This document discusses factors that affect the level of spinal and epidural anesthesia. For spinal anesthesia, key factors include drug properties like dose, baricity, and concentration. Patient characteristics like age, weight, and pregnancy status also influence block level. Procedure details such as patient position and injection site choice impact spinal block height as well. Similar factors of drug dose, patient physiology, and procedural approach determine the extent of epidural anesthesia. Drug volume, concentration, and additive selection combined with patient age, weight, and anatomical pressures guide epidural block distribution.
This document discusses factors that affect the level of spinal and epidural anesthesia. For spinal anesthesia, key factors include drug properties like dose, baricity, and concentration. Patient characteristics like age, weight, and pregnancy status also influence block level. Procedure details such as patient position and injection site choice impact spinal block height as well. Similar factors of drug dose, patient physiology, and procedural approach determine the extent of epidural anesthesia. Drug volume, concentration, and additive selection combined with patient age, weight, and anatomical pressures guide epidural block distribution.
This document discusses factors that affect the level of spinal and epidural anesthesia. For spinal anesthesia, key factors include drug properties like dose, baricity, and concentration. Patient characteristics like age, weight, and pregnancy status also influence block level. Procedure details such as patient position and injection site choice impact spinal block height as well. Similar factors of drug dose, patient physiology, and procedural approach determine the extent of epidural anesthesia. Drug volume, concentration, and additive selection combined with patient age, weight, and anatomical pressures guide epidural block distribution.
ANESTHESIA Dr. SHIKHA SHAH SPINAL ANESTHESIA • Drug factors 1. Dose, 2. Baricity 3. Volume 4. Concentration 5. Temperature of injection 6. Viscosity 7. Additive other than opoids • Patient factors 1. CSF volume 2. Advanced age 3. Pregnancy 4. Weight, height 5. Spinal anatomy 6. Intraabdominal pressure 7. Menopause 8. gender • Procedure factors 1. Patient position 2. Epidural injection post spinal 3. Level of injection (hypobaric more than hyperbaric) 4. Fluid currents 5. Needle orifice direction 6. Needle type DRUG FACTORS Baricity : • Baricity is defined as the ratio of the density (mass/volume) of the local anesthetic solution divided by the density of CSF, which averages 1.0003 ± 0.0003 g/mL at 37°C. • Solutions that have the same density as CSF have a baricity of 1.0000 and are termed isobaric. • Solutions that are more dense than CSF are termed hyperbaric, whereas solutions that are less dense than CSF are termed hypobaric. • solutions with a baricity <0.9990 can be expected to reliably behave hypobarically in all patients. • Hypobaric solutions are typically prepared by mixing the local anesthetic solution with distilled water. • Solutions with a baricity of ≥1.0015 can be expected to reliably behave hyperbarically. Hyperbaric solutions are typically prepared by mixing the local anesthetic in 5 to 8% dextrose. • The baricity of the resultant solution depends on the amount of dextrose added; however, dextrose concentrations between 1.25 and 8% result in equivalent block heights. • Baricity is important in determining local anesthetic spread and thus block height because gravity causes hyperbaric solutions to flow downward in CSF to the most dependent regions of the spinal column, whereas hypobaric solutions tend to rise in CSF. • In contrast, gravity has no effect on the distribution of truly isobaric solutions. Thus, one can exert considerable influence on block height by choice of anesthetic solution and proper patient positioning. • Spinal block can be restricted to the sacral and low lumbar dermatomes (“saddle block”) by administering a hyperbaric local anesthetic solution with the patient in the sitting position or by administering a hypobaric solution with the patient in the prone jackknife position. • Similarly, high thoracic to midcervical levels of anesthesia can be reached by administering hyperbaric solutions with the patient in the horizontal and Trendelenburg positions or by administering hypobaric solutions with the patient in a semisitting position. • The sitting, Trendelenberg, and jackknife positions have marked influences on the distribution of hypobaric and hyperbaric solutions because these positions accentuate the effect of gravity. • While the patient is turned laterally, gravity has a small but measurable effect on local anesthetic distribution in that hyperbaric solutions will produce a denser, longer lasting block on the dependent side, while hypobaric solutions will have the opposite effect. • This makes hypobaric solutions ideal for unilateral procedures performed in the lateral position (e.g., hip surgery). • Hyperbaric solutions can be used to advantage for unilateral procedures performed in the supine position if the operative side is dependent during drug injection and the patient is left in the lateral position for at least 6 minutes. Dose , volume and concentration • Dose = volume x concentration • Dose is most reliable determinant of local anesthetic spread and thus the block height. • Doses of hyperbaric 0.5% bupivacaine <10 mg results in blocks that are approximately two and one-half dermatomes lower than those achieved with doses >10 mg. Injection site • The site of injection can have an important effect on block height in some situations. • By moving from the