Combined
Spinal-Epidural Anesthesia
Joseph Eldor, MD
Preface
Origin
Soresi technique
Curelaru technique
Needle-through-needle
technique
Eldor needle technique
Huber needle technique
Eldor, Coombs and
Torrieri technique
Indications
Problems
The twin theory
Failed spinal or
epidural anesthesia
One needle technique
for combined spinal-epidural anesthesia
Aspiration pneumonia
prevention by the CSEA
Intraoperative
challenges
Anesthesia and public
image
Huber needle and Tuohy
catheter
Total spinal
anesthesia: The origin of CSEGA
What is anethesia?
Use of ephedrine in
CSEGA
Cardiovascular effects
of CSEGA
Cord ischemia and
preemptive analgesia
CSEA for Cesarean
section
Corning
Bier
A new look at the
lumbar extradural space pressure
Do not rotate the
epidural needle
Epidural rostal
augmentation of spinal anesthesia
Metallic particles in
the needle-through-needle technique
Superselective spinal
anesthesia
CSEA in uncommon
disease
CSEA for laparoscopic
operations
Postoperative epidural
analgesia
Unilateral spinal
anesthesia
CSEA for abdominal
operations
CSEA for thoracic
operations
Anesthetic risk
factors
Medico-legal aspects
of CSEA
Spinal opioid pruritus
and emesis
Endocrine responses to
spinal or epidural anesthesia
Epidural unilateral
blockade
Combined
spinal-epidural anesthesia: The anesthesia of choice
Epidural catheter
strength
Epidural catheter
paresthesias
CSEA and anticoagulation
Combined
spinal-epidural analgesia in labor
Combined
spinal-epidural anesthesia for orthopedic operations
Combined end-multiple
lateral holes (CEMLH) epidural catheter
Double-hole
pencil-point spinal needle
Epidural catheter test
dose in the combined spinal-epidural anesthesia
Spinal and epidural
opioid analgesia
The choice of the
anesthesiologists
Epidural catheter
malposition
Woolley and Roe case
Anesthetic costs
From the skin to the
spinal-epidural spaces
Myint case
Spinal needles
Meningitis post
spinal-epidural anesthesia
Preemptive analgesia
and combined spinal-epidural anesthesia
Sympathetic
innervation and CSEA
The politics of
anesthesiology
Preconclusion
Conclusion
CSEA (combined
spinal-epidural anesthesia) and CSEGA (combined spinal-epidural-general
anesthesia) are new modalities of anesthesia for almost any patient at any age.
This book highlights the subject from various points of view. It doen`t intend
to teach. It`s goal is to encourage the anesthesiologists to practise what they
already know in the best way they think is good for themselves while being a
patient. It is a kind of a balanced anesthesia which uses techniques instead of
drugs to accomplish the ideal kind of anesthesia for the patients. This new
frontier in anesthesia should open a new era of anesthetic quality and
cost-effectiveness. However, in the second edition of Principles and Practice
of Obstetric Analgesia and Anesthesia, edited by Bonica JJ and McDonald JS, and
published in 1995 by Williams & Wilkins, there are 1344 pages. The chapter
on epidural analgesia and anesthesia contains 127 pages. That on subarachnoid
block - 26 pages. On subarachnoid/epidural combination there is only half a
page with only 2 references in the chapter on cesarean section. So, the new
combined spinal-epidural anesthesia gained only 0.03% of the space in a book
published in 1995 on the practice of obstetric analgesia and anesthesia. This
is really not its present worth, neither its future...
"It has long been an axiom of mine that the little things are infinitely
the most important" (Arthur Conan Doyle).
"If pain could have cured us we should long ago have been saved"
(George Santayana).
"The greatest evil is physical pain" (St. Augustine of Hippo).
Origin
The first epidural analgesia was done by
1. Corning JL. Spinal anaesthesia and local medication of the cord. NY Med J 1885;42:483-485
2. Wynter WE. Lumbar puncture. Lancet 1891;1:981-982
3. Quincke HI. Die technik der lumbalpunktion. Verh Dtsch Ges Inn Med 1891;10:321-331
4. Von Ziemssen HW. Allgemeine behandlung
der infektionskrankenheiten.
5. Bier A. Versuche uber Cocainisirung des Ruckenmarkes. Dtsch Ztschr Chir 1899;51:361-369
6. Soresi AL. Episubdural anesthesia. Anesth Analg 1937;16:306-310
7. Curelaru I. Long duration subarachnoid anaesthesia with continuous epidural block. Praktische Anasthesie Wiederbelelung und Intensivtherapie 1979;14:71-78
8. Genesis 2:21 9. Ecclesiastes 4:9
Soresi
technique
Soresi (1) used a fine needle without stilet and introduced it into the epidural space using the hanging drop technique. While in the epidural space he injected 7-8 ml of dissolved novocain. Then he pierced the dura and poured another 2 ml of dissolved novocain into the spinal space. This gave his patients anesthesia for a period of 24-48 hours! He and his colleagues employed this method in over 200 patients. He concluded that "by combining the two methods many of the disadvantages of both methods are eliminated and their advantages are enhanced to an almost incredible degree".
