Donald H. Lambert Boston, Massachusetts

1. Spinal Anesthesia Donald H. Lambert Boston, Massachusetts http://www.debunk-it.org

2. www.debunk-it.org

5. RULE N0. 1: YOUR ATTENDING IS ALWAYS RIGHT. RULE NO. 2: IF YOUR ATTENDING IS WRONG, SEE RULE NO. 1.

6. Spinal Anesthesia • Advantages v. Disadvantages • Indications and Contraindications • Positioning • Getting ready • Getting the needle in the right spot • Baricity • Dosing • What to inject • Addition of a vasoconstrictor • Addition of narcotics • Complications (and how to avoid them)

7. Advantages of Spinal Anesthesia • Technically easy • Objective end-point • Rapid onset • Profound sensory and motor block • Low potential for systemic toxicity

8. Disadvantages of Spinal Anesthesia • Limited duration • Limited sensory and motor separation • “Hypotension” • Potential neuro-toxicity • Headache

9. Spinal Anesthesia • Advantages v. Disadvantages • Indications and Contraindications • Positioning • Getting ready • Getting the needle in the right spot • Baricity • Dosing • What to inject • Addition of a vasoconstrictor • Addition of narcotics • Complications (and how to avoid them)

10. Indications Any operation in the lower abdomen and below

11. Absolute Contraindications • Patient refusal • Uncorrected hypovolemia • Uncorrected coagulopathy • Infection at site of injection • Increased intracranial pressure

12. Relative Contraindications • Some neurologic diseases • Bacteremia • Deformities that preclude doing an LP easily

13. Spinal Anesthesia • Advantages v. Disadvantages • Indications and Contraindications • Positioning • Getting ready • Getting the needle in the right spot • Baricity • Dosing • What to inject • Addition of a vasoconstrictor • Addition of narcotics • Complications (and how to avoid them)

14. Positioning for the Lumbar Puncture • Two choices • Sitting • Lateral decubitus (recumbent)

15. Spinal Anesthesia • Advantages v. Disadvantages • Indications and Contraindications • Positioning • Getting ready • Getting the needle in the right spot • Baricity • Dosing • What to inject • Addition of a vasoconstrictor • Addition of narcotics • Complications (and how to avoid them)

22. Spinal Anesthesia • Advantages v. Disadvantages • Indications and Contraindications • Positioning • Getting ready • Getting the needle in the right spot • Baricity • Dosing • What to inject • Addition of a vasoconstrictor • Addition of narcotics • Complications (and how to avoid them)

23. Getting the needle in the right spot • What is the object of the game of basketball? • Get the ball in the hoop (Red Aurbach). • What are we trying to do with spinal anesthesia? • Get the needle into the CSF.

30. Spinal Anesthesia • Advantages v. Disadvantages • Indications and Contraindications • Positioning • Getting ready • Getting the needle in the right spot • Baricity • Dosing • What to inject • Addition of a vasoconstrictor • Addition of narcotics • Complications (and how to avoid them)

31. Baricity • The density of the local anesthetic solution in relation to the density of the CSF • More dense than CSF • hyperbaric • sinks • Same density as CSF • isobaric • stay where it is injected (relatively) • Less dense than CSF • hypobaric • floats

34. Hyperbaric Isobaric Hypobaric

35. Spinal Anesthesia • Advantages v. Disadvantages • Indications and Contraindications • Positioning • Getting ready • Getting the needle in the right spot • Baricity • Dosing • What to inject • Addition of a vasoconstrictor • Addition of narcotics • Complications (and how to avoid them)

36. Spinal Anesthesia • Dosing will affect • Spread • Duration • Quality of Anesthesia • That is, the need for supplemental IV medication

40. The dosing in this study was 10 mg, 15 mg, and 20 mg of bupivacaine The lowest dose limited spread The lowest dose also resulted in more failures than the higher doses.

42. Spinal Anesthesia • Advantages v. Disadvantages • Indications and Contraindications • Positioning • Getting ready • Getting the needle in the right spot • Baricity • Dosing • What to inject • Addition of a vasoconstrictor • Addition of narcotics • Complications (and how to avoid them)

43. Spinal Anesthesia Agents

44. Based on the spinal canal model (and many years of doing this) Hyperbaric solutions extend into the thoracic region Isobaric solution remain in the lumbar region Dosing Guidelines Hyperbaric Isobaric • I give hyperbaric solutions for operations above the L1 dermatome and isobaric solutions for those below

45. Dosing Guidelines • Hernia operations and those operations whose innervation is by nerves above L1 • HYPERBARIC • Those operations whose innervation is by nerves below L1 (pretty much all lower extremity operation including hip operations) • ISOBARIC

46. CHOOSING A LOCAL ANESTHETIC FOR SPINAL ANESTHESIABASE DECISION ON THE DURATION OF THE OPERATION

47. CHOOSING A LOCAL ANESTHETIC FOR SPINAL ANESTHESIAGIVE ENOUGH TO PROVIDE ADEQUATE ANESTHESIA ? CHLOROPRACAINE, ? ROPIVACAINE

48. Isobaric Spinal Anesthesia • Epidural Bupivacaine for spinal anesthesia is an “off label use” of this agent • It says right on the bottle: “Not for spinal anesthesia” • What is the value or wisdom behind using that agent? • It works great and I have used it since the 1980’s. • I know of no reports of complications associated with using it. • Litigation for the off-labeled use of a drug has not appeared in the ASA closed claims database. • Who would know? • Unless you wrote on your anesthesia record, “I used the bupivacaine that is not for spinal anesthesia.”

49. Spinal Anesthesia • Advantages v. Disadvantages • Indications and Contraindications • Positioning • Getting ready • Getting the needle in the right spot • Baricity • Dosing • What to inject • Addition of a vasoconstrictor • Addition of narcotics • Complications (and how to avoid them)