L3-4 to the L4-5 interspace means block height could be reduced from T6 to T10 when using isobaric 0.5% bupivacaine. Patient factors • Patient characteristics include height, weight, age, sex , pregnancy , anatomic configuration of the spine, and the CSF properties (volume and composition). • Within normal sized adults , patient height does not seem to affect the spread of spinal anesthesia. This is likely because the length of the lower limb bones rather than the vertebral column contributes most to adult height. • The CSF volume is an important patient related factor the significantly influences peak block height and regression of sensory and motor blockade. • Lumbosacral CSF has a fairly constant pressure of approximately 15cm of H2O but is volume varies form patient to patient, in part because of differences in body habitus and weight. • The density of CSF is lower in women compared with men, premenopausal compared with postmenopausal women, and pregnant compared with nonpregnant women. • Advanced age is associated with increased block height. In older patients, CSF volume decreases, whereas its specific gravity increases. Further nerve roots are more sensitive to local anesthetic in the aged population. • Gender affect block height by several mechanism. • CSF density is higher in males, thereby reducing the baricity of local anestheic solution and possibly limiting the extent of cephalad spread. • In the lateral position, the broader shoulders of males relative to their hips make the lateral position slightly more head up. • The reverse is true in females who have a slightly head down tilt in the lateral position compared with males. • Variations of spine may be an important contributor to block height. • Scoliosis makes insertion of the needle more difficult, will have little effect on local anesthetic spread if the patient is turned supine. • Kyphosis in a supine patient may affect the spread of a hyperbaric solution. • Spread of local anesthetic is enhanced by changes in the lumbar lordosis during pregnancy, as well as by the volume and density of CSF, by twin pregnancies compared with singletons, by intraabdominal pressure increases and by a progestrone mediated increase in neuronal sensitiviy. Procedure factors • Combined with the baricity and local anesthetic dose, patient position is the most important factor in determining the block height.
• A 10 degree head up tilt can reduce the spread of
hyperbaric solutions without hemodynamic compromise. • A saddle block where only the sacral nerve roots are anesthetized can be achieved by using a small dose of hyperbaric local anesthetic while the patient remains in the sitting position for up to 30mins. • The specific needle type and orientation of the orifice may affect block quality. • With hypobaric solutions, cephalad alignment of the orifice of Whitacre, but not Sprotte, needles produces greater spread. • When directing the needle orifice to one side and using hyperbaric anesthetic , a more marked unilateral block is achieved again when using a whitacre , rather than a Quincke needle.
• The level of injection affects block height.
• Even when the difference is only one interspace more cephalad, the block height is greater when using isobaric bupivacaine. • The injection of local anesthetic or even into the epidural space after a spinal anesthetic increases the block height. Epidural anesthesia • The epidural space is a collapsible, distensible reservoir through which drugs spread and are removed by diffusion, vascular transport, and leakage. • Spread of anesthetic within the epidural space, and subsequent block height, is related to a variety of factors. • Drug factors 1. Volume 2. Dose 3. Concentration 4. Additives • Patient factors 1. Elderly age 2. Pregnancy 3. Weight, height 4. Pressure in adjacent body cavities • Procedure factors 1. Level of injection 2. Patient position 3. Speed of injection 4. Needle orifice direction Drug factors • The volume and total mass of injectate are the most important factors. • As a general principle, 1 to 2ml of solution should be injected per segment to be blocked. • Additives such as bicarbonate, epinephrine, and opioids influence onset, quality and duration of analgesia but they do not affect spread. Patient factors • There is stronger correlation with age and block height. • In elderly less volume is required. • The reasons include decreased leakage of local anesthetic through intervertebral foramina, decreased compliance of the epidural space in the elderly result in greater spread or an increased sensitivity of the nerves. • Only extremes of patient height influence local anesthetic spread in the epidural space. • Weight is not well correlated with block height. • In pregnant patients, less local anesthetic is required to produce the same epidural space of anesthesia. Procedure factors • Level of injection is the most important factor that affects epidural block height. • In upper cervical region , spread is mostly caudal. • In midthoracic region , spread is equally cephalad and caudal. • And in the low thoracic region, spread is primarily cephalad. • After lumbar epidural, spread is more cephalad than caudal. • The total number of segments blocked is less in the lumbar region compared with thoracic levels. • Patient position also affect spread of lumbar epidural injections, with preferential spread and faster onset to the dependent side in the lateral decubitus position. • The sitting and supine position does not affect block height. • The head down tilt position does increase spread in obstetric patients. • Needle bevel direction and speed of injection do not appear to influence the spread of injection. THANK YOU