1. Soresi AL. Episubdural anesthesia. Anesth Analg 1937;16:306-310
Curelaru
technique
Forty two years later, the Swedish anesthesiologist,
Curelaru (1), while working in
1. Curelaru I. Long duration subarachnoid anaesthesia with continuous epidural block. Praktische Anasthesie Wiederbelelung und Intensivtherapie 1979;14:71-78
Nedle-through-needle
technique
Coates (1) from
1. Coates MB. Combined subarachnoid and epidural techniques. A single space technique for surgery of the hip and lower limb. Anaesthesia 1982;37:89-90
2. Mumtaz MH, Daz M, Kuz M. Combined subarachnoid and epidural techniques: Another single space technique for orthopaedic surgery. Anaesthesia 1982;37:90
Eldor
needle technique
The Eldor needle (1) was first described in 1990. The Eldor needle is a combined spinal-epidural needle which is composed of an 18 gauge epidural needle with a 20 gauge spinal conduit. This is a specialized needle for the combined spinal-epidural anesthesia. There is no need of long spinal needles. The epidural catheter can be inserted before the spinal anesthetic injection. The Eldor needle facilitates the insertion of very small gauge spinal needles through its spinal conduit, so significantly reduces the incidence of post-dural puncture headache. There is no danger of epidural catheter protrusion through the dural hole made by the spinal needle. There are no metallic particles production while the spinal needle passes through the bent epidural needle tip, as in the needle-through-needle technique. The procedure of the Eldor needle is quite simple and straightforward. First, the spinal needle is introduced into the guide needle as far as the distal end of the latter. Then, the now Eldor needle is introduced into the selected intervertebral space and the epidural space is located using the well-known indicator methods. After that the epidural catheter is introduced into the epidural space, confirming its position by the test dose technique. Then, the spinal needle is slowly pushed in to puncture the dura, until cerebrospinal fluid is obtained. The anesthetic solution is injected through the spinal needle into the spinal space. Subsequently, the spinal needle is slowly withdrawn from the guide needle and then the Eldor needle is withdrawn, leaving the epidural catheter in position in the epidural space.
1. Eldor J, Guedj P. Une nouvelle auguille pour l`anesthesie rachidienne et peridurale conjointe. Ann Fr Anesth Reanim 1990;9:571-572
Huber
needle technique
Huber (1), the inventor of the "Tuohy" epidural needle, also patented in 1953 an hypodermic needle with an "auxiliary outlet being disposed in transverse alignment with the channel outlet" (2). Hanaoka (3) described in 1986 its use in 500 patients. This needle has a very small hole behind the epidural needle tip ("back eye"). A small gauge spinal needle is inserted through that hole and punctures the dura. After withdrawing the spinal needle an epidural catheter is introduced through the epidural needle.
1. Eldor J. Huber needle and Tuohy catheter. Reg Anesth 1995;20:252-253
2. Huber RL. Hypodermic needle. US Patent No. 2,748,769
3. Hanaoka K. Experience in the use of
Hanaoka`s needles for spinal-continuous epidural anaesthesia (500 cases). 7th
Asian Australasian Congress of Anaesthesiologists Abstracts.
Eldor,
Coombs and Torrieri technique
Eldor (1) and Torrieri (2) described in separate letters, in 1988, an epidural needle with a spinal needle attached to it. Through the spinal needle a longer spinal needle is inserted into the subarachnoid space, while an epidural catheter is introduced through the epidural needle into the epidural space. A few months before the publication of these letters, Coombs (3) applied for a patent on the same device.
1. Eldor J, Chaimsky G. Combined spinal-epidural needle (CSEN). Can Anaesth Soc J 1988;35:537-8
2. Torrieri A, Aldrete JA. Letter to the Editor. Acta Anaesthesiologica Belgica 1988;39:65-66
3. Coombs DW. Multi-lumen epidural-spinal needle. US Patent No. 4,808,157
Indications
Combined spinal-epidural anesthesia is like "to paint the fence" from both its sides. The indications are those of the spinal or epidural alone and even more. Rawal (1) made a survey in 17 European countries on their anesthetic choices in 1992. 17% of the procedures were performed under central blocks. Among these blocks - 56% were spinal; 40% - epidural and 4% - combined spinal-epidural anesthesia. The commonest indication for combined spinal-epidural blocks was hip replacement surgery (28.2%), followed by hysterectomy (19%), knee surgery (14.4%), Cesarean section (14%), emergency Cesarean section (13%), femur fracture in elderly patients (7.2%) and prostatectomy (5.6%). This under-utility of regional anesthesia (only 17% of the procedures) is in contrast to how the anesthesiologists would like to be anesthetized in case they need an operation: In 1986, Broadman et al. (2) confirmed that 92% of the anesthesiologists preferred regional over general anesthesia for their own hypothetical surgery, while 74% preferred a regional technique for their own elective extremity surgery. This is in accordance with a previous survey done in 1973 by Katz (3) in which 68% of the American anesthesiologists surveyed preferred regional anesthesia for their own anesthetic during an unspecified elective surgical procedure. The spectrum of indications for the combined spinal-epidural anesthesia ranges from labor analgesia (4,5) to high abdominal and even thoracic and head operations (6) by the adjuvant use of an endotracheal tube ventilation. The dosages of the local anesthetics with or without opioids that are injected into the spinal and epidural spaces are now evaluated in various hospitals around the world. The dosage combinations are enormous. The story has only begun.
1. Rawal N. European trends in the use of combined spinal epidural technique - A 17-nation survey. Reg Anesth 1995;20 (Suppl):162
2. Broadman LM, Mesrobian R, Ruttiman U,
3. Katz J. A survey of anesthetic choice among anesthesiologists. Anesth Analg 1973;52:373-5
4. Abouleish A, Abouleish E, Camann W. Combined spinal-epidural analgesia in advanced labour. Can J Anaesth 1994;41:575-8
5. Arkoosh VA, Sharkey SJ, Norris MC, Isaacson W, Honet JE, Leighton BL. Subarachnoid block analgesia: Fentanyl and morphine versus fentanyl and morphine. Reg Anesth 1994;19:243-246
6. Eldor J. Combined spinal-epidural-general anesthesia. Reg Anesth 1994;19:365-6
Problems
Blumgart et al. (1) found that the mechanism of extension of spinal anesthesia by extradural injection of local anesthetics is largely a volume effect. Using extradural saline 10 ml and extradural bupivacaine 0.5% 10 ml - the extension of the block was found to be similar in the saline or the bupivacaine groups, and significantly faster than the group which received no extradural injection after spinal injection of 1.6-1.8 ml of 0.5% hyperbaric bupivacaine. Suzuki et al. (2) found that spinal puncture with a 26 gauge spinal needle, with no spinal anesthetic injection, immediately before epidural injection of 18 ml 2% mepivacaine resulted in rapid caudal spread of analgesia as compared to an epidural anesthetic alone. They attributed it to the flow of local anesthetic into the subarachnoid space through the perforation produced by the spinal needle. In all the techniques, except the Eldor needle and Curelaru`s double-space techniques, there is inability to perform the epidural catheter test dose due to the fact that the epidural catheter is inserted after the subarachnoid local anesthetic injection. This can result in epidural catheter malposition in the subarachnoid space or intravascular with a danger of total spinal, delayed cardiorespiratory arrest due to opioid overdosage (3,4) or convulsions. Due to the insertion of the spinal needle through the bent tip of the epidural needle in the needle-through-needle technique there is friction that produces metallic microparticles that can be introduced further into the epidural space by the epidural catheter insertion (5,6). If there is a delay in epidural catheter threading in the needle-through-needle technique there is a partial spinal anesthesia while using the hyperbaric anesthetic solution (7), with the need to supplement it further through the epidural route. The incidence of epidural needle or catheter unintentional dural puncture ranges from 2.5% (8) to 0.6% (9) and even 0.26% (10). However, using the needle-through-needle technique the chances are greater because of the same pathway shared by the spinal needle and the epidural catheter in the epidural space and the force exerted by the friction between the spinal needle and the epidural needle`s tip that can advance forward the epidural needle causing an unrecognized dural tear by the epidural needle, through which an epidural catheter can be threaded inadvertently.
