Regional Anaesthesia

&
Temperature Control
Aizat
Content
Definition
Types
LA agent
Specific type
Temperature control
Definition
Techniques of abolishing pain using local
anaesthetic agents as opposed to general
anaesthesia.
Drugs that produce reversible conduction
blockade of impulses along central &
peripheral nerves producing ANS, sensory
blockade and skeletal muscle paralysis in the
area innervated by affected nerve
Types
REGIONAL
ANAESTHESIA
TOPICAL
CENTRAL
NERVE BLOCK
SPINAL
ANAESTHESIA
EPIDURAL
ANAESTHESIA
PERIPHERAL
NERVE BLOCK
PLEXUS BLOCK
SINGLE NERVE
BLOCK
INTRAVENOUS
REGIONAL
(BIER BLOCK)
Aim

Provide anesthesia for a surgical procedure
Provide analgesia pre& post-operatively or
during labour and delivery
Diagnosis or therapy for patients with chronic
pain syndromes


LA agent
Esters Procaine, chloropropaine, tetracaine,
amethocaine, cocaine
Amides lignocaine, etidocaine, mepivacaine,
bupivacaine,ropivacaine


Mechanism of action
LA prevent the transmission of
nerve impulse by inhibiting
passage of Na ions through the
ion selective NA channel at the
nerve membrane.
Reduction in Na conductance
(GNA )
Slows the rate of depolarisation,
threshold potential not reached
& action potential not
propagated
DRUGS
Lignocaine (USA Lidocaine)
Presentation Clear aq solution lidocaine HCL
Plain 0.5%(local infiltration, IVRA ), 1%, 2%(nerve blocks,
extradural anaesthesia)
with adrenaline 1:200 000
Use of adrenaline: Vasoconstiction at site of injection rate of
absorption, systemic toxicity, duration of action
Gel 2% with or without chlorhexidine
Clinical : onset in 2-20min; duration 60-120min
Recommended max dose 1-3mg/kg (7mg/kg with adrenaline)
How to prepare
Lignocaine concn : O.5%: 5mg/ml, 1%: 10mg/ml,
2%:20mg/ml
E.g: 70kg 210mg : do not use more than 10ml of 2%
lignocaine
C/I : Do not use with adrenaline in end arterial supply (fingers,
toes, pinna, penis and nose)
Bupivacaine
Presentation clear colourless, aq solution
(bupivacaine hydrochloride )
Plain (0.25%, 0.5%, 0.75%)
With 1:200 000 (5g/ml ) adrenaline
Heavy 0.5% with 80mg/ml dextrose ( SG 1.026)
Recommended max dose 2mg/kg (150mg plus up to
50mg 2 hourly subsequently)
Clinical- onset within 10-20min, duration of action 4-
8hrs. 4X as potent as lidocaine, propensity for
cardiotoxicity
ADVANTAGES
Conscious patients
assist in positioning
early warning of adverse effects
avoid airway manipulation & complications
Good quality block in term of motor and sensory
adequate as per surgical requirement
surgical / hormonal / psychological stress
Less post operative complications
less sedated
less nausea / vomiting
reduce atelectasis pneumonia
reduce risk of dvt
early oral intake
DISADVANTAGES
Patients anxiety
increased sympathetic tone
unwanted psychological stress
Technically difficult procedure
Co-operation from patients are required
Abnormal sensation :
paraesthesia / hyperaesthesia
COMPLICATIONS
Allergic reaction (rare <1%)
Local tissue toxicity
Direct trauma to nerves, vessels and soft tissues
Haematoma
Abscess formation
Anterior spinal artery syndrome (spinal)
Cauda equina syndrome (spinal)
Systemic toxicity
Due to excessive/ IV injection
Cardiac arrythmias, convulsion, bradycardia
Methaemoglobinaemia (in prilocaine)

Topical Anesthesia
Application of local anesthetic to mucous membrane
- cornea, nasal / oral mucosa
Uses : absorb into dermis and block the nerve end
awake oral, nasal intubation, superficial surgical procedure
Advantages :
technically easy
minimal equipment
Disadvantages :
potential for large doses leading to toxicity

Local/Field Anesthesia
Application of local subcutaneously to anesthetise
distal nerve endings
Uses:
Suturing, minor superficial surgery, line placement, more
extensive surgery with sedation
Advantages:
minimal equipment, technically easy, rapid onset
Disadvantages:
potential for toxicity if large field

Forehead block
2 nerves from superior orbital margin
Supraorbital n: 2.5cm from midline
Supratrochlear n: upper medial corner of orbit

Insert needle from eyebrow midline direct
laterally
Auricular block
Nerve: auriculotemporal, greater auricular and lesser
occipital
Peripheral Nerve Block
Injecting local anesthetic near the course of a named
nerve
Uses:
Surgical procedures in the distribution of the blocked
nerve
Advantages:
relatively small dose of local anesthetic to cover large area;
rapid onset
Disadvantages:
technical complexity, neuropathy

Wrist block
Median nerve : lies superficially between palmaris longus and FCR
Ulnar nerve : lies between FCU and ulnar artery
Radial nerve: over radial styloid up to extensor surface
Digital nerve block
Web space approach. 2 dorsal & 2 palmar. NEVER use adrenaline
Ankle block
Saphenous nerve: ant and just above medial malleolus
Superficial peroneal nerve: above the ankle joint from anterior border of tibia to lateral
malleolus
Deep peroneal n: above ankle joint between tibialis ant tendon and ext hallucis longus
Sural n: Lateral to achilles tendon to lateral malleolus
Tibia n: Medial to achilles tendon to lateral PTA (by palpation)

Femoral block
Femoral nerve : Lateral to artery under inguinal ligament
Plexus Blockade
Injection of local anesthetic
adjacent to a plexus,e.g
cervical, brachial or lumbar
plexus
Uses :
surgical anesthesia or post-
operative analgesia in the
distribution of the plexus
Advantages:
large area of anesthesia with
relatively large dose of agent
Disadvantages:
technically complex, potential
for toxicity and neuropathy

Biers block (IVRA)
Indication : M&R of forearm #
Drugs: 10ml of 1% lignocaine
Dosage :0.4ml/kg(2mg/kg), onset 3mins
Technique
V/S monitoring & IV branula on both
hands
Torniquet affevted limb: 50-100mmhg
above SBP
Elevate hand above heart beofre
torniquet
Confirm dissappearnace of radial pulse
before injecting LA
Dont deflate cuff within <20mins, may
cause high concn to circulation
Spinal vs Epidural
SPINAL

EPIDURAL
site of
administration :
subarachnoid space
CSF (+)
extra dural space --
loss of resistance
technically : easier
Spinal needle
LOR
more difficult
Tuohy needle
CSF fluid
failure rate : low high
Spinal vs Epidural
SPINAL EPIDURAL
onset : Fast Slow
duration : 2 to 2.5 hours
( flexible)
flexible
level : lumbar ; sacral cervical to caudal
volume of LA : small
1.0 to 3.0 mls
large
5.0 to 30 mls
Temperature control
Hypothalamus is the body thermostat
Normal core temp: 37C (if taken internally)
36.8 0.4C (98.2 0.7F) in oral,axilla&rectal
Ideal site : Pulmonary artery (gold standard)
Using thermistor cathether
Blood mix from skin to viscera

Thermoregulation
Drugs influence in thermoregulation
Neuromuscular blocking agent : Scoline
Malignant hyperthermia initiated by uncontrolled
release of Ca ions leading to incr muscle metabolism
Cx features : muscle spasm, rigidity, contracture, metabolic
acidosis
Tx : Rapid cooling, O2, correct met H+, IV dantrolene
Opioids : Morphine, Fentanyl
Promote heat loss by vasodilatation
Impair hypothalamic thermoregulation resulting reduce
sympathetic outflow
Tx: Warm IV fluids, warmer, blanket
Usually occurs in GA, however, may occur in RA esp in
spinal/epidural (Volatile anaesthetic agent, propofol)
Take home message
LA produce reversible conduction blockage by
inhibiting passage of Na ions through the ion
selective NA channel at the nerve membrane.
Lignocaine 1-3mg/kg, 2% = 20mg/ml
Serious systemic effect are cardiac arrythmias
and convulsion
Identify anatomy first before giving LA
Hypothalamus controls the body temp