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The Safe Spinal Anaesthetic Spinal Anaesthesia Is Not Without Its Complications and Should Only Be Performed for the Correct Indications

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The Safe Spinal Anaesthetic Spinal Anaesthesia Is Not Without Its Complications and Should Only Be Performed for the Correct Indications The safe spinal anaesthetic Spinal anaesthesia is not without its complications and should only be performed for the correct indications. Mariane Gertruida Senekal, BMedSc, MB ChB, DA, MMed (Anaesthesiology) Principal Specialist, Department of Anaesthesiology, 3 Military Hospital, and Senior Lecturer, Department of Anaesthesiology, University of the Free State, Bloemfontein Mariane Senekal did her undergraduate training at Stellenbosch University and her postgraduate anaesthesia training at the University of the Free State where she obtained the MMed (Anaesthesiology) in 2005. She has an interest in obstetric anaesthesia, orthopaedic anaesthesia, anaesthesia-related physiology and teaching and training of anaesthesia. Correspondence to: M Senekal ([email protected]) Spinal anaesthesia is relatively easy to must be titrated with care. During the avoided. Indications and contra-indications perform and can potentially be excellent postoperative period the patient should are listed in Table 1. for below the umbilicus. However, it be admitted to the recovery room and can also give rise to serious side-effects monitored. Physiology and complications. To perform a safe Local anaesthetic solution injected into the procedure, the anaesthetist must have A spinal anaesthetic subarachnoid space blocks conduction of adequate knowledge of the indications should only be impulses along all nerves with which it comes and contra-indications, and of the relevant in contact. It acts mainly at spinal nerve roots, anatomy, physiology and pharmacology performed for the although some effect is possible at the cord of spinal anaesthesia. The patient must correct indications. itself. Smaller autonomic and sensory fibres be assessed before administration of the are blocked more easily than motor fibres. spinal anaesthetic and the theatre must be Indications and contra- Consequently, it produces a rapid sympathetic correctly prepared. The anaesthetist must indications block, which causes peripheral vasodilatation be familiar with the correct technique. A spinal anaesthetic should only be and hypotension, and the patient may be After administration of the anaesthetic, administered for the correct indications. If aware of pressure or movement but feel no the patient must be monitored so that side- relative contra-indications exist, extreme pain when surgery starts. effects and complications are recognised caution should be taken, and if there are immediately and treated early. Sedatives absolute contra-indications, it should be Table 1. Indications and contra-indications for spinal anaesthesia Indications Surgical procedures to the lower body below the umbilicus Caesarean section Respiratory disease (avoid high blocks) Pain relief Relative contra-indications Aortic stenosis/mitral stenosis (fixed cardiac output states) Systemic sepsis Neurological disease (medicolegal implications) Anatomical deformities of the patient’s back Difficult airway Long operating time Children Absolute contra-indications Inadequate drugs and equipment Clotting disorders/anticoagulation Refusal Severe hypovolaemia or shock Localised sepsis Increased intracranial pressure 16786 ECOTRIN isl-MOD MED.indd 1 3/28/12 1:42:07 PM 207 CME June 2012 Vol.30 No.6 Spinal anaesthesia Preoperative assessment and Table 2. Factors affecting the spread of the local anaesthetic solution premedication Factor Mechanism The preoperative assessment of the patient should be done as for a general anaesthetic. Baricity of the local anaesthetic solution Blocks can be better controlled with hyper- baric solutions It is important to explain the procedure, side-effects and possible complications to Position of the patient Level of the block may change if the patient’s the patient and to obtain informed consent. position is altered It should be explained that although a spinal Concentration of and volume injected A higher concentration produces a denser anaesthetic eliminates pain, the patient may block; a larger volume produces a block over a larger area be aware of some sensation in the relevant area and that the patient’s legs may become Speed of injection Rapid injection produces eddy currents within the CSF and a less predictable spread weak. Patients should be reassured that if they feel pain they will be given a general Increased abdominal pressure Leads to engorgement of the epidural veins and reduction in CSF volume anaesthetic. The usual ‘nil by mouth’ rule (i.e. no solids for 6 hours and no clear fluids up to 2 hours before anaesthesia) must be Intravenous access and it is recommended that spinals should not be observed unless the operation is urgent. preloading inserted above L3/4. Several cases of trauma Premedication is often unnecessary, but if Obtain IV access before starting the block. to the conus are documented in the literature,4 a patient is apprehensive, hydroxyzine may A large bore is recommended, preferably an mostly involving spinal insertion believed be given orally 2 hours before the operation. 