1. Blumgart CH, Ryall D, Dennison B, Thompson-Hill LM. Mechanism of extension of spinal anaesthesia by extradural injection of local anaesthetic. Br J Anaesth 1992;69:457-460
2. Suzuki N, Koyanemaru M, Onizuka S, Takasaki M. Dural puncture with a 26-gauge spinal needle affects epidural anesthesia. Reg Anesth 1995;20 (Suppl):118
3. Myint Y, Bailey PW, Milne BR. Cardiorespiratory arrest following combined spinal epidural anaesthesia for caesarean section. Anaesthesia 1993;48:684-686
4. Eldor J, Guedj P, Levine S. Delayed respiratory arrest in combined spinal-epidural anesthesia. Reg Anesth 1994;19:418-422
5. Eldor J, Brodsky V. Danger of metallic particles in the spinal-epidural spaces using the needle-through-needle approach. Acta Anaesthesiol Scand 1991;35:461
6. Eldor J. Metallic particles in the spinal-epidural needle technique. Reg anesth 1994;19:219-220
7. Fan SZ, Susetio L, Wang YP, Cheng YJ, Liu CC. Low dose of intrathecal hyperbaric bupivacaine combined with epidural lidocaine for cesarean section - a balance block technique. Anesth Analg 1994;78:474-7
8. Dawkins CJM. An analysis of the complications of extradural and caudal block. Anaesthesia 1969;24:554-563
9. Tanaka K, Watanabe R, Harada T, Dan K. Extensive application of epidural anesthesia and analgesia in a university hospital: Incidence of complications related to technique. Reg Anesth 1993;18:34-38
10. Macdonald R, Lyons G. Unintentional dural puncture, Anaesthesia 1988;43:705
The twin
theory
Spinal anesthesia is a safe, cost-effective and reliable form of anesthesia. Many anesthesiologists would regard the epidural as an insurance against unsatisfactory spinal anesthesia, aiming to provide complete anesthesia by the subarachnoid route (1). Another approach is the use of a minimal dose of spinal anesthesia for a shorter duration with the flexibility of epidural reinforcement if necessary. For many years in many anesthetic departments around the world there was a philosophy that extradurals are for young people and the intrathecal route for the old, with few exceptions. Seeberger et al. (2) addressed the question: Is the spinal or the epidural technique better? Two hundred and two patients younger than 50 years underwent spinal or epidural anesthesia. Spinals were performed with 24-gauge Sprotte needles and epidurals with 18 gauge Tuohy needles and catheters. The failure rate of both techniques was 5%. Patient acceptance was high in both groups (97% in the spinal; 93% in the epidural). The authors concluded that spinal anesthesia was superior, because of better quality of anesthesia, no risk of intoxication, less time needed to perform the block, and less expensive kits. However, using the combined spinal-epidural anesthesia there is no more a question of which is better, as Greene and Brull (3) wrote: "Epidural and spinal anesthesia are indeed related to each other, but only to the same extent as cousins, or, at best, siblings; monozygotic twins they are not".
1. Brownridge P. Epidural and subarachnoid analgesia for elective caesarean section. Anaesthesia 1981;36:70
2. Seeberger MO, Lang ML, Drewe J, Schneider M, Hauser E, Hruby J. Comparison of spinal and epidural anesthesia for patients younger than 50 years of age. Anesth Analg 1994;78:667-73
3.
Failed
Spinal or Epidural Anesthesia
Failure of regional anesthesia has been reported to be in the order of 4% (1,2). The failure rate of spinal anesthesia alone ranged between 3.1% - 17% involving 100 to 1,891 patients respectively (3,4). Johr et al. (5) investigated the incidence of failed spinal anesthesia in a Swiss teaching institution. Of 3,004 blocks 197 (6.5%) did not provide satisfactory analgesia. The 197 failures included: absent blockade - 36; failure to obtain CSF - 6; level too low - 90; duration too short - 36; intensity too weak - 28; unclear - 1. However, 531 (17.4%) blocks were excessively high (45 - cervical level; 2 - required intubation). The management of the 197 failed blocks included: additional spinal anesthesia - 117; epidural anesthesia - 2; local infiltration - 1; general anesthesia - 30; IV supplementation - 47. Manchikanti et al. (6) found that the failure rate with sole use of spinal anesthesia ranges between 0.46% and 35% . Epidural analgesia sometimes falls short of perfection due to the variable "compartmentalisation" of the epidural space (7). Shesky et al. (8) studied in 1983 the dose-response of bupivacaine for spinal anesthesia. Sixty males having transurethral surgery were studied using 10-, 15- and 20 mg doses of glucose-free bupivacaine as either a 0.5 or a 0.75% solution. Both 15 and 20 mg of either concentration of bupivacaine provided satisfactory spinal anesthesia. However, three of 20 patients receiving 10 mg dose required supplementation with general anesthesia. Lyons et al. (9) used a 26G spinal needle through the Tuohy epidural needle for the combined spinal-epidural anesthesia. Unsuccessful spinal anesthesia occurred in 8 of the 50 patients (16%). In four patients, anesthesia was provided by the epidural route, while in the remainder another intrathecal injection was made using a different intervertebral space. Lesser et al. (10) evaluated the use of a 30G spinal needle through the Tuohy epidural needle for the combined spinal-epidural anesthesia. Unsuccessful spinal anesthesia was in 12 of the 50 patients (24%) studied. Six failures were due to unsuccessful dural puncture and six to inadequate block. Due to requirement of large doses of local anesthetics for epidural block there is a risk of toxic complications (11,12). In spite of large doses epidural block may fail to provide adequate analgesia in up to 25% of patients due to difficulty in blocking sacral roots (13-15). Failure to obtain CSF when using the needle-through-needle technique may occur despite successful dural puncture if the needle orifice is occluded, for example by a nerve root. It may also happen if dural puncture has failed to occur because the spinal needle is too short or is placed too laterally as the epidural needle may have entered the epidural space at an angle (16). One technical problem of the needle-through-needle method is the occasional difficulty in threading the catheter into the epidural space after injection of the spinal solution. If some minutes are spent in replacing the epidural needle, the spinal solution may become relatively "fixed" on the dependent side (17). However, when spinal and epidural anesthesia are combined, recourse to general anesthesia becomes a very rare event.
