Conduct of Local Anesthesia Technique and Complication

8/14/2019 Conduct of Local Anesthesia Technique and Complication

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Conduct of LocalConduct of Local Anesthesia TechniqueAnesthesia Technique

And ComplicationAnd Complication ss

.Dr . HAYTHAM ZIEN , MD.Dr . HAYTHAM ZIEN , MDM.D. AnesthesiaM.D. Anesthesia and ICU Cairo University and ICU Cairo University

S. specialist of AnesthesiaS. specialist of Anesthesia

K.F.U.H K.F.U.H




Advantages of Regional AnesthesiaAdvantages of Regional AnesthesiaAvoid the cardiacAvoid the cardiacinhibitory effect of GA ininhibitory effect of GA incardiac patients .cardiac patients .Postop. Analgesia .Postop. Analgesia .

Patient satisfaction .Patient satisfaction .Neuromuscular disease .Neuromuscular disease .Difficult impossibleDifficult impossible

intubationintubationCritically ill patients .Critically ill patients .Ext. operation .Ext. operation .Embolism prevention .Embolism prevention .




Regional

Anesthesia

Central NeuroaxialSpinal

EpiduralCaudal Plexus block

.Peripheral N block

Localinfilteration

CervicalStillate gang

BrachialLumbarCeliac




L.A ActionL.A ActionL.A are NaL.A are Na ++++ ch. Blockersch. Blockers

Diffuse through theDiffuse through themyeline sheeth blockmyeline sheeth block

NaNa ++++

ch.ch.

Prevent the Na entryPrevent the Na entrymaintain RMPmaintain RMP

preventspreventsdepolarization Nodepolarization NoAction PotentialAction Potentialpropagationpropagation




Spinal CordSpinal CordSpinal cord extend toSpinal cord extend to

T12-L1 in adultT12-L1 in adultL3 in pedia.L3 in pedia.Covered with fatty tissue,Covered with fatty tissue,v.plexus and meningies .v.plexus and meningies .Pia Arachinoid DuraPia Arachinoid DuramattermatterCSF between Pia – Arach .CSF between Pia – Arach .

Dural sac extend to filumDural sac extend to filumterminaleterminaleback of S2 in adultback of S2 in adult

S3 in childS3 in child




Physiology of neuroaxial blockPh

ysiology of neuroaxial blockSomatic Block Somatic Block

L.A block Na ch. Prevent the action potential

propagation depend on : Fibre size Myelinated or not

Drug Conc. Duration Symp. Block 2 segments above

loss of Temp (Autonomic ) .

Sensory block 2 seg aboveloss of pain and light touch .

Motor block loss of motor andproperioceptive




Symp. outflowSymp. outflow thoracolumbar T1 – L2 .thoracolumbar T1 – L2 .

Parasymp. outflowParas ymp. outflowcraniosacral .craniosacral .

Neuroaxial BlockNeuroaxial Block

blockblocksympathetic .sympathetic .

↑↑↑↑ parasymp.parasymp.




Successful Spinal BlockSuccessful Spinal Block

Autono

Temp

Pain touchSensory

Motor

Properioceptive




Physiological EffectsPhysiological EffectsCVSCVST1- T4 block cardiac symp.T1- T4 block cardiac symp.supplysupply

Parasymp. PredominantParasymp. Predominant ↓↓↓↓HRHR ↓↓↓↓ ContractilityContractility ↓↓ COCO

T5-L5 block symp VascularT5-L5 block symp Vascular

supplysupplyVDVD

↓↓↓↓ VRVR ↓↓↓↓ COCO ↓↓↓↓ BPBP

treated bytr eated by preload IV fluid 10-20ml/kgpreload IV fluid 10-20ml/kgPositioningPositioningVasopressorsVasopressors




RespR esp High block may block theHigh block may block theaccessory respiratory Ms.accessory respiratory Ms.IntercostalsIntercostals

Total High spinal mayTotal High spinal mayblock C4-5block C4-5Diaphragmatic (phrenicDiaphragmatic (phrenicnerve).nerve).Apnea may devlop withApnea may devlop withhigh blocks due tohigh blocks due to↓↓↓↓ COCO ↓↓↓↓ BPBP↓↓↓↓

medullary Bl. Flowmedullary Bl. Flow




Spinal BlockSpinal Block Midline app.Midline a pp.

SkinSkinSubcutaneous tissueSubcutaneous tissueSupraspinous ligSupraspinous ligInterspinous ligInterspinous lig

Ligamntum FlvumLigamntum FlvumDura matterDura matterAracinoid matterAracinoid matter paramedian approach paramedian approach

Skin S.CSkin S.CLumbar apeneurosisLumbar apeneurosislumbar Ms .lumbar Ms .Lig. FlavumLig. Flavum







Spinal BlockSpinal BlockRapid onset .Rapid onset .

Intense Block .Intense Block .Easy tech .Easy tech .Low L.A dose required .Low L.A dose required .Smaller the gauge the lowerSmaller the gauge the lowerP.D.P.H ( G23 –G 25 ) .P.D.P.H ( G23 –G 25 ) .

More hypotensive more CVS effect .More hypotensive more CVS effect .Shorter duration ( 2 -3 hr )Shorter duration ( 2 -3 hr )Inability to extend the duration .Inability to extend the duration .




Epidural AnesthesiaEpidural AnesthesiaShould not puncture duraShould not puncture durahigh incidence of PDPHhigh incidence of PDPHSlower onset . Acting on myelinatedSlower onset . Acting on myelinatednerves .nerves .Unpredicted block level .Unpredicted block level .Difficult tech.Difficult tech.

High failure rate (patchy) .High failure rate (patchy) .High dose of L.A used systemic TOX.High dose of L.A used systemic TOX.

Catheter prolong the duration .Catheter prolong the duration .72 -96 hr .72 -96 hr .Less hypotensive less CVS effect .Less hypotensive less CVS effect .Postop. analgesia .Postop. analgesia .






P.D.P.HP.D.P.H

Frontal headacheFrontal headache bilateral bilateral 24 – 72 hr post puncture24 – 72 hr post punctureCSF leakage from dural CSF leakage from dural

puncture puncture traction on braintraction on brain

sensitive structures .sensitive structures . ppt by : p pt by :

female > malefemale > maleLarge size needleLarge size needle

treated by :treated by :

rest hot drinks caffeinerest hot drinks caffeine

analgesicsanalgesics IV FluidsIV Fluids

epidural Bl. patchepidural Bl. patch




ContraindicationContraindication Absolute Absolute

patient refusal Coagulopathy Hemodynamic instability

Hypovol.Infectionneurological deficit High CSf pressure

Relative Anticoagulant previous spine operation psychic time surgeon




Brachial Plexus BlockBrachial Plexus BlockIndication :Indication :

Upper limboperationshoulder operation.

Postop. analgesia .

ApproachesInterscaline

SupraclvicularInfraclavicular

Axillary

DisadvantageDifficult tech.

IV injection




Brachial Plexus BlockBrachial Plexus Block




IV Regional AnesthesiaIV Regional AnesthesiaBeir’s BlockBeir’s Block

In Forearm operation .In Forearm operation .Iv canula inserted .Iv canula inserted .Limb evacuated from BlLimb evacuated from Bl

Tourniquet inflatedTourniquet inflated 100mmhg > SBP .100mmhg > SBP .LA injectedLA injected

20 -40 ml Lidocaine20 -40 ml Lidocaine2% or prilocaine2% or prilocaine

not Bupivacaine !!!!!.not Bupivacaine !!!!!.

Deflating after 45 min .Deflating after 45 min .




Caudal block and othersCaudal block and others

Caudal BlockCaudal Blockintra and postop analgesia inintra and postop analgesia in

pediatric pediatric 1ml /kg L.A dose1ml /kg L.A dose15-20 ml to fill space15-20 ml to fill space

Ilioinguinal iliohypogastricIlioin guinal iliohypogastric

Penile blockPenile block circumcisioncircumcision




Ankle BlockAnkle BlockIndicationIndication Foot surgeryFoot surgeryDistal toes .Distal toes .Depridement in Ð.Depridement in Ð.

BlockingBlock ing Superficial peronialSuperficial peronial

Deep peronialDeep peronialSuralSuralSaphenousSaphenousPost. tibial .Post. tibial .






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Conduct of Local Anesthesia Technique and Complication