NEURAXIAL ANAESTHESIA.

MULTIPLE CHOICE QUESTIONS:

1- Bradycardia is more likely with block level upto

a-T 10 .
b-Sacral nerve roots.
c-T 6
d-T 4
2-Para-sympathetic nervous system is not blocked with Neuraxial anesthesia due to
a-Presence of Ach receptors at pre-synaptic & post-snaptic receptors
b-Cranio-sacral distribution of para-sympathetic outflow.
c-Presence of para-sympathetic ganglia
d-Dominance of sympathetic nervous system.
3-For Caesarean section what block level is adequate.
a-T 10
b-T 12
c-T 4
d-T 6
4-Supplementation of general anesthesia with neuraxial anesthesia leads to improved
surgical conditions due to.
a-Hypotension leading to decreased surgical bleeding.
b-More efficient motor blockade.
c-More potent analgesia.
d-Vagal dominance .
5-A patient comes to you in ER for emergency C-section with history of poor control pf
asthma. What would be your anesthetic of choice.
a-Spinal anesthesia.
b-General anesthesia.
c-Epidural anesthesia.
d-General anesthesia with epidural placement.
Introduction
Neuraxial anaesthesia is the name used for spinal ,epidural and caudal blocks each of
these different blocks can be achieved either with a single injection or through intermittent
boluses or an infusions delivered through a catheter. Neuraxial anaesthesia have been shown
to blunt the stress response to surgery, decrease intra operative blood loss ,lowers the
incidence of postoperative thrombo embolic events possibility, decrease morbidity in high risk
surgical patients and serve as a useful method to extend analgesia into the post operative
period.

Historical perspective

CSF was first time discovered by domenico catugno in 1764 and CSF circulation was
described by F. Magendie in 1825. Quinkec in 1891 performed and described the lumbar
puncture as a practicable procedure, but the first planned spinal anaesthesia was
administered by Augut Bier in 1899 for surgical procedure. Kreis in 1901 use spinal
anaesthesia for operative vaginal dilvery.
Epidural space was first described by corning in 1901. Fidel pages in1921, first time
used epidural anaestthesia in human being.In 1945 Tuohy introduced epidural needle, since
then it is being commonly used for epidural anaesthesia.

MECHANISM OF ACTION
 The main site of action for neuraxial blockade is the nerve root.In spinal blocks, local
anaesthetic is injected around the nerve root in the subarachnoid space. Direct injection into
the CSF allows a relatively small dose and volume to achieve a dense sensory and motor
blockade.

• In epidural and caudal blocks, local anaesthetic is injected into the epidural
space to bathe the nerve roots. In contrast to spinal blocks, a higher volume and dose
of local anaesthetic is needed to achieve the same depth of anaesthesia. Conduction
blockade of posterior nerve roots interrupts somatic and visceral sensation whereas
blockade of anterior nerve root prevents efferent motor and autonomic transmission.
Blocking painful stimuli and abolishing skeletal muscle tone is ideal for surgical
procedures, providing analgesia and muscle relaxation.
Afferent transmission of painful stimuli both somatic & visceral pain are blocked.
Efferent transmission of skeletal muscle tone is interrupted.Effect of L.A on nerve is
determined by its length,myelination & concentration of L.A.In the nerve root smaller
and unmyelinated fibres are blocked before larger and myelinated fibres. As the
concentration of local anaesthestic decreases with increasing distance from the site of
injection, leads to the pnenomenon of differential blockade.

Sympathetic block (tested by temp) occurs two level above the sensory block (tested by
pin prick or light touch) which in turn is again two level above the motor blockade.
• Interruption of autonomic efferents results in sympathetic blockade.Sympathetic
outflow from spinal cord is THORACO-LUMBAR(T1-L2).So only sympathetic outflow is
bocked with the neraxial anesthesia leading to un-opposed para-sympathetic activity.

TECHNIQUE
a. Neuraxial anaesthesia should be performed only after appropriate monitors are
applied in a setting where equipments for airway management and resuscitation
are immediately available.

b. Needles spinal and epidural needles are named for the design of their tips for
example(“ Pencil point” bevelled tip with cutting edge).

(1) Epidural needles have a larger diameter than spinal needle, facilitating injection of air
or fluid for the loss of resistance technique and passage of catheter.

(2) The outside diameters of spinal and epidural needles are used to determine their
gauges. Post dural puncture headache is less likely when small gauge spinal needles are used.

SPINAL ANAESTHESIA
INDICATIONS:
Can be used alone or in conjunction with G.A for all surgeries below neck.
• Minimally invasive coronary artery surgery has been performed under thoracic
epidural.
• Most useful in lower abdominal,urologic,rectal and lower extremity surgery.
• Neuraxial anesthesia has been used for upper abdominal surgeries but it is difficult
to achieve safe sensory level so G.A is prefferred.
CONTRA-INDICATIONS:

ABSOLUTE:
• Infection.
 • Pt refusal.
• Coagulopathy.
• Severe hypovolemia.
• Raised I.C.P.
• Severe aortic & mitral stenosis.
RELATIVE:
• Sepsis.
• Un-coopertive patient.
• Pre-existing neurologic deficit.
• Demyelinating lesions.
• Moderate to severe stenotic lesions.
• LV outflow obstruction (HOCMP).
• Severe spinal deformity.

POSITION

a. Lateral decubitus
b. Sitting
c. Prone (Jackknife). This position is considered when surgery is to be performed
in this positions.
LANDMARK
Using the iliac crests as land mark, the L2-3 L3-4 and L4-5 inter space are identified and
desired inter space chosen.
PREPARTION
a. All antiseptic solution are neurotoxic, and care must be taken not to
contaminate spinal needle or local anaesthetics.

b. chlorhexidine – alcohol antiseptic prevents colonization of percutaneous

catheters better than 10% povidine / 10 %pyodine and is recommended prep
for skin asepsis before regional anaesthesia procedure.

APPROACH
a.Mid line - Commonly used.

b.Para median - Is used when the patient can not flex the spine or
interspinous ligaments are calcified. The needle is inserted
one cm lateral to desired inter space with advancement
towards the mid line .
c.The Lumbosacral - Is a para median approach directed at the L5-S1 inter
space.
PROCEDURE
While inserting needle if the patient experiences a paresthesia. It is important to
immediately stop advancement of needle and determine whether the needle tip has
encountered a nerve root in the epidural space or in the sub arachnoid space (the presence of
CSF confirms that the needle has encountered a cauda equine nerve root.

After completing the injection of local anaesthesia solution a small volume of CSF is
again aspirated to confirm that needle tip has remained in the Arachnoid space.
After the block has been placed, strict attention must be directed to the patient's
hemodynamic status with blood pressure and heart rate supported if necessary. The level of
anaesthesia should be assessed by pin prick or temperature sensation. If he anaesthesia is not
rising high enough, the table may be tilted to influence spread of LA.
Continuous spinal anaesthesia can also be administered by using spinal catheter. The
catheter is inserted 2-3 cm into the sub arachnoid space. Although smaller catheters decrease
the risk of post dural puncture headache but they have been associated with reports of
neurological injury. (The recommendation is to avoid using catheters smaller than 24 gauge)

EPIDURAL ANAESTHESIA.

Positions and approaches for epidural anaesthesia are same as for spinal anaesthesia.
However unlike spinal anaesthesia,Epidural anaesthesia may be performed at any inter
vertebral space. While inserting epidural needle into epidural space proper hand position is
important when using loss of resistance technique to locate the epidural space.After placing
tip of the needle in the ligamentum flavum a syringe containing 2-3ml N/saline or air is
attached to needle hub. The dominant hand maintains constant pressure on the syringe
plunger while the non dominant hand rest against the patient back and is used to slowly
advance the needle. As the needle tip enters the epidural space there will be a sudden loss of
resistance and the saline/ air will be easily ejected from the syringe. Then epidural test dose
i.e, 3 ml of local anaesthetic solution containing 5ug/ml of epinephrine (1:200,000) is given to
help detect unrecognised I/V or subarachnoid placement of epidural needle. After negative
test dose, the desired volume of local anaesthetic solution should be administered in 5 ml
increments.
CONTINUOUS EPIDURAL ANAESTHESIA
Epidural catheters are usually inserted through a curved tip needle to help direct the
catheter away from the dura matter, the catheter should be advance only 3 to 5 cm into
epidural space, this minimises the risk of forming a knot, entering a vein, puncturing
duramater, exiting via interverteloral foreman or wrapping around a nerve root.

COMBINED SPINAL – EPIDURAL ANAESTHESIA

This techniques combine the rapid onset and dense block of spinal anesthesia with the
flexibility afforded by an epidural catheter. After the peak spinal block height has been
established the injection of LA solution into epidural space causes the block height to increase,
presumably reflecting compression of the spinal meninges forcing CSF cephaloid as well as a
local anaesthetic effect.

Potential risk of this technique is that the meningeal hole made by the spinal needle
may allow high concentration of subsequently administered epidural drugs to reach the sub
arachnoid space.

PHYSIOLOGICAL EFFECTS OF NEURAXIAL BLOCKADE

Effects on Cardiovascular system.

Neuraxial blockade has specific physiologic consequences, for example hypotension is
not a complication but a normal manifestation of neuraxial blockade, understanding the
homoeostatic mechanism responsible for control of blood pressure and heart rate is essential
for understanding and treating the cardiovascular changes associated with neuraxial
anaesthesia. Neuraxial anaesthesia blocks the sympathetic nervous system efferent fibres, this
is the principal mechanism by which spinal anaesthesia produces cardiovascular
derangements. The incidence of significant hypo tension or bradycardia is generally related to
the extent of sympathatic nervous system blockade hypo tension during spinal anaesthesia is
the result of arterial (decrease SVR) dilatation and venous (decrease pre load and cardiac
output) dilatation. An intact rennin Angiotensin system help to offset the hypotensive effects of
sympathetic block (caution should be exercised when administering central neuraxial block to
patients taking antihypertensive that impair the angiotensin system.)Heart rate slows
significantly in 10% to 15% of patients because of ,
.

a. Blockade of sympathetic cardio accelerator fibres.

b. Diminished venous return and associated decreased stretch of intra cardiac

stretch receptors.

Neuraxial anaesthesia can also produce second and third degree heart block. Pre existing first
degree heart block may be a risk factor for progression to higher grade heart block.

The hemodynamic change produced by epidural anaesthesia are largely dependent on

whether or not epinephrine is added to the LA solution. When epinephrine is added to the LA
solution the resulting beta mediated vaso dilation leads to a greater decrease in blood pressure
than occur in the absence of epinephrine:-

TREATING HEMODYNAMIC CHANGES SECONDARY TO NEURAXIAL BLOCK

a. Vasopressor
(1) Ephedrine 5-10mg I/V Increases blood pressure b increasing cardiac output (venous
return) and SVR.

(2) Dopamine, long term infusion because tachyphylaxis can develop to repeated doses
of ephedrine.

(3) Phenylephrine. Increases blood pressure by increasing SVR which may decrease
cardiac output. This may be specific treatment for hypo tension during epidural anaesthesia
provided by epinephrine containing LA solution.
(4) Fluid Administration. Rehydration with 500-1500ml of crystallised solution or 500 ml
of colloid.

RESPIRATORY PHYSIOLOGY

Neuraxial anaesthesia to mid thoracic level have little effect on pulmonary function in
patients without pre existing pulmonary disease however caution should be exercised when
using neuraxial anaesthesia in patients with chronic obstructive airway disease and those who
rely on the accessory muscle of respiration to maintain adequate ventilation. Patient with
high neuraxial anaesthesia may complain of loss of feeling of chest movement while breathing,
this is usually adequately treated by reassurance . A normal speaking voice suggests that
ventilation is normal with excessively high block patients.
GASTRO-INTESTINAL PHYSIOLOGY
G.I sympathetic outflow is at T5-L1 level. Sympathectomy leads to vagal dominance which
results in contracted gut with active peristalsis.This can improve operative conditions for
laparoscopy when used as an adjunct to G.A. Post op epidural analgesia with minimal
opioids hastens G.I Recovery.
RENAL PHYSIOLOGY
Renal blood flow is maintained by auto-regulatory mechism until severe hypotension
ensues.Both sympathetic & para-sympathetic control of bladder is lost & Urinary
retention follows till block wears off.
COAGULATION PARAMETERS AND NEURAXIAL BLOCK

Platlet Count
> 100,000/ cubic mm– safe
70,000-100,000/cubic mm – safe if coagulation screening is within normal limit.
< 70,000/cubic mm – unsafe
Prothrombin time
INR > 1.5 – unsafe hepatic blood flow up
Activated partial thromboplastime time
APTT > 40 sec – unsafe

liver Diseases

Epidural anaesthesia is preferred over spinal anaesthesia. Local anaesthetic dose

should be titrated (flow limited dose). Hypotension more likely with high spinal. Block at T4
level can reduce hepatic blood flow upto 20% ,increasing susceptibility for infection.
Epidural is useful for post operative analgesia and also decrease PostOperative pulmonary
complication.