1. Milne MK, Lawson JIM. Epidural analgesia for Caesarean section. A review of 182 cases. Br J Anaesth 1973;45:1206-10
2.Moir DD. Local anaesthetic techniques in obstetrics. Br J Anaesth 1986;58:747-59. 3. Tarkkila PJ. Incidence and causes of failed spinal anesthetics in a university hospital: a prospective study. Reg Anesth 1991;16:48-51
4. Levy JH, Islas JA, Ghia JN, Turnbull C. A retrospective study of the incidence and causes of failed spinal anesthetics in a university hospital. Anesth Analg 1985;64:705-10
5. Johr M, Hess FA, Balogh S, Gerber H. Incidence and management of failed spinal anaesthesia in a teaching institution: A prospective evaluation of 3,004 epidural blocks. Acta Anaesthesiol Scand 1995;39:A421
6. Manchikanti L, Hadley C, Markwell SJ, Colliver JA. A retrospective analysis of failed spinal anesthetic attempts in a community hospital. Anesth Analg 1987;66:363-6.
7. Husemeyer RP,
8. Sheskey MC, Rocco AG, Bizzari-Schmid M, Francis DM, Edstrom H, Covino BG. A dose-response study of bupivacaine for spinal anesthesia. Anesth Analg 1983;62:931-5.
9. Lyons G, Macdonald R, Mikl B. Combined epidural/spinal anaesthesia for Caesarean section: Through the needle or in separate spaces? Anaesthesia 1992;47:199-201.
10. Lesser P, Bembridge M, Lyons G, Macdonald R. An evaluation of a 30-gauge needle for spinal anaesthesia for Caesarean section. Anaesthesia 1990;45:767-8.
11. Abouleish E, Bourke D. Concerning the use and abuse of test doses for epidural anesthesia. Anesthesiology 1984;61:344-5.
12. Thorburn J, Moir DD. Bupivacaine toxicity in association with extradural analgesia for Caesarean section. Br J Anaesth 1984;56:551-3.
13. Larsen JV. Obstetric analgesia and anaesthesia. Clinics in Obst Gyn 1982;9:685-710.
14. Thorburn J, Moir DD. Epidural analgesia for elective Caesarean section. Technique and its assessment. Anaesthesia 1980;35:3-6.
15. Kileff ME, James FM, Dewan DM, Floyd HM. Neonatal neurobehavioral responses after epidural anesthesia for Cesarean section using lidocaine and bupivacaine. Anesth Analg 1984;63:413-7.
16. Patel M, Samsoon G, Swami A, Morgan BM. Flow characteristics of long spinal needles. Anaesthesia 1994;49:223-225.
17. Carrie LES. Epidural versus combined spinal epidural block for Caesarean section. Acta Anaesthesiol Scand 1988;32:595-596.
One
needle technique for combined spinal-epidural anesthesia
Vitenbeck (1), in 1980, described the use of combined spinal-epidural anesthesia in 210 patients using the same needle for the spinal and the epidural injections. He first injected 1-2 ml Dicaine 0.2% into the subarachnoid space. Five minutes later he injected through the same needle, which was withdrawn into the epidural space, 25-37 ml of Dicaine 0.2-0.3% in distilled water with adrenaline 1:1,000. Anesthesia lasted for 2.5-3.5 hr. In only 3 patients he needed to induce general anesthesia because the operation lasted more than the effect of the regional anesthesia. Only 2 patients (0.9%) had postdural puncture headaches.
1. Vitenbeck IA. Associated spino-peridural anesthesia as a variant of conduction anesthesia during operation. Vestn Khir 1981;126:123-128.
Aspiration
pneumonia prevention by the CSEA
In a review of maternal mortality published in 1991 (1) Glassenberg quoted statistics collected up to the mid-1980`s in the UK, USA and Sweden. Over the preceding decade, aspiration as a cause of maternal death had fallen to two deaths per million births, or one death per 30,000 anesthetics, still seven times the aspiration fatality rate for the non-obstetric surgical population, and closely associated with failed intubation. Dennis W. Coombs (2) wrote in 1983 an editorial entitled "Aspiration pneumonia prophylaxis". He said that "unfortunately, the magic prophylactic bullet is not available yet for all situations". However, instead of a "cimetidine prophylaxis" it is suggested to use the "CSEA prophylaxis"...