18G IV catheter. It seems that no amount of to be above L3/4. Evidence suggests that fluid preloading can prevent hypotension in injection of fluid into the cord may not always Preparation of theatre, all cases, but 500 - 1 000 ml is advantageous. be involved, and that simple needle trauma instruments and drugs Crystalloids are more effective than no is sufficient to produce a syrinx resulting in Facilities for resuscitation and progression to fluids and colloids are more effective than foot drop, numbness and sometimes urinary general anaesthesia must be available. Make crystalloids in preventing hypotension.1 No problems. It is recommended not to inject sure that a reliable anaesthesia machine is differences were detected for different doses, once pain is experienced, but the damage may available, as well as suction and intubation rates or methods of administering colloids already have been done. equipment, and standard anaesthetic and or crystalloids.1 resuscitation drugs. A number of factors affecting the spread The preoperative of the injected local anaesthetic solution within the CSF and the ultimate extent of assessment of the the block are given in Table 2. patient should be done as for a general Local anaesthetics Any anaesthetic technique must produce anaesthetic. adequate surgical anaesthesia of sufficient duration and with minimal side-effects. Positioning the patient, The main side-effect of spinal anaesthesia anatomy, and factors affecting is a reduction in blood pressure. Reducing spread of local anaesthetic the dose of intrathecal local anaesthetic will Patients should be sitting or lying on their improve cardiovascular stability but may side. Back flexion opens the intervertebral not provide adequate surgical anaesthesia. spaces. The spinal cord terminates at L1/2 The anaesthetist needs to decide which local and the subarachnoid space at S2 in adults. It anaesthetic to use and the dose. is advisable to enter the lumbar subarachnoid space below the termination of the cord, Some preparations of local anaesthetics usually between vertebrae L4 and L5. The line contain additives such as preservatives joining the iliac crests is at L3/4 and is called and are not suitable for intrathecal Tuffier’s line. Aim to identify the L3/4, L4/5 or administration. Bupivacaine has a faster L5/S1 interspace. Considering the inaccuracy onset and longer duration (2 - 3 hours) of clinical means of identifying lumbar of analgesia and motor block than both interspaces, the tendency of anaesthetists to ropivacaine and levobupivacaine. The err upwards,2 and the uncertainty of the length duration of action of lignocaine may be too 16786 ECOTRIN isl-MOD MED.indd 1 3/28/12 1:42:07 PM of the spinal cord, even in normal individuals,3 short to guarantee adequate surgical time 208 CME June 2012 Vol.30 No.6 Spinal anaesthesia Table 3. Guideline for local anaesthetic volume (not applicable to pregnant patient head-up. See treatment of a high patients) or total spinal anaesthetic below. Type of block 0.5% hyperbaric bupivacaine Monitoring Saddle block 1 ml Establish full monitoring before Lumbar block 2 - 3 ml administering a spinal anaesthetic, including blood pressure monitoring (preferably with Mid-thoracic block 2 - 4 ml an automatic oscillometric monitor), an electrocardiogram and pulse oximetry. and it has a higher incidence of transient than 60 minutes to fix finally.6 If the patient Confirm the alarm levels for every patient radicular irritation.5 A guideline for the is unable to lift his/her legs from the bed, before starting the anaesthetic. volume of local anaesthetic to be used is the block is at least up to the mid-lumbar given in Table 3. The lower volumes should region. Test for a loss of temperature Side-effects and complications generally be given to small individuals. sensation. The side-effects and complications of spinal anaesthesia are shown in Table 4. Facilities for Problems with the block • No block. If after 10 minutes the patient Treatment of hypotension resuscitation and still has full power in the legs and normal Hypotension is due to vasodilatation progression to general sensation, then the block has failed, and a functional decrease in the effective anaesthesia must be probably because the injection was not circulating volume. This should be treated intrathecal. by reversing the vasodilatation with available. • The block is one-sided. Position the vasoconstrictor drugs and increasing the patient on the side that is inadequately circulating volume by giving IV fluids.
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