required in 29.5 oI patients in the SFI group and in 15.3 in the epidural group
(P 0.05). Postoperative supplemental analgesic drugs administered and length oI
hospital stay were similar in the 4 groups. No diIIerence in intra- and postoperative
complications was observed among the 4 groups. In conclusion, both SFI and epidural
anaesthesia are saIe and suitable Ior the inguinal hernioplasty procedure, without
intra- or postoperative complications.
53
In 2002 Gnal O, Arikan Y and Celikel conducted a study where they compared the
eIIect oI spinal and epidural anaesthesia on surgical outcome measures oI inguinal
herniorrhaphy. Ninety-eight male patients undergoing inguinal hernia repair were
randomized to either spinal or epidural anaesthesia. Anaesthesia onset time (AOT),
postoperative stand-up time (SUT), Iirst pain sensation time (FPT), operation time
4S
(OT), analgesic requirement (AR), hospital stay (HS), visual analogue scores oI pain
(VAS), per- and postoperative complications, and post anaesthesia complications
were recorded and compared with each other. No statistically signiIicant diIIerence
was Iound between the SA and EA groups with respect to the other outcome measures
that were considered. Concluded as spinal and epidural anaesthesia show some
diIIerences Irom each other with respect to outcome measures such as OT, SUT, FPT,
and 12- and 24-h VAS scores.
54
In 2005,Todorovic Dragana, Konstatinovic Slavko, Jankovic Radmilo studied the
eIIiciency and saIety oI administration oI minor anaesthetic concentrations in epidural
anaesthesia Ior operations oI inguinal hernia .HalI oI the patients were given 20 ml
2 lidocaine and halI patients were given 20 ml 1.5 lidocaine. In patients with 2
lidocaine motor blockade occurred aIter 14.37-1.04 mins and duration
110.45min.Only 20 oI the patients on whom 1.5 lidocaine was given had motor
blockade aIter 11.16-2.02 mins and duration 100.3 mins. Systolic pressure
signiIicantly decreased aIter 20ml oI 2 lidocaine administration compared to the
group to whom 1.5 was given. The Iirst group had to stay longer in the post
operative ward than the second group, and concluded stating that minor
concentrations oI anaesthetics can be eIIicient and saIe in epidural analgesia and they
achieve adequate amount oI analgesia Ior surgical interventions.
55
In 2007 Srivastava U, Kumar A, Saxena S, Neeraj and Sehgal conducted a
prospective randomized study in 92 adult male patients to compare the local
anaesthesia with conventional spinal and general anaesthesia Ior elective unilateral
inguinal hernia repair. The operative conditions were excellent in majority oI the
46
patients in local anaesthesia group similar to other two groups. The main disadvantage
oI local anaesthesia was dome pain or discomIort at the operative site during
dissection oI sac but this did not aIIect the satisIaction by the patients and its use
again. 87 percent oI surgeons and 90 percent oI patients were satisIied with the local
anaesthesia. The main advantages oI this method were excellent operative conditions,
quick recovery, long analgesia and minimal postoperative complications.
56
In 2007 A. A. J. Van zundert, G. Stultiens, J. J. Jakimowicz, D. Peek, W. G. J. M.
Van der ham, H. H. M. Korsten and J. A. W. Wildsmith studied laparoscopic
cholecystectomy under segmental thoracic spinal anaesthesia where twenty ASA I or
II patients undergoing elective laparoscopic cholecystectomy received a segmental
(T10 injection) spinal anaesthetic using 1 ml oI bupivacaine 5 mg/ml mixed with 0.5
ml oI suIentanyl 5 g/ml. Other drugs were only given to manage patient anxiety,
pain, nausea, hypotension, or pruritus during or aIter surgery. The block was eIIective
Ior surgery in all 20 patients, six experiencing some discomIort which was readily
treated with small doses oI Ientanyl, but none requiring conversion to general
anaesthesia. Two patients required midazolam Ior anxiety and two ephedrine Ior
hypotension. Recovery was uneventIul and without sequelae, only three patients (all
Ior surgical reasons) not being discharged home on the day oI operation. This
preliminary study has shown that segmental spinal anaesthesia can be used
successIully and eIIectively Ior laparoscopic surgeryin healthy patients.
57
In 2008 Yang B, Liang MJ and Zhang Y, conducted a randomized trial to investigate
the eIIicacy and saIety oI local anaesthesia and epidural anaesthesia in tension-Iree
repair oI inguinal hernia. 269 patients underwent inguinal hernia repair were
47
randomly divided into two groups, receiving local anaesthesia (143 cases) and
epidural anaesthesia (126 cases). The clinical data Irom the two groups were analyzed
retrospectively. The operation time, ambulation time, length oI hospital stay and cost
oI hospitalization in local anaesthesia group were signiIicantly less than those in
epidural anaesthesia group. No signiIicant diIIerences were Iound in intra-operative
use oI ancillary sedation drugs, postoperative recovery situation, pain scores and
operation-correlated complications between the two groups.
58
48
METHODOLOGY
A clinical study was undertaken Ior anaesthetising 100 patients aged between 18-70
years posted Ior elective inguinal hernia repair, agreeing and co-operative Ior epidural
anaesthesia. Study was conducted at MVJ Medical College and Research Hospital
Hosakote, Bengaluru during the period oI September 2008 to August 2010.
Selection of patients:
Inclusion criteria:
1. Patients undergoing inguinal hernia repair.
2. Age 18 70 years.
3. Normal adults belonging to ASA Grade I and ASA Grade II
Exclusion criteria:
1. Patients below 18 and above 70 years.
2. Patients with ASA Grade III and ASA Grade IV.
3. Patients allergic to local anaesthetics.
4. Presence oI ischemic heart diseases, hypertension, symptomatic asthma,
inability to climb a Ilight oI stairs, uncontrolled diabetes, epilepsy, renal
problems, bleeding disorders, patients on chronic drug medications such as
MAO inhibitors, acute substance abuse, previous problem with anaesthesia,
obesity, neurological deIicit, inIection at injection site and patients unwilling
to comply with instructions.
49
Pre-anaesthetic evaluation:
Pre-anaesthetic evaluation was done a day prior to the elective surgery. History oI
present complaints, duration oI swelling and any co-existing disease, previous surgery
were noted. A thorough physical, systemic examination was done which included the
size oI the swelling, type oI hernia, weight oI the patient, vital signs and airway
assessment.
The Iollowing investigations were carried out in all patients:
BLOOD: Haemoglobin percentage, bleeding time, clotting time and random blood
sugar.
URINE: Urine Ior routine examination, urine albumin and urine sugar were done.
ECG & chest x-ray Ior patient above 45 years.
All patients were assessed and they were graded according to the ASA physical status
I and II. They were educated regarding the anaesthetic technique. Consent Ior the
same was obtained. Local anaesthetic test dose was carried out on the previous day oI
surgery. Patients were premedicated with oral Alprazolam 0.5 mg and Oral Ranitidine
150 mg on the night prior to surgery and 2 hours beIore the surgery.
Regional anaesthetic equipment:
There are several important requisites Ior optimal results in regional anaesthesia. In
order to have consistently good results, the anaesthesiologists must have a genuine
interest in and be convinced oI the advantages oI regional anaesthesia. AIter attaining
the necessary skill and clinical application, thorough knowledge oI the pertinent
anatomy and landmarks, Iamiliarising with the pharmacology oI the local anaesthetic
S0
agents as well as the physiological changes that accompany these anaesthetics. He can
thus anticipate any changes and be prepared to institute immediate treatment iI
necessary (i.e. intravenous Iluids, vagolytics and possible vasopressors). Equally
important is the careIul preparation and management oI the individual patient and the
availability oI appropriate anaesthesia equipment, as well as equipment Ior
resuscitation and the treatment oI adverse reactions.
The department oI anaesthesiology in which regional anaesthesia is to be perIormed
in a sophisticated Iashion must have a signiIicant inventory oI regional anaesthetic
technique must be kept ready.
Needles:
A wide selection oI high quality disposable epidural (Tuohy) needles 16 and 18G.
Syringe:
Disposable and glass barrel syringes with close Iitting plungers and various sizes
ranging Irom 2ml, 5ml, 10ml, 20ml are kept ready.
Drugs:
Inj.Bupivacaine 0.5 isotonic.
Resuscitation:
To perIorm epidural analgesia, equipments and drugs Ior resuscitation and treatment
oI complications should be kept ready.
S1
This should include a means oI administering oxygen by positive pressure, such as an
anaesthesia machine or an resuscitation bag and mask connected to a source oI
oxygen, airway equipment, working laryngoscope, oro-pharyngeal airways oI several
sizes, cuIIed endotracheal tubes oI appropriate sizes, a suction apparatus and labelled
syringes that contain atropine and a dilute solution oI vasopressors.