1. Glassenberg R. General anaesthesia and maternal mortality. Semin Perinatol 1991;15:386-396.
2. Coombs DW. Aspiration pneumonia prophylaxis. Anesth Analg 1983;62:1055-8.
Intraoperative
challenges
Although developments in anesthesia and
surgery have improved overall surgical outcome during recent decades, there is
still concern about the detrimental effects of operative procedures, such as
myocardial infarction, pulmonary complications, thromboembolism,
gastrointestinal paralysis, immunosuppression,etc., that cannot be attributed
solely to imperfections in surgical technique (1). Edwards et al. (2) studied
100 patients undergoing transurethral surgery, who were allocated randomly to
receive either general or spinal anesthesia. The overall incidence of
myocardial ischemia increased from 18% to 26% between the preoperative and
postoperative periods, but no significant difference between the two anesthetic
techniques. Nakatsuka et al. (3) used spinal anesthesia combined with epidural
anesthesia in nine patients with ischemic heart disease having femoral-distal
artery bypass surgery. A 20-gauge epidural catheter and a 24-gauge spinal
catheter were inserted. Epidural anesthesia was initiated using 10-12 ml of 2%
lidocaine and switched to continuous epidural anesthesia with 0.5% bupivacaine
(5-7 ml/hr). Spinal bupivacaine 0.75% was injected up to 5 mg through the
spinal catheter as needed to manage surgical pain of lower leg and foot. Seven
out of 9 patients required additional spinal anesthesia. Juelsgaard et al. (4)
examined continuous spinal anesthesia vs single dose spinal anesthesia vs
general anesthesia in 44 elderly patients scheduled for hip surgery and
receiving medication for angina or displaying ECG signs of coronary sclerosis.
In the continuous spinal anesthesia they injected 1.5 ml isobaric bupivacaine
0.5% with 0.5 ml increments to establish T10 anesthesia. In the single dose
spinal anesthesia group they injected 2.5 ml isobaric bupivacaine 0.5%. The
general anesthesia consisted of fentanyl, thiopentone, N2O/O2 and enflurane.
There were only 3 hypotensive events in the continuous spinal group (3/10
patients) compared to 24/13 patients in the single dose spinal group and 29/11
patients in the general anesthesia group. There was only 1 ischemic event in
the continuous spinal group compared to 93 ischemic events in the single dose
spinal and
1. Kehlet H. Postoperative pain relief: A look from the other side. Reg Anesth 1994;19:369-377.
2. Edwards ND, Callaghan LC, White T, Reilly CS. Perioperative myocardial ischemia in patients undergoing transurethral surgery: a pilot study comparing general with spinal anaesthesia. Br J Anaesth 1995;74:368-372.
3. Nakatsuka M, Long SP, Shy DG. Spinal anesthesia combined with epidural anesthesia for peripheral vascular emergency with dual catheters. Anesth Analg 1994;78:S309.
4. Juelsgaard P, Sand NPR, Felsby S, Dalsgaard J, Brink O, Thygesen K. Continuous spinal anaesthesia vs single dose spinal anaesthesia vs general anaesthesia: Perioperative holter monitoring of patients with coronary atherosclerosis. Acta Anaesthesiol Scand 1995;39:A428
Anesthesia
and public image
Swinhoe and
1. Swinhoe CF,
2. Gajraj NM,
3. Ali S, Vivekanaandan P, Tierney E. Patient`s perception of the anaesthetist and anaesthesia. Anaesthesia 1994;49:644-5.
4. Keep PJ, Jenkins JR. As others see us. The patient`s view of the anaesthetist. Anaesthesia 1978;33:43-5.
5. Katz J. A survey of anesthetic choice among anesthesiologists. Anesth Analg 1973;52:373-5.
6. Broadman LM, Mesrobian R, Ruttiman U,
Huber
needle and Tuohy catheter
On April 23, 1941, Edward B. Tuohy (1)
presented his experience of continuous spinal anesthesia in the Proceedings of
the Staff Meetings of the Mayo Clinic. The method of continuous spinal
anesthesia was first used in the Mayo Clinic in November 1940 according to the
technic and equipment advocated by William T. Lemmon (2). It consisted of a
special operating table mattress, special spinal needles, 18 gauge, with
stylet, which were soft and malleable, a 10 ml Luer-lok syringe with special
stopcock connections and rubber tubing to connect the spinal needle with the
glass syringe. The rubber-covered mattress had a gap
1. Tuohy EB. Continuous spinal anesthesia. Proceedings of the Staff Meetings of the Mayo Clinic 1941;17:257-259.
2. Lemmon WT. A method for continuous spinal anesthesia. Ann Surg 1940;111:141-144.
3. Tuohy EB. Continuous spinal anesthesia: its usefulness and technic involved. Anesthesiology 1944;5:142-148.
4.
5. Manalan SA. Caudal block anesthesia
in obstetrics. J
6. Love JG. Continuous subarachnoid drainage of meningitis by means of a ureteral catheter. JAMA 1935;104:1595.
7. Tuohy EB. The use of continuous spinal anesthesia utilizing the ureteral catheter technic. JAMA 1945;128:262-264.
8. Tuohy EB. Continuous spinal anesthesia: A new method utilizing a ureteral catheter. Surg Clins N. Am 1945;25:834-840.
9. Cousins MJ, Bridenbaugh
11. Winnie AP. A letter to Ostheimer GW. March 17, 1994.
Total
spinal anesthesia: The origin of CSEGA
Evans (1) described in 1928 the possible
complications of spinal anesthesia. Concerning respiratory paralysis he
wrote:" If respiration should cease , keep cool. Raise the lower jaw, pull
the tongue forward and begin artificial respiration at a uniform rate. Mouth to
mouth insufflation is the most convenient and efficacious method of artificial
respiration". Twenty years before, in September 1908, before the Congress
of the International Society of Surgery, in
1. Evans CH. Possible complications with spinal anesthesia. Their recognition and the measures employed to prevent and to control them. Am J Surgery 1928;5:581-593.
2. Jonnesco T. Remarks on general spinal analgesia. Br Med J 1909;2:1396-1401.
3. Jonnesco T. Concerning general rachianesthesia. Am J Surgery 1910;24:33
4. Koster H, Kasman LP. Spinal anesthesia for the head, neck and thorax: its relation to respiratory paralysis. Surg Gynecol Obstet 1929;49:617.
5. Vehrs GR. Spinal anesthesia: Technic
and clinical application.
6. Jones RGG. A complication of epidural technique. Anaesthesia 1953;8:242.
7. Huvos MC, Greene NM, Glaser GH. Electroencephalographic studies during acute subtotal denervation in man. Yale J Biol Med 1962;34:592.
8. Greene NM. Hypotensive spinal anesthesia. Surg Gynecol Obstet 1952;95:331.
9. Kendig JJ. Spinal cord as a site of anesthetic action. Anesthesiology 1993;79:1161-2.
10. Bromage PR, Joyal AC, Binney JC. Local anaesthetic drugs: Penetration from the spinal extradural space into the neuraxis. Science 1963;140:392.
11. Evans TI. Total spinal anaesthesia. Anaesth Intensive Care 1974;2:158-63.
12. Yamashiro H, Hirano K. Treatment with total spinal block of severe herpetic neuralgia accompanying median and ulnar nerve palsy. Masui 1987;36:971-5.
13. Gillies IDS, Morgan M. Accidental total spinal analgesia with bupivacaine. Anaesthesia 1973;28:441-5.
14. DeSaram M. Accidental total spinal analgesia. A report of three cases. Anaesthesia 1956;11:77.
15. Goda Y, Kimura T, Goto Y, Kemmotsu O. Power spectral analysis of heart rate and peripheral blood flow variations during total spinal anesthesia. Masui 1989;38:1275-81.
16. Palkar NV, Boudreaux RC, Mankad AV. Accidental total spinal block : a complication of an epidural test dose. Can J Anaesth 1992;39:1058-60.
17. Kimura T, Goda Y, Kemmotsu O, Shimada Y. Regional differences in skin blood flow and temperature during total spinal anaesthesia. Can J Anaesth 1992;39:123-7. 18. Kobori M, Negishi H, Masuda Y, Hosoyamada A. Changes in respiratory , circulatory, endocrine, and metabolic systems under induced total spinal block. Masui 1991;40:1804-9.
19. Kobori M, Negishi H, Masuda Y, Hosoyamada A. Changes in systemic circulation under induced total spinal block and choice of vasopressors. Masui 1990;39:1580-5.
20. Matsuki M, Muraoka M, Oyama T. Total spinal anaesthesia for a Jehovah`s Witness with primary aldosteronism. Anaesthesia 1988;43:164-5.
21. Mets B, Broccoli E,
What is
anesthesia?
Definitions of the state of anesthesia:
1. Drug-induced unconsciousness; the patient neither perceives nor recalls
noxious stimulation (1). 2. Reversible oblivion and immobility (2). 3.
Paralysis, unconsciousness, and attenuation of the stress response (3). 4.
Sensory block, motor block, blocking of reflexes, and mental block (4). 5. All
separate effects used to protect the patient from the trauma of surgery (5).
Jorgensen et al. (6) studied the anesthetic choice of 705 patients of
outpatient surgery candidates prior to speaking to the anesthesiologist. Sixty
five percent preffered general anesthesia, 22% - spinal anesthesia, and 12%
were unsure. Of those who had spinal anesthesia previously, only 33% would
select it in the future. Conversely, 70% of patients who had general anesthesia
would prefer it again. Concerns about spinal anesthesia were : paralysis, nerve
damage, being awake, infection, inadequate anesthesia, backache, fear of needle
and headache. The use of regional anesthesia in residency training programs has
increased from 21.3% in 1980 to 29.8% in 1990, primarily because of a two-fold
rise in the use of epidural anesthesia (7). Advantages of spinal anesthesia:
Obviates the need for deep general anesthesia, profound muscle relaxation,
cheap, easy to perform, danger of toxic drug signs - negligible. Disadvantages
of spinal anesthesia: hypotension, postoperative headache, some patients prefer
to be asleep during operation. The combined spinal-epidural anesthesia combines
the rapid onset and good muscle relaxation of subarachnoid block with the
ability to supplement analgesia through the epidural catheter, intraoperatively
and after the operation. Reynolds et al. (8) using plain lumbar x-rays and CT
after injection of iodized oil into the extradural space of 19 subjects
recorded the depth of the extradural space at the caudal end: 8.3 ±
1. Prys-Roberts C. Anaesthesia: a practical or impractical construct? Br J Anaesth 1987;59:1341-5.
2.
3. Pinsker MC. Anesthesia: a pragmatic construct. Anesth Analg 1986;65:819-27.
4. Woodbridge PD. Changing concepts concerning depth of anesthesia. Anesthesiology 1957;18:536-50.
5. Kissin I, Gelman S. Components of anaesthesia. Br J Anaesth 1988;61:237-42.
6. Jorgensen NH, Harders M, Hullander RM, Leivers D. Survey of preference for spinal vs. general anesthesia: Education makes a difference. Reg Anesth 1993;18:S53. 7. Kopacz DJ, Bridenbaugh LD. Are anesthesia residency programs failing regional anesthesia? The past, present and future. Reg Anesth 1993;18:84-87.
8. Reynolds AF, Roberts PA, Pollay M, Stratemeier PH. Quantitative anatomy of the thoracolumbar epidural space. Neurosurgery 1985;17:905-907.
9. Westbrook JL, Renowden SA, Carrie LES. Study of the anatomy of the extradural region using magnetic resonance imaging. Br J Anaesth 1993;71:495-498.
10. Pitkin GP. Controllable spinal anesthesia. Am J Surg 1928;5:537-553.
11. Koster H. Spinal anesthesia, with special reference to its use in surgery of the head, neck and thorax. Am J Surg 1928;5:554-570.
12. Babcock WW. Spinal Anesthesia. An experience of twenty-four years. Am J Surg 1928;5:571-6.
13. Bromage PR. Physiology and pharmacology of epidural analgesia. Anesthesiology 1967;28:592-622.
14.
Use of
Ephedrine in CSEGA
Ephedrine is the sympathomimetic drug which is most widely used to sustain blood pressure during spinal anesthesia. The active principal was isolated from the chinese herb ma huang in 1885 by Yamanashi (1). Butterworth et al. (2) found that a mixed adrenergic agonist such as ephedrine more ideally corrected the noncardiac circulatory sequelae of total spinal anesthesia in dogs than did either a pure alpha (phenyl-ephrine) or a pure beta-adrenergic agonist (isoproterenol). Butterworth et al. (3) also demonstrated in dogs the effectiveness of dobutamine and dopamine as possible alternatives to ephedrine for the pharmacologic correction of the noncardiac circulatory sequela of total spinal anesthesia. Goertz et al. (4) investigated the effect of ephedrine on left ventricular function in patients without cardiovascular disease under high thoracic epidural analgesia combined with general anesthesia. Ephedrine improved left ventricular contractility without causing relevant changes of left ventricular afterload.
1. Goodman L, Gilman A. The
pharmacological basis of therapeutics.
2. Butterworth JF, Piccione Jr W, Berrizbeitia LD, Dance G, Shenim RJ, Cohn LH. Augmentation of venous return by adrenergic agonists during spinal anesthesia. Anesth Analg 1986;65:612-6.
3. Butterworth JF, Austin JC, Johnson MD, Berrizbeitia LD, Dance GR, Howard G, Cohn LH. Effect of total spinal anesthesia on arterial and venous responses to dopamine and doputamine. Anesth Analg 1987;66:209-14.
4. Goertz AW, Hubner C, Seefelder C, Seeling W, Lindner KH, Rockemann MG, Georgieeff M. The effect of ephedrine bolus administration on left ventricular loading and systolic performance during high thoracic epidural anesthesia combined with general anesthesia. Anesth Analg 1994;78:101-5.
Cardiovascular
effects of CSEGA
Combining epidural analgesia with general anesthesia in humans reduces the hemodynamic demand on the heart (1-3) and provides more stable intraoperative hemodynamics (4). In animal experiments epidural analgesia has inhibited sympathetic coronary constriction secondary to a flow-limiting stenosis (5), reduced infarct size (6) and reduced ST-segment changes on the electrocardiogram in an acute coronary artery occlusion model (7). However, Mergner et al. (8) investigated epidural analgesia combined with general anesthesia in a swine model with a tight coronary artery stenosis. Distal to the coronary stenosis was a moderate decrease in regional myocardial function and a severe reduction in blood flow. The epidural analgesia reaching the level of T1 was added to an animal which already had a decreased blood pressure and sympathetic tone from the isoflurane/fentanyl anesthesia. No correction of the reduced blood pressure was done in this study. Stenseth et al. (9) investigated the cardiovascular and metabolic effects of T1-T12 epidural block in 18 patients receiving chronic beta-adrenergic blocker medication and scheduled for aortocoronary bypass surgery. Thoracic epidural analgesia induced a moderate decrease in mean arterial pressure, coronary perfusion pressure, free fatty acids and myocardial consumption of free fatty acids. Blomberg et al. (10,11) also found no cardiac effects after a T1-T8 or T1-T6 block in beta-adrenergic blocked patients with ischemic heart disease. Christensen et al. (12) evaluated myocardial ischemic events by Holter monitoring of ST-segment depression in 14 patients with angina pectoris given spinal analgesia for minor surgery. Ephedrine in doses of 5 mg was given, if rapid infusion of saline did not improve the arterial pressure.The first ischemic event occurred at a mean of 338 minutes after spinal analgesia, and not in association with the onset of block, with the decrease in mean arterial pressure after spinal analgesia or with the administration of ephedrine. This could be explained by increased cardiac pre- and afterload, probably further aggravated by the volume load. 1. Baron JF, Coriat P, Mundler O, et al. Left ventricular global and regional function during lumbar epidural anesthesia in patients with and without angina pectoris: influence of volume loading. Anesthesiology 1987;66:621-7.
2. Diebel LN, Lange MP, Schneider F, et al. Cardiopulmonary complications after major surgery: a role for epidural analgesia. Surgery 1987;102:660-6.
3. Yeager MP, Glass DD, Neff RK, Brinck-Johnson T. Epidural anesthesia and analgesia in high-risk surgical patients. Anesthesiology 1987;66:729-36.
4. Her C, Kizelshteyr G, Walker V, et al. Combined epidural and general anesthesia for abdominal aortic surgery. J Cardiothorac Anesth 1990;4:552-7.
5. Heusch G, Deussen A, Thamer V. Cardiac sympathetic nerve activity and progressive vasoconstriction distal to coronary stenoses: feed-back aggravation of myocardial ischemia. J Auton Nerv Syst 1985;13:311-26.
6. Davis RF, DeBoer LWV, Maroko PR. Thoracic epidural anesthesia reduces myocardial infarct size after coronary artery occlusion in dogs. Anesth Analg 1986;65:711-7.
7. Vik-Mo H, Ottesen S, Renck H. Cardiac effects of thoracic epidural analgesia before and during acute coronary artery occlusion in open-chest dogs. Scand J Clin Lab Invest 1978;38:737-46.
8. Mergner GW, Stolte AL, Frame WB, Lim HJ. Combined epidural analgesia and general anesthesia induce ischemia distal to a severe coronary artery stenosis in swine. Anesth Analg 1994;78:37-45.
9. Stenseth R, Berg EM, Bjella L, Christensen O, Levang OW, Gisvold SE. The influence of thoracic epidural analgesia alone and in combination with general anesthesia on cardiovascular function and myocardial metabolism in patients receiving beta-adrenergic blockers. Anesth Analg 1993;77:463-8.
10. Blomberg S, Emanuelsson H, Kvist H, et al. Effects of thoracic epidural anesthesia on coronary arteries and arterioles in patients with coronary artery disease. Anesthesiology 1990;73:840-7.
11. Blomberg S, Emanuelsson H, Ricksten SE. Thoracic epidural anesthesia and central hemodynamics in patients with unstable angina pectoris. Anesth Analg 1989;69:558-62.
12. Christensen EF, Sogaard P, Egebo K, Bach LF, Riis J. Myocardial ischemia and spinal analgesia in patients with angina pectoris. Br J Anaesth 1993;71:472-5.
Cord
ischemia and preemptive analgesia
Breckwoldt et al. (1) investigated the effect of intrathecal tetracaine on the neurological sequelae of spinal cord ischemia and reperfusion with aortic occlusion in rabbits. They found that intrathecal tetracaine significantly and dramatically abrogated the neurological injury secondary to spinal cord ischemia and reperfusion after aortic occlusion at 30 minutes. Peripheral tissue injury provokes two kinds of modification in the responsiveness of the nervous system: peripheral sensitization and central sensitization. The optimal form of pain treatment may be one that is applied both pre-, intra-, and postoperatively to preempt the establishment of pain hypersensitivity during and after surgery. Woolf and Chong (2) in their review of preemptive analgesia concluded that "although evolution has conserved sensitization in humans, the capacity to inflict `controlled injury` during surgery has clearly not been anticipated". 1. Breckwoldt WL, Genco CM, Connolly RJ, Cleveland RJ, Diehl JT. Spinal cord protection during aortic occlusion: Efficacy of intrathecal tetracaine. Am Thorac Surg 1991;51:959-63.
2. Woolf CJ, Chong MS. Preemptive analgesia - treating postoperative pain by preventing the establishment of central sensitization. Anesth analg 1993;77:362-79.
CSEA for
Cesarean section
An increasing number of parturients wish
to be awake during cesarean section (1) and opt for regional rather than
general anesthesia. Spinal block is a simple technique which requires a small
dose of local anesthetic to provide surgical anesthesia (1,2) with rapid,
intense and reliable block without missed segments (1,3), greater muscle
relaxation (1) and minimal risk of drug toxicity to the mother as well as to
the fetus (3). For these reasons it has been proposed as the anesthetic method
of choice for emergent cesarean section (4). Visceral pain is a poorly
localized, dull and deep pain which is often accompanied by nausea, vomiting
and sweating. Instead of pain, some patients describe it as a feeling of
heaviness, pressure, tightness and/or squeezing. Alahuhta et al. (5) compared
the incidence of visceral pain in 46 patients undergoing elective cesarean
section under spinal or epidural anesthesia with 0.5% bupivacaine. Visceral
pain occurred in 12/23 patients in the spinal group and in 13/23 patients in
the epidural group. Rawal et al. (1) used the combined spinal-epidural
anesthesia in 15 parturients scheduled for cesarean section. With the patients
in the sitting position they injected 1.5-2 ml of 0.5% (7.5-10 mg) hyperbaric
bupivacaine through the spinal needle to achieve an S5-T8-9 block. After
withdrawing the spinal needle, the epidural needle was rotated and an epidural
catheter introduced through it. After aspiration for blood or spinal fluid,
0.5-1 ml saline was injected in the epidural catheter to test its patency.
15-20 min after the spinal injection, 0.5% plain bupivacaine 1.5-2 ml per
unblocked segment were injected till a T4-5 level was reached. The combined
mean total dose of bupivacaine was 40.2±4.24 mg. It means that only 5-7 ml of
0.5% bupivacaine injected through the epidural catheter were needed to rise the
anesthetic level from T8-9, reached by the previous spinal injection, to T3-4
achieved by the epidural augmentation. Riley et al. (6) compared the spinal
versus epidural anesthesia for cesarean section in relation to time efficiency.
They have found that patients who received epidural anesthesia had
significantly longer total operating room times than those who received spinal
anesthesia (101 ±20 vs 83 ±16 min). This was caused by longer times spent in
the operating room until surgical incision (46 ±11 vs 29±6 min). Supplemental
intraoperative intravenous analgesics and anxiolytics were required more often
in the epidural group (38%) than in the spinal group (17%). Vucevic and Russell
(7) compared 12 ml 0.125% plain bupivacaine with 3 ml 0.5% plain bupivacaine
for cesarean section in 40 women using the combined spinal-epidural technique.
The initial spread was greater with the 12 ml solution but within 5 min of
placing the women in the supine tilted (right hip up) position, there were no
differences in the levels of sensory blockade. The study also showed that the
12 ml solution resulted in more intensive blockade as there was less need for
extradural anesthesia in this group than in the 3 ml group. Parturients
receiving 15 mg of spinal hyperbaric bupivacaine for cesarean delivery
developed a higher mean level and longer duration of sensory analgesia than
those receiving 12 mg (8). Fan et al. (9) examined four regimens of combined
spinal-epidural anesthesia in 80 parturients for cesarean section: 1. 2.5 mg
bupivacaine 0.5% intrathecally combined with 22.2±4.6 ml of lidocaine 2%
epidurally. This combination provided insufficient muscle relaxation. 2. 5 mg
of bupivacaine 0.5% - spinally with 10.1 ±2.0 ml of lidocaine 2% epidurally
resulted in satisfactory anesthesia with rapid onset and minimum side effects.
3. Spinal 7.5 mg of bupivacaine 0.5% . 4. Spinal 10 mg of bupivacaine 0.5%.
Anesthesia in these groups (7.5 mg and 10 mg bupivacaine 0.5%) was mostly due
to the spinal block. Their conclusion was that the combined spinal-epidural
technique, using 5 mg of bupivacaine and with sufficient epidural lidocaine to
reach a T4 level, had the advantages of both spinal and epidural anesthesia
with few of the complications of either. Ciccozzi et al. (10) evaluated the
combined spinal-epidural anesthesia by the needle-through-needle technique in
40 parturients (
1. Rawal N, Schollin J, Wesstrom G. Epidural versus combined epidural block for cesarean section. Acta Anaesthesiol Scand 1988;32:61-6
2. Covino BG. Rationale for spinal anesthesia. International Anesthesiology Clinics 1989;27:8-12
3. Hunt
4. Marx GF, Lughx WM, Cohen S. Fetal-neonatal status following Caesarean section for fetal distress. Br J Anaesth 1984;56:1009-12
5. Alahuhta S, Kangas-Saarela T, Hollmen AI, Edstrom HH. Visceral pain during caesarean section under spinal and epidural anaesthesia with bupivacaine. Acta Anaesthesiol Scand 1990;34:95-98
6. Riley ET, Cohen SE, Macario A, Desai JB, Ratner EF. Spinal versus epidural anesthesia for cesarean section: A comparison of time efficiency, costs, charges, and complications. Anesth Analg 1995;80:709-12
7. Vucevic M, Russell IF. Spinal anaesthesia for Caesarean section: 0.125% plain bupivacaine 12 ml compared with 0.5% plain bupivacaine 3 ml. Br J Anaesth 1992;68:590-595
8. De Simone CA, Leighton BL, Norris MC. Spinal anesthesia for cesarean delivery: A comparison of two doses of hyperbaric bupivacaine. Reg Anesth 1995;20:90-94
9. Fan SZ, Susetio L, Wang YP, Cheng YJ, