A Technique for Obtaining Successful Sacral Spread With Continuous Lumbar Epidural Anesthesia Techniques for obtaining sacral

spread of the injected local anesthetic solution are necessary in many instances for assuring successful lumbar epidural anesthesia. Normally, the level of skin analgesia during continuous lumbar epidural anesthesia extends more cephalad than caudad from the site of injection (l), with analgesia taking longer to develop in the first sacral dermatome than in the second and third sacral dermatomes because of the differences in nerve root size (2,3). In this study we compared the extent of loss of cold sensation in the sacral area when two different methods of injecting local anesthetics into the epidural space were used: in one the injection was made through both the epidural needle with bevel pointed caudally and through the catheter; in the other the injection was made through the epidural catheter only. Methods Forty gynecologic patients without neurological disease, hypertension, diabetes mellitus, large intra-abdominal mass, or pregnancy were studied. All patients were informed about the nature of the study, and consent was obtained. They were premedicated with atropine (0.25-0.5 mg) and hydroxyzine (25-50 mg) 45 min before the procedure. A 17-gauge Tuohy needle was inserted into the epidural space at the L3-4 interspace using a midline approach and a loss of resistance technique with the bevel pointed in a cephalad direction. We used two methods for injection of a total volume of 15 mL of 2% mepivacaine without epinephrine. In group A (20 cases), the epidural catheter was advanced 5 cm cephalad into the epidural space and fixed in position; after careful aspiration, a test dose of 3 mL of 2% mepivacaine was injected. After turning the patient to the supine position and assuring that the test dose had not been injected intravascularly or into the subarachnoid space, the remaining 12 mL of 2% mepivacaine was injected through the catheter 3-5 min after the test injection. In group B (20 cases), the bevel of the epidural needle was pointed in a caudad direction, and, after careful aspiration, 5 mL of 2% mepivacaine was injected within a few seconds, after which the bevel was pointed in the cephalad direction and an epidural catheter introduced, with the remaining 10 mL of 2% mepivacaine being injected through the catheter 3-5 min after the caudad injection. The cutaneous extent of loss of cold sensation was determined using a swab of cotton wool soaked with absolute alcohol 15 and 25 min after the test injection, with special attention being paid to cold sensation in the first sacral segment (2,3). The dermatomal chart described by Cousins and Bromage was used for the mapping (1). The loss of cold sensation was used for the determination of the spread of epidural anesthesia because Wugmeister and Hehre have reported that anesthetic levels to cold and pinprick sensation showed little or no change between 15 and 30 min (4). Moreover, repetitivenoxiousstimulationto skin to measure the level of analgesia might cause skin damage and discomfort to the patient. Statistical analysis was performed using the non- paired t-test or Wilcoxon rank-sum test. P < 0.05 was considered statistically significant. Results There were no cases of failed or unilateral epidural anesthesia. The cephalad level of the loss of cold sensation 15 min after the injection was T-8.5 (T-2 to T-12) (median [range]) in group A and T-8 (T-1 to L-1) in group B; 25 min after the injection these were T-5.5 (T-1 to T-12) and T-5.5 (T-1 to T - l l ) , respectively. There was no significant difference in the cephalad level between the two groups. The caudad level of loss of cold sensation 15 min after injection was

L-3 (L-1 to S-3) in group A and S-3 (L-1 to S-4) in group B ( P < 0.01). Twenty-five minutes after injection, these were S-3 (L-2 to S-4) for group A and S-3 (S-3 to S-5) for group B (P < 0.01, Table 2). Twenty-five minutes after the injection, complete blockade in the third sacral dermatome was present in 11 patients (55%) in group A and in 20 patients (100%) in group B. However, the number of patients who had complete blockade of the first sacral der matome was low in both groups, 2 (10%) and 13 (65%), respectively. Discussion Many factors-such as a site of injection, nerve root size, weight, height, age, posture, speed of injection of local anesthetic, volume, concentration, and type. an epidural Tuohy needle with its bevel pointed to caudad than it was when the entire injection was made through the epidural catheter. There were no significant differences in other factors that might affect the spread of anesthetic level; therefore, our results can be ascribed to the difference in the method of injection of the local anesthetic solution into the epidural space. Why was the extent of loss of cold sensation in the sacral area so great with partial caudad injection of mepivacaine through the Tuohy needle? It has been reported that epidural pressure affects spread of anesthetic solutions in epidural space (10, l l) . The initial caudad injection might create greater epidural pressure and thus greater spread of loss of cold sensation than an injection through a catheter advanced in a cephalad direction alone. Equally likely- or even more likely-the direction in which the bevel of the Tuohy needle was pointing at the time of injection might have been responsible for the in- creased spread in the sacral area. It has been reported that rotation of an epidural needle may puncture the dura mater, and thus an epidural needle should not be rotated in the epidural space (13). Although there was no case of dural puncture in our study while rotating the epidural needle from caudad to cephalad, the possibility of dural puncture should be kept in mind. here are conflicting reports of the sacral spread of analgesia during injection of local anesthetic into the lumbar epidural space. Galindo et al. reported that the failure to block the first sacral segment occurred in 20% of patients (2,3). On the other hand, complete sacral analgesia has been reported by some investi- gators (9,12). Although there is a difference between testing for cold discrimination and testing for pain (pinprick) when evaluating spread of local anesthetic in the epidural space, our results showed the same incomplete sacral anesthesia as reported by Galindo et al. We conclude that the initial partial injection of local anesthetic solution through an epidural Tuohy needle with its bevel pointed in the caudad direction before injecting the remainder of the local anesthetic through an epidural catheter directed in a cephalad direction results in greater spread of anesthesia in the sacral area than does the same amount of local anesthetic solution injected into an epidural catheter only. Source: anesthesia-analgesia.org

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St. Scholasticas College Tacloban Manlurip, San Jose Tacloban City

Journal Reading In Related Learning Experience

(Continuous Lumbar Epidural Anesthesia)

Submitted By: Tegio, Jhon Carlo S. BSN3-B Group IV