Monitors:
In the operation theatre an IV line was secured with no. 18 or 20 G IV cannula.
The monitors pulse oxymeter, ECG, NIBP were connected.
Segmental epidural block denotes the use oI local anaesthetic solution enough to
cover only the segments involved in the Iield oI surgery by injecting a low volume
and selecting site oI puncture oI epidural space, so it becomes the midpoint oI
segments involved.
Procedure:
Each patients selected Ior the study was positioned laterally (on aIIected side) on the
operation theatre table. With all aseptic precautions the epidural space was identiIied
at L1-L2 space , with 18G epidural needle 5ml oI 0.5 Bupivacaine is injected very
slowly only to block the segments(T12-L2) involved in the Iield oI surgery. Later
epidural catheter was inserted and secured and patient positioned back to supine
position.
Level oI analgesia was checked by needle prick. AIter conIorming the adequacy and
level oI analgesia, the surgery was commenced. II the patient complained oI pain
S2
during needle prick, then injected local anaesthetic (0.5 Bupivacaine) with an
incremental dosage oI 1ml at a time, till the complete onset oI analgesia.
Pulse Rate and Blood Pressure were recorded at an interval oI 1 minute Ior Iirst 5
minutes and then every 5 minutes till the end oI the surgery. Oxygen saturation and
ECG monitoring was done continuously.
Onset oI analgesia, level oI analgesia (pre & post operatively), duration oI analgesia,
total dosage oI local anaesthetic used were recorded.
Complications like bradycardia, hypotension, respiratory depression, shivering,
nausea and vomiting, sweating and inadvertent dural puncture were recorded.
Criteria Ior hypotension was taken as a Iall in systolic Blood pressure more than 20
oI patients basal reading and treated with vasopressors like Inj.Ephedrine 3-5 mg IV.
Bradycardia as heart rate less than 60 and treated with Inj.Atropine 0.6 mg IV.
II any inadvertent dural puncture occured, those cases were excluded Irom the study
and was given homologous epidural blood patch to prevent post dural puncture
headache.
AIter conIirming the onset oI analgesia patient was sedated with Inj.midazolam 1 mg
IV.
S3
In the present study the Iollowing scale was adopted to grade quality oI analgesia and
relaxation.
1. Excellent: Patient comIortable, analgesia and surgical relaxation adequate, no
supplementation required during surgery.
2. Good: Analgesia and relaxation adequate, minimal discomIort present during
surgical procedure. Additional top-ups oI local anaesthetic at an incremental
dose oI 1 ml are given.
3. Fair: Analgesia and relaxation adequate, discomIort present even aIter
additional top-up oI epidural local anaesthetic, this was alleviated by analgesic
dose oI Ing.Fentanyl 1 Mcg/kg IV.
4. Poor: Patients complaining oI severe intolerable pain during surgery without
relaxation. These cases were supplemented with general anaesthesia.
Statistical analysis:
Descriptive data included mean, standard deviation and percentage which were
determined Ior the study group.
S4
Fig-10 Epidural Tray
Fig-11 Postion of The Patient
SS
Fig-12 Loss of Resistance
Fig-13 Epidural Catheter Insitu
S6
a
b
Fig-14 a, b Dermatomes
S7
RESULTS
Segmental epidural anaesthesia was given to one hundred patients undergoing
inguinal hernia repair at MVJ Medical College and Research Hospital, during the
period oI September 2008 to August 2010 and these cases were taken up Ior study as
outlined in the methodology.
AGE DISTRIBUTION:
TABLE - 4
Age Group No. Of Cases
18-30 21
31-40 30
41-50 22
51-60 17
61-70 10
Total 100
S8
GRAPH - 1
Age oI these patients ranged Irom 18 to 70 years and this incidence is shown in Table
IV.
Mean Age 42.65 years
STD Deviation 12.85
Majority oI the patients were in 31-40 Age group.
0
S
10
1S
20
2S
30
18-30 31-40
21
30
S8
GRAPH - 1
IV.
STD Deviation 12.85
31-40 41-50 51-60 61-70
30
22
17
10
S8
GRAPH - 1
IV.
STD Deviation 12.85
61-70
10
S9
SEX INCIDENCE:
TABLE - 5
Sex No. of Cases
Male 97
Female 3
Total 100
GRAPH - 2
Regarding the sex incidence it is the male who predominates as compared to Iemales,
which is shown in the Table- V
97
3
SEX INCIDENCE
MALE
FEMALE
60
WEIGHT DISTRIBUTION:
TABLE - 6
Weight in Kgs No. Of Cases
31-40 3
41-50 27
51-60 32
61-70 32
71-80 6
GRAPH - 3
TABLE VI shows the weight distribution oI patients.
Maximum weight was 85 Kgs
Minimum weight was 37 Kgs
Mean weight 57.65 Kgs with a standard deviation oI 9.1
3
27
32 32
6
0
S
10
1S
20
2S
30
3S
31-40 41-50 51-60 61-70 71-80
WEIGHT INCIDENCE
61
HEIGHT DISTRIBUTION:
TABLE - 7
Height in cms No. of Cases
141-150 5
151-160 30
161-170 36
171-180 29
GRAPH - 4
TABLE VII shows the Height distribution oI patients.
Maximum Height 180 cms
Minimum Height 148 cms
Mean Height 165.16 cms with a standard deviation oI 8.24.
0
S
10
1S
20
2S
30
3S
40
141-150 151-160 161-170 171-180
Height
Height
62
TYPE OF HERNIA:
TABLE - 8
Type of Hernia No. Of Cases
Indirect 73
Direct 27
Total 100
GRAPH - 5
Incidence in type oI hernia is shown in the Table- VIII
Direct hernia 27 cases
Indirect hernia 73 cases
73
27
TYPE OF HERNIA
INDIRECT
DIRECT
63
VOLUME OF BUPIVACAINE USED:
TABLE - 9
Volume oI drug No. OI Cases
5ml 53
6ml 22
7ml 16
8ml 9
GRAPH - 6
Volume oI Bupivacaine required, ranged Irom 5 ml to 8 ml. with a mean volume oI
5.8 ml.
53
22
16
9
VOLUME OF DRUG
5 ml
6 ml
7 ml
8 ml
64
QUALITY OF ANALGESIA:
TABLE - 10
No. Of Cases
Excellent 53
Good 34
Fair 10
Poor 3
Cases excluded Irom study 2
Total 102
GRAPH - 7
53
34
0
10
20
30
40
50
60
EXCELLENT GOOD
64
TABLE - 10
No. Of Cases
Excellent 53
Good 34
Fair 10
Poor 3
Total 102
GRAPH - 7
34
10
3
2
GOOD FAIR POOR CASES
EXCLUDED
64
TABLE - 10
No. Of Cases
Excellent 53
Good 34
Fair 10
Poor 3
Total 102
GRAPH - 7
CASES
EXCLUDED
6S
Table X shows the quality oI analgesia and relaxation in patients.
53 patients had an excellent type oI analgesia and relaxation. Patients were
comIortable no supplementation required during surgery.
In 34 patients analgesia and relaxation was adequate, minimal discomIort was present
during surgical procedure. Additional top-ups oI local anaesthetic at an incremental
dose oI 1 ml were given.
In 10 patients, discomIort was present even aIter additional top-up oI epidural local
anaesthetic, this was alleviated by analgesic dose oI Ing.Fentanyl 1 Mcg/kg IV.
3 patients had no analgesia at all, Patients were complaining oI severe intolerable
pain during surgery without relaxation. These cases were converted to general
anaesthesia.
2 cases were withdrawn Irom the study as there was an inadvertent dural puncture.
66
DURATION OF ANALGESIA:
TABLE - 11
Time range in minute Number of patients
120-130 12
131-140 11
141-150 11
151-160 13
161-170 12
171-180 15
181-190 4
191-200 9
201-210 7
211-220 0
221-230 1
231-240 2
67
GRAPH - 8
TABLE XI shows the Duration oI analgesia in minutes. The patients who received general
anaesthesia, had no analgesia.
Mean duration 167.42 min
Minimum duration 120 min
Maximum duration 240 min
In 3 patients who had poor quality oI analgesia and converted to general anaesthesia,
duration oI analgesia could not be recorded.
12
11 11
13
12
1S
4
9
7
0
1
2
0
2
4
6
8
10
12
14
16
uu8A1lCn
68
LEVEL OF ANALGESIA PRE-OPERATIVELY:
TABLE - 12
LEVEL NO. OF CASES
T8 2
T9 16
T10 54
T11 22
T12 3
GRAPH - 9
TABLE XII shows the sensory level oI analgesia pre operatively.
In majority oI the patients (54) level oI analgesia was up to T10
In 22 patients T11
In 16 patients T9
In 3 patients T12
In 2 patients T8
In 3 patients who had poor quality oI analgesia and converted to general anaesthesia,
level oI analgesia could not be appreciated.
2
16
54
22
3
0
10
20
30
40
50
60
T8 T9 T10 T11 T12
69
LEVEL OF ANALGESIA POST OPERATIVELY
TABLE - 13
LEVEL NO. OF CASES
T7 2
T8 33
T9 43
T10 17
T11 1
T12 1
GRAPH - 10
TABLE XIII Shows the sensory level post operatively
In majority oI the patients (43) level oI analgesia was up to T9
In 33 patients T8
In 17 patients T10
In 2 patients T7
In 2 patients T11 & T12
2
33
43
17
1 1
0
S
10
1S
20
2S
30
3S
40
4S
S0
17 18 19 110 111 112
70
SIDE EFFECTS:
TABLE - 14
SIDE EFFECTS NO. OF CASES
Inadvertent dural puncture 2
Shivering 5
Sweating 9
Hypotension NIL
GRAPH - 11
TABLE XIV Shows the incidence oI side eIIects.
Sweating is seen in 9 patients.
Shivering in 5 patients.
Inadvertent dural puncture in 2 patients.
No cases oI Hypotension.
9
70
SIDE EFFECTS:
TABLE - 14
Shivering 5
Sweating 9
Hypotension NIL
GRAPH - 11
2
5
0
SIDE EFFECTS
IDP
SH
SW
HYPOTENSION
70
SIDE EFFECTS:
TABLE - 14
Shivering 5
Sweating 9
Hypotension NIL
GRAPH - 11
IDP
SH
SW
HYPOTENSION
71
ANALGESIA AND RELAXATION SUCCESS RATE
TABLE 15
QUALITY OF ANALGESIA NO. OF CASES
EXCELLENT
53
34
10
97
GOOD
FAIR
POOR 3
GRAPH - 12
SUCCESS RATE 97
97
3
NO.OFCASES
SUCCESS
FAILURE
72
MEAN HEART RATE CHANGES
TABLE- 16
MINUTES MEAN HEART RATE
PREOP 83.8
0 87.22
1 86.58
2 86.44
3 86.72
4 85.9
5 85.06
10 85.24
15 85
20 84.32
25 83.8
30 84.44
35 84.14
40 84.03
45 83.48
50 83.76
55 83.36
60 83.08
END 83.42
73
GRAPH- 13
81
82
83
84
85
86
87
88
P8
74
MEAN BLOOD PRESSURE CHANGES
TABLE- 17
MINUTES MEAN SYST.BP. MEAN DIAST.BP.
PREOP 130.26 80.44
0 132.84 82.6
1 132.3 82.18
2 130.56 81.56
3 130.56 80.9
4 129.62 81.12
5 126.55 80.66
10 127.76 79.98
15 127.87 79.88
20 127.7 79.46
25 127.82 79.5
30 128.26 79.66
35 128.92 79.48
40 128.42 78.82
45 128.3 79.66
50 128.58 79.9
55 128.36 79.48
60 129.08 80.06
END 130.48 81
7S
GRAPH -14
0
20
40
60
80
100
120
140
P
R
E
O
P 0 1 2 3 4 5
1
0
1
5
2
0
2
5
3
0
3
5
4
0
4
5
5
0
5
5
6
0
E
N
D
SYSTOLIC
DIASTOLIC
TABLE - XVIII
SUMMARY OF RESULTS ( AGE GROUPS)
AGE
GROUP
(YEARS)
NO.CASES MEAN
AGE
(YEARS)
MEAN
WEIGHT
(Kg)
MEAN
HEIGHT
(cm)
MEAN
DRUGVOL
(ml)
MEAN
ONSET
(Min)
MEAN
DURATION
(Min)
MEAN
BP
FALL
MEAN
BP
FALL
18-30 21 26.19
(STD DEV 3.31)
55.66
(STD DEV 8.77)
164.90
(STD DEV 8.08)
6.81
(STD DEV 1.07)
8.11
(STD DEV 1.24 )
171.42
(STD DEV 30.21)
8.76 6.69
31-40 30 36-63
(STD DEV2.95 )
56.23
(STD DEV9.05 )
166.57
(STD DEV 7.24)
5.60
(STD DEV 0.85)
8.03
(STD DEV 1.19)
162.03
(STD DEV 26.24)
8.74 6.64
41-50 22 46.09
(STD DEV 2.88)
60.50
(STD DEV 9.63)
167.09
(STD DEV 7.43)
5.59
(STD DEV 0.73)
7.88
(STD DEV 0.90)
166.67
(STD DEV 24.56)
9.90 7.36
51-60 17 55.47
(STD DEV 3.28)
59.47
(STD DEV 8.90)
162.56
(STD DEV 10.55)
5.53
(STD DEV 0.79)
8.36
(STD DEV 1.17)
174.11
(STD DEV 34.65)
14 10.20
61-70 10 65.9
(STD DEV 2.51)
56.17
(STD DEV 9.10)
161.3
(STD DEV 8.40)
5.3
(STD DEV 0.94)
8.17
(STD DEV 1.09)
163.89
(STD DEV 28.26)
15.56 13.38
77
DISCUSSION
Inguinal hernia repair is one oI the most commonly encountered surgical corrections
in men representing 12.5 oI total surgical repair in Britain. In providing anaesthesia
Ior inguinal herniorraphy, the technique chosen must be cost eIIective with respect to
speed oI recovery, patient comIort, and associated incremental costs.
Inguinal hernia repair is one oI the common treatments perIormed. Which can be
perIormed under spinal, epidural, general and inguinal Iield block.
Epidural anaesthesia is suitable as a sole agent Ior lower abdominal surgery and on
lower limbs. It has some deIinite advantages over spinal anaesthesia like avoidance oI
post spinal headache, minimal chances oI meningitis, and minimal chances oI nausea
and vomiting in post operative period.
Segmental epidural block, though introduced by Fidel Pages (1921) and Dogliotti
(1931), clinically its use has been advocated by Massey Dawkins (1971) Ior thoracic
epidural Ior upper abdominal surgery and Doughty (1969) and Steel (1972) in labour
analgesia Ior uterine and perineal pain and have recommended that this technique to
be a very saIe and satisIactory procedure to all concerned.
These works have given a useIul suggestion Ior extending the technique as
'Segmental Epidural Block Ior Inguinal hernia repair as the nerve supply to this area
is very suitable Ior carrying out this procedure and also has some attractive
advantages over the conventional epidural block using larger doses.
78
The study oI Segmental Epidural Analgesia Ior inguinal hernia repair was carried out
with an intension oI administering limited quantity oI drug required to make the
procedure precise and saIe.
Segmental or conventional block can be perIormed at any region like cervical,
thoracic, lumber or caudal. However the volume used in the segmental block is very
small so that the block covers only the particular segments concern. Whereas in
conventional block, the volume used is large enough to spread widely giving rise to
complications like arterial hypotension, bradycardia etc.
Advantages claimed with segmental epidural analgesia are:
1. Small quantity oI local anaesthetic drug enabling to use an eIIective dose or
higher concentration without the Iear oI complications like extensive muscular
paralysis and toxic eIIects.
2. Complications like hypotension and bradycardia are reduced.
3. Even in accidental subarachnoid block the cardio-respiratory involvement is
minimal, as these small doses used will act as subarachnoid block.
4. Economical.
In our study the Iollowing parameters were studied.
1. Volume oI local anaesthetic used.
2. Level oI sensory blockade achieved pre-operatively (using standard
dermatome map).
3. Level oI sensory blockade achieved post operatively.
4. EIIectiveness oI block or quality oI analgesia.
79
5. Onset and Duration oI analgesia.
6. Complications encountered.
In our study site oI puncture Ior epidural space is Iixed (L1-L2) so as to block only
the segments involved in the Iield oI surgery and keep the dose to minimum.
Along with the site oI injection, posture oI the patient was also important so as to get
a denser block on the operative side.
13
Hence with the patient on the side oI surgery
the slow injection oI small volume oI drug permits gravity to deposit all the solution
on the dependent side to block the nerves which supplies the region involved in the
surgical procedure thereby minimising the complications associated with large
volume.
59
Volume of the drug used:
Sicard stated that spread oI analgesia depends upon the volume oI the drug injected.
12
Cedric Prys-Roberts and Andrew M.S.Black stated that segmental epidural block with
local anaesthetic is Iar more satisIactory when placed at correct vertebral level and in
more than 90 patients undergoing lower abdominal surgeries where block required
is between T10-L2 the volume oI local anaesthetic required is 5ml.
52
Studies conducted by Dr.M.H.Rao, and Dr.Phani Thota, on Segmental dose
requirement oI epidural lignocaine stated that dose required to block each segment in
males was about 22.3mg/segment and in Iemales about 19.7 mg/segment.
50
Based on these studies volume oI the drug injected by us was 5 ml, so as to limit the
spread to only the segments involved in the Iield oI surgery.
80
In this study, a majority oI patients (53 patients) who received 5ml the analgesic
eIIect was Iound to be satisIactory. 22 patients received 6 ml, 16 patients 7 ml and 9
patients received 8ml. It is observed that the majority oI patients who required the
additional topups upto 7 and 8 ml were younger age group. This can be explained by,
in younger age group the spread is minimal due to spillage oI drug through the patent
intervertebral Ioraminae. But escape oI Iluid is reduced to minimum in the elderly
patients due to the stenosed intervertebral Ioraminae which can be observed by the
largest spread oI volume as seen in two patient aged 70 and 65 years, where the
spread was upto T8 with 5ml oI drug.
The mean volume oI drug is 5.8 ml. The TABLE XVIII shows that, with the increase
in age the volume required decreases.
Level of sensory blockade achieved pre-operatively and post operatively:
While using the minimal quantity oI local anaesthetic drug oI 5 ml, the extent oI
spread oI analgesia was tested 5-10 minutes aIter the block was given and at the end
oI surgery. The extent oI analgesia was elicited with the help oI pin prick.
Bromage in 1954 demonstrated that there are two mechanisms in the spread oI
analgesia, one by the longitudinal spread and the other by neuraxial spread. DiIIusion
gradient appears to be important in relation to solutions oI small volume but oI high
concentration. With these small volumes oI concentrated solution longitudinal spread
in the epidural space is presumeably conIined to a Iewer segments but neuraxial
spread is extensive owing to the concentration gradient blocking more segments
which was seen at the end oI surgery. The same has been corroborated in this study
81
aIter the block and beIore starting oI the surgery the longitudinal ascent oI analgesia
with the small volume was minimal, aIIecting only Iew segments. Whereas at the end
oI surgery the spread was deIinitely wider than what it was in the beginning which
was probably due to the neuraxial spread owing to the diIIusion gradient with higher
concentration solution oI 0.5 Bupivacaine.
Bromage in 1962
15
has also drawn attention to the exaggerated spread oI epidural
analgesia in atherosclerotic patients. 56 patients who were severely atherosclerotic
reacted to 2 ligocaine as iI they had received the drug oI higher concentration than
that. It is probable that the degenerative changes in the connective tissue associated
with atherosclerotic disease produces increased permeability oI neural coverings.
Furthermore sclerosis oI vasa nervosium hastens the neural degeneration oI myelin
sheaths which occur with increasing age, thus bringing the solution more readily into
contact with the axons oI the posterior nerve roots.
In our study, even with 5 ml oI local anaesthetic when injected at L1-L2 in elderly
patients (60 years and above) it has been Iound that the spread has been usually high
(T8).
Effectiveness of block or quality of analgesia:
In the present study we graded 53 patients as excellent analgesia and relaxation, i.e.
patient comIortable, analgesia and surgical relaxation adequate no supplementation is
required during surgery.
82
34 patients had good analgesia and mild discomIort during surgical procedure, which
required Additional top-ups oI local anaesthetic at an incremental dose oI 1 ml.
10 patients had analgesia graded as Iair where mild discomIort was present even aIter
additional top-up oI epidural local anaesthetic; These patients were given an analgesic
dose oI Inj.Fentanyl 1 g/kg IV to alleviate the pain.
3 patients had severe intolerable pain during surgery, requiring conversion to general
anaesthesia.
It has been observed by various authors that at the time oI traction on the sac, patients
oIten complain oI discomIort.
60
This Iinding was observed in 9 patients in our present
clinical study.
Onset and Duration of analgesia:
Many studies did not mention about duration oI analgesia.
A study conducted by Hollman A et al. In 418 parturients, the onset oI analgesia was
rapid that is 3-5 mins and the duration was on average 150 mins.
41
In a study by Prys Roberts and Andrew Black, stated that in 90 oI the patients
undergoing lower abdominal surgeries where block required is between T10-L2 the
volume oI local anaesthetic required is 5 ml and the duration oI block with
Bupivacaine 0.5 is limited to 3-4 hours.
52
83
In the present study mean onset oI analgesia was 8.09 minutes and mean duration oI
analgesia was 167.42 minutes (120 min 240min).
In the present study onset oI analgesia was relatively late and duration oI analgesia
correlates with studies done by Hollman A et al.
Complications encountered:
Hypotension: Criteria Ior hypotension was taken as a Iall in systolic blood pressure
more than 20 oI patient`s basal reading.
Odom (1936), Guiterrez (1939), Doglitotti (1939) and Dawkins (1954) claimed that
the hypotension in epidural block is less than that Irom spinal analgesia. But the
works oI Bromage (1954) and Bonica et al (1957) Iound that the extent oI Iall in
blood pressure is similar in both the techniques, speed oI onset is slow in epidural
analgesia.
Factors contributing to the hypotension in epidural block have been enumerated as the
advanced age oI the patient, high volume oI the drug and height oI the block.
In our study as the volume oI the drug used is minimal and height oI the block is
limited, thereby the incidence oI hypotension is nil.
Only 4 patients had a 15-17 Iall in blood pressure, in 20 patients 10-15, in 50
patients 5-10 and in 24 patients 1-5 Iall in blood pressure. TABLE XVI Shows
that percentage oI Iall in blood pressure increases with the increase in age.
84
Inadvertent Dural Puncture: The incidence oI dural puncture was claimed to be low
with thoracic epidurals than with lumbar epidurals. Dawkins and Steel (1971) claimed
to be as 1.6 in 282 cases oI thoracic epidurals as against 2.6 in 397 cases oI
lumbar epidurals. This is because oI the obliquity oI the anatomy oI spinous
processes.
In this present study there were 2 cases oI dural puncture. These cases were
withdrawn Irom the study as the epidural puncture site was Iixed at L1-L2.
In 9 cases symptoms oI sweating are seen, majority oI these cases were under Iair or
poor quality oI analgesia groups. So poor quality oI analgesia may be the reason Ior
sweating. The symptoms were decreased aIter the analgesic dose oI Inj.Fentanyl IV.
5 patients complained oI shivering, was relieved by sedation.
Other complications like massive subarachnoid block, massive extradural block, toxic
reaction to local analgesic drug, bradycardia, respiratory depression, nausea and
vomiting, retention oI urine and any neurological complications were not encountered
in the present study.
8S
CONCLUSION
It can be concluded that
Segmental epidural block with 5-6 ml oI 0.5 Bupivacaine is Iound to be saIe
and IulIils the surgical requirement.
Could be successIully employed Ior inguinal hernia repair with limited spread
oI analgesia involving only Iew segments.
Fall in blood pressure and other complications were very minimal.
This technique can be saIely used in elderly patients.
In respiratory and cardiac cripple, this segmental epidural analgesia is saIest
mode oI regional anaesthesia.
In Iit patients ideal as a day care anaesthesia.
86
SUMMARY
A clinical study 'SEGMENTAL EPIDURAL BLOCK FOR INGUINAL HERNIA
REPAIR was undertaken at the Department oI Anaesthesiology, M.V.J. Medical
College and Research Hospital, Bangalore during the period oI September 2008 to
August 2010.
This study includes a brieI outline oI the historical events in the development oI
Epidural analgesia, the physiological and pharmacological aspects including the site
oI action oI the drug and the Iactors aIIecting the spread oI the epidural block.
The segmental epidural block denotes the use oI a small volume enough to block only
the segments involved in the Iield oI surgery. This was achieved by selecting the site
oI puncture, position and speed oI injection oI the local anaesthetic drug.
The study population consisted oI 100 patients undergoing Inguinal hernia repair oI
ASA class I and II. All the patients were explained about the procedure and
anaesthetic technique and consent Ior the same obtained. Local anaesthetic test dose
was carried out on previous day. Patients were premedicated with oral Alprazolam 0.5
mg and Oral Ranitidine 150 mg on the night prior to surgery and 2 hours beIore the
surgery.
Each patients selected Ior the study was positioned laterally (on herniated side) on the
operation theatre table. With all aseptic precautions the epidural space was identiIied
at L1-L2 space , with 18G epidural needle 5ml oI 0.5 Bupivacaine is injected very
87
slowly only to block the segments(T12-L2) involved in the Iield oI surgery. Later
epidural catheter was inserted and secured and patient positioned back to supine
position.
Level oI analgesia was checked by needle prick. AIter conIorming the adequacy and
level oI analgesia, the surgery was commenced. II the patient complains oI pain
during needle prick, then injected local anaesthetic (0.5 Bupivacaine) with an
incremental dosage oI 1ml at a time, till the complete onset oI analgesia.
Irrespective oI discomIort during hernia repair, Inj. Medazolam 1mg was given as a
sedative. Pulse Rate and Blood Pressure were recorded at an interval oI 1 minute Ior
Iirst 5 minutes and then every 5 minutes till the end oI the surgery. Oxygen saturation
and ECG monitoring was done continuously.
Onset oI analgesia, Level oI analgesia (pre & post operatively), Duration oI analgesia,
Total dosage oI local anaesthetic used were recorded.
II the patient complained oI discomIort even aIter additional top-up oI epidural local
anaesthetic, an analgesic dose oI Ing. Fentanyl 1 Mcg/kg IV was given.
The Iollowing observations were made Irom the present study:
Total study population 100 patients
Mean Age 42.65 years (18-70 years)
Sex M/F 97/3
Mean weight 57.65 Kgs (37-85 Kgs)
88
Mean height 165.16 cms (148-180 cms)
ASA Physical status I and II
Type oI Hernia Direct / Indirect 27 / 73
Volume oI Drug 5.8 ml (6-8 ml)
Duration oI Analgesia 167.42 minutes
Quality of Analgesia
1) Excellent 53
2) Good 34
3) Fair 10
4) Poor 3
53 oI patients had excellent quality oI analgesia and relaxation. 34 patients had
good quality analgesia and relaxation, mild discomIort while handling sac. 10 oI
patients had Iair quality oI analgesia and relaxation only. In 3 patients the epidural
block Iailed, in whom general anaesthesia was given. Overall success rate was 97.
Complications
Intraoperative and post operative complications were very minimal. No cases oI
hypotension, bradycardia, nausea vomiting, total spinal block and respiratory
depression were seen.
2 cases oI inadvertent dural puncture, which were excluded Irom the study.
89
9 patients complained oI sweating and 5 patients complained oI shivering, which may
be due to inadequate analgesia or anxiety and successIully treated with Inj.Fentanyl 1
mcg/Kg IV.
From the present study it can be inIerred that 0.5 Bupivacaine 5-6 ml is eIIective Ior
segmental epidural block Ior inguinal hernia repair. Segmental epidural block is saIe
anaesthesia with minimal physiological alterations.
90
BIBLIOGRAPHY
1) Kingsnorth, Bennett DH. Hernias, Umbillilus, Abdominal Wall. In: Short
practice oI surgery Bailey and Love. 23rd ed. 2000.p.1143.
2) Dexter F, Macario A, Penning DH, Chung P. Development oI an appropriate list
oI surgical procedures oI a speciIied maximum anaesthetic complexity to be
perIormed at a new ambulatory surgery Iacility. Anesth Analg 2002;95:78-82.
3) Song D, Greilich NB, White PF, Watcha MF, Tongier WK. Recovery proIiles
and costs oI anaesthesia Ior outpatient unilateral inguinal herniorrhaphy. Anesth
Analg 2000;91:876-81.
4) Cheng P.A. The anatomical and clinical aspects oI epidural analgesia, part I and
II. Anesth Analg 1963;42:398-407.
5) Cousins MJ, Bromage PR. Epidural neural blockade, neural blockade in clinical
anesthesia and management oI pain. Cousins MJ,Bridenbaugh PO (eds): Neural
Blockade. Philadelphia: JB Lippincott; 1988. p.253260.
6) P.Prithviraj. Textbook oI regional anaesthesia. Vol (1). Elsevier (USA):
Churchill Livingstone;2003.p.568.
7) Reynolds FJM. Spinal and Epidural block. In: Wylie and Churchill D.
A Practice oI Anaesthesia 5th ed. New Delhi: PG Publishers; 1984.p.856-888.
8) Christoper MB. Epidural and Spinal Anaesthesia. In: Paul BG, Bruce CF,
Robert SK. Clinical Anaesthesia 4th ed. Pheladelphia: Lippincott Williams and
Wilkins;1992.p.689-714.
91
9) Blomberg R. The dorsomedian connective tissue band in the lumbar epidural
space oI humans an anatomic study using epiduroscopy in autopsy cases.
Anesth Analg1986;65:747.
10) Brown LD. Spinal, Epidural, Caudal Anesthesia. In: Miller RD. Miller`s
Anesthesia. 6
th
ed. Philadelphia : Churchill Livingstone; 2005.p.1653-84.
11) Collins VJ. Epidural Anaesthesia. In: Principles oI Anesthesiology. 3rd ed.
Philadelphia: Lee and Febiger; 1993.p.1571-1610.
12) Sicard M. 'Les injections medicamenteuses extradurales par voie sacro-
coccygienne C R Soc Dev Biol 1901;53:396-398.
13) Burn, J.M.Guyer, B.P.Langdon L. Spread oI solution injected in the epidural
space. Br J Anaesth 1973;45:338.
14) Usubiaga JE, Wikinski JA, Usubiaga LE. Epidural pressure and its relation to
spread oI anaesthetic solution in epidural space. Anesth Analg Curr Reser
1967;46:440.
15) Bromage P.R. Exaggerated spread oI epidural analgesia in atherosclerotic
patients. Dose in relation to biological and chronological ageing. BMJ
1962;2:1634.
16) Kingsnorth, Bennett DH. Hernias, Umbillilus, Abdominal Wall. In: Short
practice oI surgery Bailey and Love. 23rd ed. 2000.p.1143.
17) Atkinson RS, Rushman GB, Lee JA. Regional techniques. Lees synopsis oI
anaesthesia. 11th ed. 1993.p.666.
18) Singh I. The abdomin and pelvis. In: Text book oI anatomy with colour atlas.
Vol. 2. 2nd ed. 1999.p. 597-602.
19) Snell RS. The abdomen. Part I. The abdominal wall. In: Clinical anatomy. 4
th
ed. 2004. p.172-174.
92
20) Healy CJ, Borley NR. Posterior abdominal wall and retroperitoneum, Section 7,
Abdomen and pelvis. In: The anatomical basis oI clinical practise, Grays
Anatomy. 39th ed. 2005.p.1124-1126.
21) Prys Roberts C, Brown BR. Local Anaesthetic Pharmacology. In: International
Practice oI Anaesthesia, 1st ed. Vol. 2 OxIord: Butterworth, Heinemann; 1996.
22) Hardman JG, Limbird LE, Goodman Gillman A. Local Anaesthetics in: The
Pharmacological Basis oI Therapeutics. 10th ed. United States oI America:
McGraw Hill: 2001.
23) Dollery C. Bupivacaine Hydrochloride in: Therapeutic Drugs. 2
nd
ed.
Edinburgh: Churchill Livingstone; 1999.
24) Miller Ronald D. Local Anaesthetics in: Anesthesia. 6th ed. Vol. 1 Philadelphia:
Churchill Livingstone; 2005.
25) Stoelting RK. Local Anaesthetics in: Pharmacology & Physiology. In:
Anaesthetic Practice. 3rd ed. Philadelphia (New York): Lippincott Raven;1999.
26) Bromage PR. Epidural analgesia. Philadelphia: WB Saunders; 1979.p.118.
27) Miller Ronald D. Anesthesia. 6th ed. Vol. 1 Philadelphia: Churchill Livingstone;
2005.p. 27.
28) Lund, PC Charles, C Thomas. Peridural analgesia and anaesthesia; 1966.p.4.
29) P.Andrade. A new interpretation oI the origin oI extradural space negative
pressure. Br J Anaesth 1983;55: 857.
30) Bromage P. The 'Hanging Drop sigh. Anaesthesia 1953;8:237-241.
31) Odom.C. Epidural anesthesia .Am J Surg 1936;34:547-558.
32) Lemmon.W. A method oI continuous spinal anaesthesia: A preliminary report.
Ann surg 1940;111:141-144.
93
33) Touhy E. Continuous spinal anaesthesia: its useIulness and technique involved.
Anesthesiology 1944; 5:142-148.
34) Cubelo MM. Continuous peridural segmental anesthesia by means oI a ureteral
catheter. Anesth Analg 1949; 28:13-23.
35) Bromage P. Epidural analgesia. Philadelphia: WB Saunders; 1979.
36) Bonica J. Regional anaesthesia recent advances and current status. Philadelphia:
Davis; 1969.
37) Ekboln L, Widman. A comparison oI the properties oI LAC43, prilocaine and
bupivacaine in extradural anaesthesia. Acta Anaesthesiol Scand 1966; 21:33.
38) Philip R. Bromage. Unblocked segments ESI epidural analgesia Ior relieI oI
pain in labour; Br J Anaesth 1972; 44(7):676-679.
39) Bromage P R. Lower limb reIlex changes in segmental epidural analgesia. Br J
Anaesth 1974; 46(7): 504-508.
40) Maltau JM. The Irequency oI Ietal bradycardia during selective epidural
anaesthesia. Acta Obstet Gynecol Scand 1975;54(4):357-61.
41) Hollman A, Jouppila R, Pihlajaniemi R, Karvonen P, SjostedtE. Selective
lumbar epidural block in labour. A clinical analysis. Acta Anaesthesiol Scand
1977; 21 (3):174-81.
42) Jouppila R, Pihlajaniemi R, Hollman A, Jouppila P. Segmental epidural
analgesia and postpartum sequelae. Ann Chir Gynaecol 1978; 67(2):85-8.
43) Jouppila R, Jouppila P, Karinen JM, Hollman A. Segmental epidural analgesia
in labour: related to the progress oI labour, Ietal malposition and instrumental
delivery. Acta Obstet Gynecol Scand 1979; 58(2):135-9.
94
44)Willdeck-Lund G, Lindmark G, Nilsson BA. EIIect oI segmental epidural block
on the course oI labour and the condition oI the inIant during the neonatal
period. Acta Anaesthesiol Scand 1979; 23(4):301-11.
45)Gal D, Choudhry R, Ung KA, Abadir A, Tancer ML. Segmental epidural
analgesia Ior labor and delivery. Acta Obstet Gynecol Scand 1979; 58(5):429-
31.
46)Pentti Jouppila, RiittaJouppila, Arno Hollman, Antero Koivula. Lumbar
Epidural Analgesia to Improve Intervillous Blood Flow During Labor in Severe
Preeclampsia. Obstet gynaecol 1982;59:158- 161.
47) Kanto J, Erkkola R, Mansikka M, Arimaa L. Segmental epidural analgesia - a
modern method Ior saIe and eIIective management oI labor pains. Biol Res
Pregnancy Perinatol 1983;4(4):172-6.
48) Anthony C. Webster, J. D. McKishnie, J. T. Watson, W. Donald Reid. Lumbar
epidural anaesthesia Ior inguinal hernia repair in low birth weight inIants. Can J
Anaesth 1993;40(7): 670-675.
49) Peutrell JM, Hughes DG. Epidural anaesthesia through caudal catheters Ior
inguinal herniotomies in awake ex-premature babies. Anaesthesia 1993;
48(2):128-31.
50) M.H.Rao, Phani Thota. Segmental dose requirement oI epidural lignocaine. J
Anaesth Clin Pharmacol 1995; 11: 99-102.
51) William M. Splinter, Juan Bass, Lydia Komocar. Regional anaesthesia Ior
hernia repair in children: local vs caudal anaesthesia. Can J Anaesth 1995;42:3.
52) Cedric Prys-Roberts and Burnell R.Brown. International practice oI anaesthesia.
1st ed. Vol. 2. OxIord: Butterworth, Heinemann; 1996.p.140/9.
9S
53) Della RoccaG, Giampalmo M, Giorni C, Di Marco PA, Monaco S, Romboli
D, Gossetti F, et al., Anesthesia Ior inguinal hernioplasty: a comparison oI
techniques. Chir Ital 2000; 52(6):687-93.
54) Gunal O, Arikan Y, Celikel N. Clinical assessment oI spinal and epidural
anaesthesia in inguinal hernia repair. J Anesth 2002; 16(2):119-22.
55) Todorovic Dragana, Konstatinovic Slavko, Jankovic Radmilo. Administration oI
epidural anaesthesia in operations oI inguinal hernia: Comparison oI diIIerent
anaesthetic concentrations. Acta Medica Mediane 2005; 44(4):25-29.
56) Srivastava U, Kumar A, Saxena S, Neeraj, Sehgal . Comparison oI local spinal
and general anaesthesia Ior inguinal hernia repair. Journal oI Anaesthesiology
2007; 23(2): 151-4.
57) A. A. J. Van zundert, G. Stultiens, J. J. Jakimowicz, D. Peek, W. G. J. M. Van
der ham, H. H. M. Korsten et al., Laparoscopic cholecystectomy under
segmental thoracic spinal anaesthesia: A Ieasibility study. Br J
Anaesth 2007; 98 (5):682-686.
58) Yang B, Liang MJ, Zhang YC. Use oI local or epidural anaesthesia in inguinal
hernia repair: a randomized trial. Zhonghua Wai Ke Za Zhi 2008; 46(16):1234-
6.
59) Swerdlow M, Sayle Creer W. A study oI extradural medication in the relieI oI
lumbosciatic syndrome. Anaesthesia 1970; 25:341-345.
60) Tverjkoy M, Cozacovc, Ayache M, Bradley EL, Kissin I. Post operative pain
aIter inguinal herniuorrhaphy with diIIerent type oI anaesthesia. Anesth Analg
1990;70:29-35.
96
ANNEXURE - I
~SEGMENTAL EPIDURAL ANALGESIA FOR INGUINAL HERNIA
REPAIR - A CLINICAL STUDY
PROFORMA
Name: I.P.No: Age/Sex: Wt:
Kg Ht: cms
Diagnosis: Surgery: Date oI
Operation:
Pre Anaesthetic Evaluation:
Cardiovascular system: PR: BP: Heart:
Respiratory system: RR: Lungs: Airway:
MP: MO: cm
Central nervous system:
Investigations:
BLOOD: Hb: TC: DC: CT: BT:
Bl.Urea: Sr.Creatinine: FBS/RBS:
HIV: HbSAg:
URINE: Albumin: Sugar: Microscopy:
OTHERS : ECG: CXR:
97
INTRA OP VITAL SIGNS:
Drug used.
Dosage.
Time of infection.
Level of infection.
Observations
mins
0 1 2 3 4 5 1
0
1
5
2
0
2
5
3
0
3
5
4
0
4
5
5
0
5
5
6
0
END oI
surg
Heart rate
B.P.
Systolic
diastolic
Respiratory rate
SpO2
MONITORING SENSORY BLOCK
Onset oI Analgesia:
Height oI Analgesia pre op: Height post op :
Duration oI Analgesia : Quality oI Analgesia: E / G / F / P
SEDATION GIVEN:
SIDE EFFECTS DURING SURGERY:
1. Bradycardia
2. Hypotension: Fall in systolic: diastolic:
3. Respiratory Depression 4. Shivering 5. Nausea & vomiting 6.
Sweating
7. Inadvertent dural puncture
98
ANNEXURE - II
CONSENT FORM FOR ANAESTHESIA/OPERATION
I ........ Hosp. No.......in my Iull senses hereby give my complete
consent Ior ........or any other procedure deemed Iit which is a / and
diagnostic procedure / biopsy / transIusion / operation to a be perIormed on me / my
son / my daughter / my ward ......age ...under any anaesthesia deemed
Iit. The nature and risk involved in the procedures have been explained to me to my
satisIaction. For academic and scientiIic purpose the operation / procedure may be
televised or photographed.
Date:
Signature / Thumb Impression oI
the Patient / Guardian
Name:
Place:
Guardian
Relationship
Full Address
KEY TO MASTER CHART

ASerial number
A1I.P. No.
A3Name
A4Sex
A5Weight in kilograms
A6Height in centimetres
A7ASA grade
A8Type oI hernia : Direct- D : Indirect- IN
A9Volume oI bupivacaine in millilitres
A10Injection level
A11Onset oI analgesia in minutes
A12Preoperative sensory level
A13Postoperative sensory level
A14Duration oI analgesia in minutes
A15Quality oI block (Analgesia)
E-Excellent; G-Good; F-Fair; P-Poor
HEART RATE
A16Preoperatively
A17At 0 minute (immediately aIter block)
A18At 1 minute
A19At 2 minutes
A20At 3 minutes
A21At 4 minutes
A22At 5 minutes
A23At 10 minutes
A24At 15 minutes
A25At 20 minutes
A26At 25 minutes
A27At 30 minutes
A28At 35 minutes
A29At 40 minutes
A30At 45 minutes
A31At 50 minutes
A32At 55 minutes
A33At 60 minutes
A34At the End
BLOOD PRESSURE
A35Preoperatively
A36At 0 minutes
A37At 1 minutes
A38At 2 minutes
A39At 3 minutes
A40At 4 minutes
A41At 5 minutes
A42At 10 minutes
A43At 15 minutes
A44At 20 minutes
A45At 25 minutes
A46At 30 minutes
A47At 35 minutes
A48At 40 minutes
A49At 45 minutes
A50At 50 minutes
A51At 55 minutes
A52At 60 minutes
A53At the End
A54Fall in Systolic Blood Pressure
A55Percentage oI Iall in Blood Pressure
A56Side eIIects
A57Remarks
A A1 A2 A3 A4 A5 A6 A7 A8 A9 A10 A11 A12 A13 A14 A15 A16 A17 A18 A19 A20 A21 A22 A23 A24 A25 A26 A27 A28 A29 A30 A31 A32 A33 A34
SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST
1 63449 Munishammappa 65 M 60 167 1 IN 5 L1-L2 8 T8 T8 190 E 64 56 56 58 56 54 52 58 58 60 62 66 64 68 60 60 64 62 58 126 82 130 80 126 80 122 80 122 82 124 80
2 64077 Shanthamma 63 F 41 156 2 D 5 L1-L2 8 T12 T11 200 E 84 82 84 88 86 84 86 82 88 96 76 98 96 80 88 86 80 76 74 130 80 126 80 124 80 122 78 126 78 128 78
3 64737 Lakshmana 18 M 46 152 1 IN 8 L1-L2 6 T11 T10 240 G 78 86 82 82 84 86 80 80 78 72 76 68 80 78 76 82 80 74 74 124 80 128 84 130 80 124 80 128 74 126 82
4 64455 Fayaz Khan 48 M 64 168 1 D 5 L1-L2 7 T11 T9 180 E 70 80 78 76 78 80 82 88 88 90 86 88 86 86 84 84 88 86 84 110 72 120 80 122 82 116 80 118 80 116 80
5 64557 Salmath Khan 52 M 65 164 1 D 5 L1-L2 7 T10 T8 210 E 88 90 88 88 90 90 88 92 90 88 86 88 84 82 80 78 80 86 82 128 72 132 78 132 78 134 76 130 78 124 70
6 64522 Venkatesh 38 M 40 158 1 IN 8 L1-L2 0 0 0 P 70 84 86 86 88 90 86 88 88 90 98 96 106 110 98 78 72 76 78 110 70 138 80 136 78 138 78 142 78 148 78
7 64800 Govindappa 52 M 58 156 1 D 5 L1-L2 7.3 T10 T9 150 E 82 88 90 90 92 90 86 88 88 88 86 86 84 82 80 88 82 86 86 128 80 138 90 136 88 124 82 128 80 126 84
8 64300 Shivappa 37 M 57 160 1 IN 7 L1-L2 8.3 T10 T9 170 G 86 82 82 82 82 86 84 86 86 88 88 84 82 84 78 82 80 80 80 124 84 130 86 128 84 128 86 126 82 134 88
9 66429 Venkataravanappa 41 M 73 169 1 IN 6 L1-L2 7 T11 T10 180 G 84 110 112 116 112 112 110 108 110 98 104 98 102 100 98 94 98 92 96 136 90 122 74 120 72 118 72 120 70 116 70
10 65837 Manjunath 26 M 49 158 1 IN 8 L1-L2 9 T12 T10 200 F 86 88 86 86 84 82 80 82 80 82 86 88 88 78 80 82 84 84 82 110 70 124 78 128 76 120 76 126 78 128 80
11 65444 A.Nagaraj 25 M 60 168 1 IN 5 L1-L2 7 T11 T10 180 E 86 86 82 82 84 86 80 80 86 72 76 62 70 62 64 66 60 62 70 126 80 128 84 128 82 128 82 126 80 122 80
12 66411 Venkataswamy 25 M 58 166 1 IN 7 L1-L2 9 T11 T10 210 F 92 98 96 96 92 94 94 92 94 92 92 88 90 94 86 92 88 92 96 128 90 138 88 140 94 136 96 128 90 130 92
13 66620 Nagarj 38 M 75 166 1 D 5 L1-L2 12 T9 T7-8 180 E 88 86 88 84 84 82 82 86 88 88 86 88 88 82 86 88 86 86 88 120 86 122 90 124 88 126 86 124 88 124 84
14 66885 Chikkanna 48 M 58 154 1 IN 5 L1-L2 8 T12 T10 180 E 86 90 92 90 88 86 88 86 84 84 86 78 76 84 78 76 78 78 76 120 82 122 80 120 80 122 80 124 86 120 80
15 66890 Anjanappa 49 M 62 160 1 IN 5 L1-L2 7 T10 T8 140 E 86 88 88 90 86 92 88 94 90 92 88 92 90 88 86 86 88 84 82 128 90 132 94 128 92 130 94 126 92 128 90
16 67763 Nagappa 55 M 49 158 1 IN 5 L1-L2 9 T11 T10 150 E 84 78 78 80 78 76 76 78 74 82 78 80 82 78 80 80 78 74 72 100 70 118 76 116 76 116 74 114 72 116 72
17 68226 Rudrappa 51 M 57 156 1 IN 6 L1-L2 8 T10 T8 210 G 86 90 88 92 94 92 90 90 90 82 88 86 82 88 88 88 86 86 88 150 86 148 92 148 90 148 90 148 90 140 90
18 68261 Prabhakar 46 M 46 164 2 D 5 L1-L2 9 T11 T10 190 E 86 82 82 82 84 84 84 86 86 82 84 84 80 84 92 82 90 80 78 124 82 132 80 134 80 132 78 130 80 128 80
19 69641 Bhavani 27 F 46 150 1 IN 7 L1-L2 7 T11 T10 200 F 88 90 88 92 94 90 86 82 86 88 86 80 84 90 88 86 84 84 92 136 82 136 84 138 86 136 84 136 84 134 84
20 69951 Sudharani 22 F 37 158 1 D 5 L1-L2 6.3 T10 T8 130 E 74 88 86 88 90 92 90 94 90 86 88 86 82 88 80 86 84 86 92 128 72 134 78 134 78 132 78 130 72 132 72
21 68640 Kiran 29 M 68 172 1 IN 6 L1-L2 8 T10 T9 180 G 86 86 88 88 88 88 90 86 88 84 82 88 86 88 86 90 84 94 92 130 82 136 84 136 84 130 82 128 78 128 78
22 69680 Venkateshmurthy 32 M 64 164 1 IN 5 L1-L2 7 T10 T8 130 E 96 106 100 100 98 96 92 106 98 100 98 98 98 94 96 98 94 98 96 126 84 130 90 128 92 130 90 138 94 138 90
23 71056 Machaiah 46 M 53 168 2 D 5 L1-L2 7.3 T10 T8 120 E 90 92 90 90 94 90 86 88 84 94 88 90 92 88 86 84 84 86 90 138 80 140 86 138 86 138 86 140 88 136 86
24 71203 Kodappa 65 M 56 164 2 IN 8 L1-L2 0 0 0 P 86 86 84 84 82 84 84 90 98 106 108 100 102 98 90 88 88 86 88 150 86 146 86 138 84 140 88 142 88 146 90
25 71416 Kodandaram 40 M 64 174 1 IN 5 L1-L2 7 T10 T9 140 E 88 82 78 76 76 76 78 74 74 74 72 76 78 76 78 76 76 78 82 126 82 130 72 128 64 122 60 118 60 122 64
26 71641 Narayanappa 40 M 63 178 1 D 6 L1-L2 8 T10 T9 200 F 98 100 100 94 98 98 100 92 90 92 90 92 92 92 94 94 88 96 96 120 78 128 80 126 80 120 74 118 72 120 78
27 67183 Lakshmanna 50 M 55 156 1 D 5 L1-L2 7.3 T10 T8 170 E 76 90 92 92 100 88 92 90 94 86 88 88 86 80 84 88 90 86 88 132 84 138 88 138 90 130 82 130 80 128 80
28 71553 Subramani 36 M 50 164 1 D 5 L1-L2 8 T9 T8 160 E 70 80 78 82 84 82 80 86 86 90 88 88 86 82 80 82 80 88 84 110 72 120 80 122 80 116 80 118 80 116 80
29 71890 Sudhakar 35 M 50 160 1 IN 6 L1-L2 8.3 T9 T8 200 G 82 88 86 88 82 84 82 84 84 80 82 80 78 82 80 86 80 88 84 136 80 140 80 138 80 136 82 138 82 136 84
30 72352 Rajanna 43 M 63 172 1 IN 5 L1-L2 7 T10 T8 170 E 78 88 88 82 84 82 80 80 84 86 84 84 82 86 88 84 86 86 88 132 80 138 80 138 78 138 82 136 80 136 82
31 72363 Nagesh 38 M 49 164 1 IN 5 L1-L2 7.3 T10 T9 180 E 78 86 88 86 84 86 84 86 88 82 80 82 82 86 84 84 88 80 84 130 80 134 82 132 82 130 80 130 80 130 80
32 72444 Murthy 45 M 58 171 2 IN 5 L1-L2 7.3 T11 T9 180 E 78 86 90 84 82 80 80 84 84 90 86 88 88 88 90 82 86 82 86 128 74 130 76 132 74 124 74 132 78 130 76
33 72593 ChanneGowda 47 M 68 178 1 IN 7 L1-L2 8 T10 T9 210 F 70 88 86 84 82 84 82 86 88 86 86 84 82 84 80 82 80 78 80 118 76 126 84 124 82 128 80 130 74 128 72
34 73002 Nandan 32 M 54 172 1 D 5 L1-L2 8.3 T10 T8 140 E 86 88 90 86 82 80 78 76 70 70 72 82 80 82 88 82 80 80 86 126 80 132 80 132 78 130 78 130 78 130 78
35 73130 Abhishek 29 M 51 161 1 IN 5 L1-L2 7.3 T10 T9 150 E 90 100 98 100 102 100 98 98 100 82 90 86 92 86 90 90 96 90 88 126 80 124 70 122 74 124 72 128 74 126 76
36 73174 Yuvraj 36 M 53 174 1 IN 6 L1-L2 7.3 T10 T8 180 G 86 88 86 88 88 86 80 80 76 84 78 82 80 82 86 88 86 88 86 128 80 132 90 130 90 130 90 132 88 132 86
37 73343 Nagendra 39 M 39 168 1 IN 5 L1-L2 6.3 T9 T8 130 E 86 90 88 86 84 82 82 82 80 84 80 88 88 84 82 88 86 88 88 136 78 132 80 132 84 132 80 130 80 130 78
38 73555 Ramaiah 55 M 50 160 2 D 5 L1-L2 6 T10 T9 120 E 96 110 116 112 114 112 110 126 124 136 120 130 128 116 118 108 112 104 100 150 90 150 90 148 90 146 90 148 88 138 98
39 73861 Mallikarjun 46 M 50 164 1 IN 7 L1-L2 9 T10 T8 180 G 86 90 88 90 92 86 84 86 84 86 82 88 84 84 86 88 88 86 84 136 82 140 82 140 84 138 82 136 80 132 78
40 74178 Muniraj 53 M 64 170 1 D 8 L1-L2 7.3 T11 T10 170 G 86 90 90 88 90 88 88 86 88 84 86 84 86 84 82 90 90 88 86 128 76 130 78 132 78 128 76 128 78 132 80
42 73901 Narayanappa 70 M 68 158 1 D 5 L1-L2 6.3 T10 T9 140 E 68 88 80 80 86 82 86 84 82 80 76 76 78 82 80 80 78 82 80 144 88 140 88 140 86 138 86 132 80 136 82
43 75395 Ravikumar 42 M 65 172 1 IN 6 L1-L2 7 T11 T10 150 G 92 90 92 92 96 90 90 84 86 88 86 82 88 88 86 84 82 84 86 134 80 136 88 138 88 132 86 136 84 138 88
44 75750 Rajesh 43 M 72 176 1 IN 5 L1-L2 7.3 T10 T10 130 E 78 80 78 84 82 80 82 84 80 76 78 82 80 80 76 80 78 78 84 136 80 136 80 136 78 132 76 134 78 130 76
45 75967 Varun 38 M 49 158 1 IN 6 L1-L2 9 T10 T9 135 G 86 90 88 82 86 84 80 82 78 82 80 88 82 88 78 86 78 86 88 128 80 130 80 132 80 134 80 132 78 130 76
46 75958 Shammi 37 M 49 168 1 IN 7 L1-L2 7.3 T9 T9 140 G 94 94 92 94 96 96 98 92 94 92 90 92 88 92 92 90 90 90 88 136 84 136 84 138 84 140 88 134 80 136 82
47 75383 Ravindraraj 55 M 64 178 2 IN 6 L1-L2 8 T10 T9 150 G 74 72 74 78 68 72 76 76 78 68 74 60 64 70 70 72 78 76 70 128 80 136 86 132 82 134 84 130 80 128 80
48 76846 Ravichari 40 M 58 164 1 IN 5 L1-L2 7.3 T10 T9 160 E 94 90 96 94 96 94 92 92 90 92 88 92 90 88 96 90 90 86 84 128 70 136 78 134 76 136 78 138 82 136 84
49 76831 Girish 30 M 62 168 1 IN 7 L1-L2 7.3 T10 T9 150 G 86 88 86 88 82 84 82 80 78 78 76 82 80 84 88 86 88 84 90 128 80 132 80 132 82 132 82 136 82 130 80
50 77114 Gangaraj 32 M 60 172 1 IN 6 L1-L2 8 T10 T8 140 G 92 92 90 90 88 84 80 92 90 92 88 86 86 82 80 84 84 88 86 134 86 130 78 128 80 120 86 142 100 140 94
A35 A36 A37 A38 A39 A40
99
A54 A55 A56 A57
SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST SYST DIAST
122 80 120 80 120 78 120 76 118 76 122 76 118 72 118 68 118 70 112 72 110 68 110 68 116 74 20 15.38 NIL
126 76 120 78 124 80 128 80 128 80 126 80 128 82 128 80 130 82 130 84 130 84 130 86 130 84 6 4.76 NIL
124 86 128 80 132 88 136 82 130 80 132 78 128 84 126 82 136 80 130 78 128 78 134 76 132 82 4 3.13 NIL
112 78 110 82 110 76 118 74 112 72 114 72 114 74 120 82 122 78 118 78 118 76 116 74 118 76 10 8.33 NIL
126 72 124 74 122 78 124 76 126 72 128 72 126 76 124 70 120 70 122 72 126 74 124 74 126 74 12 9.09 NIL
129 80 126 78 145 88 146 90 136 80 130 78 128 78 128 80 126 88 130 88 132 80 132 82 128 82 SW INADEQUATE BLOCK-CONVERTED TO GA
130 86 132 88 138 94 136 92 136 90 136 88 136 88 134 88 136 90 138 92 130 84 132 88 136 88 14 10.14 SH
130 88 128 86 132 88 124 82 120 80 124 82 120 80 120 80 122 80 118 80 120 80 120 82 122 86 12 9.23 NIL
118 70 116 68 118 68 118 70 118 72 122 72 120 76 124 78 128 82 132 78 130 86 130 84 132 88 6 4.92 NIL
130 80 130 80 128 80 126 76 130 78 132 76 136 76 140 74 132 78 128 80 128 76 128 80 136 76 4 3.23 SW
124 82 122 77 124 74 118 72 118 70 120 68 120 68 124 66 118 68 118 70 124 68 124 70 124 74 10 7.81 NIL
138 92 136 84 136 88 134 86 136 86 130 86 130 84 128 84 130 86 130 86 130 84 132 88 132 86 10 7.25 SW
122 88 116 86 112 90 112 82 116 86 118 84 116 84 118 82 118 84 120 86 122 82 120 80 120 86 12 9.84 NIL
118 76 116 76 116 76 118 78 114 76 114 76 114 70 110 70 112 72 112 72 112 76 112 74 110 78 10 8.2 NIL
126 88 128 86 128 88 122 86 124 88 126 86 124 88 126 86 130 90 130 92 128 90 132 88 128 90 10 7.58 NIL
118 78 116 78 110 78 110 70 112 70 112 74 112 72 114 72 120 78 118 76 118 76 114 78 112 76 8 6.78 NIL
138 86 140 92 142 90 144 92 142 94 136 82 142 88 146 86 144 84 136 82 138 82 140 88 142 90 14 9.46 NIL
130 80 126 76 126 82 128 74 126 70 120 68 128 72 128 76 130 70 128 76 128 76 126 70 120 68 4 3.03 NIL
136 82 132 78 126 80 126 80 132 82 130 82 132 82 130 84 132 82 130 80 128 80 136 82 138 84 10 7.35 SW
132 72 138 74 140 78 130 80 132 78 132 78 128 70 126 70 126 72 128 74 128 72 130 74 130 78 8 5.97 NIL
130 78 130 84 132 84 126 82 128 80 136 82 130 82 132 82 134 84 130 80 126 78 128 82 126 80 10 7.35 NIL
140 96 136 92 138 88 134 90 138 94 136 92 136 88 134 88 136 90 138 92 130 86 132 88 136 88 2 1.54 NIL
136 86 146 82 138 82 138 82 154 82 150 78 148 78 150 82 134 82 136 84 136 84 136 86 136 90 12 8.57 NIL
134 84 130 88 138 82 128 80 130 86 136 88 142 90 128 84 132 86 136 84 132 82 138 90 142 86 18 12.32 SW INADEQUATE BLOCK-CONVERTED TO GA
120 62 120 64 126 64 130 66 136 66 142 74 142 74 142 76 144 76 150 76 146 74 146 76 148 72 12 9.23 NIL
122 76 124 76 124 76 124 74 124 74 122 70 122 70 116 68 116 68 116 70 116 70 128 76 126 76 12 9.38 SW
130 80 132 82 130 84 130 80 122 78 124 80 132 80 128 82 126 80 128 82 130 80 128 80 126 82 16 11.59 NIL
112 78 110 82 110 76 118 74 112 72 114 72 114 74 120 82 120 82 118 78 122 78 116 74 118 76 10 8.33 NIL
134 88 132 78 134 74 126 72 132 72 128 70 134 72 132 74 130 72 134 74 132 76 136 74 138 76 14 10 NIL
130 84 128 82 128 80 124 72 128 80 128 80 130 82 132 82 128 80 126 80 126 78 126 74 128 78 12 8.7 NIL
128 80 120 78 120 72 122 72 120 70 124 72 128 74 126 76 130 76 132 78 128 80 126 78 134 86 14 10.37 NIL
126 74 128 76 124 72 126 76 126 76 126 76 124 72 124 72 128 76 128 76 128 74 128 74 126 72 6 4.62 NIL
128 70 128 80 128 82 126 84 128 82 126 80 128 82 126 84 124 82 122 80 120 78 124 80 122 82 6 4.76 SH
124 76 118 68 120 80 128 82 132 86 126 74 124 80 126 90 124 86 122 84 124 86 128 82 132 74 14 10.61 NIL
130 74 132 72 128 74 124 76 126 72 124 74 126 72 122 70 124 72 126 78 128 78 126 76 132 74 2 1.61 NIL
132 88 130 82 128 80 124 80 122 78 124 76 120 84 118 82 122 80 120 78 120 80 122 78 128 84 12 9.09 NIL
128 76 126 76 128 78 122 72 124 72 128 72 124 74 122 74 122 70 128 72 122 72 124 74 128 74 10 7.58 NIL
142 88 140 86 140 88 128 86 132 88 132 94 138 94 138 92 138 92 138 90 130 90 138 92 146 92 20 13.33 NIL
132 76 134 80 136 84 132 76 136 78 136 74 136 74 138 76 138 76 132 78 134 80 136 82 134 78 8 5.71 NIL
130 80 132 82 132 80 130 80 124 78 122 76 126 74 124 72 128 78 134 84 128 80 132 86 130 84 8 6.15 NIL
128 84 120 80 118 76 124 80 138 86 138 88 138 86 136 84 136 84 138 88 140 88 136 86 138 88 22 15.71 SH
136 88 132 82 132 82 130 80 130 80 132 82 132 82 126 74 126 74 134 82 134 82 130 80 136 80 10 7.35 NIL
134 78 132 76 132 76 132 72 132 72 130 72 130 70 134 74 134 74 138 76 138 76 140 80 136 78 6 4.41 NIL
130 76 130 74 130 76 134 80 132 82 134 80 132 76 134 78 132 76 136 78 130 72 132 74 136 78 0 0 NIL
132 82 134 84 132 82 134 80 134 82 134 86 132 82 136 86 132 80 132 80 130 82 134 84 132 80 6 4.41 NIL
120 72 124 76 120 72 122 74 124 72 122 72 124 74 120 70 122 74 128 76 136 86 128 82 134 88 16 11.76 NIL
134 80 132 70 132 70 134 72 124 74 126 72 124 74 122 72 122 70 126 68 126 70 128 72 130 70 6 4.41 NIL
128 82 120 84 122 82 126 82 128 84 132 86 128 82 130 84 132 82 130 80 128 88 120 78 132 78 12 9.09 NIL
128 92 158 106 148 106 156 110 158 106 148 116 156 110 128 80 148 116 132 88 128 80 140 98 142 96 10 7.69 NIL
A44 A45 A46 A41 A42 A43 A53 A47 A48 A49 A50 A51 A52
99

Segmental Epidural Anaesthesia

Загружено:

Сведения о документе

Исходное описание:

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Segmental Epidural Anaesthesia

Загружено:

Авторское право:

Доступные форматы

SEGMENTAL EPIDURAL ANAESTHESIA FOR

INGUINAL HERNIA REPAIR

RA1IV GANDHI UNIVERSITY OF HEALTH SCIENCES,

CERTIFICATE BY THE GUIDE

ENDORSEMENT BY THE HEAD OF THE DEPARTMENT,

It gives me immense pleasure to extent my sincere thanks to ProIessors

KEY TO MASTER CHART

Вам также может понравиться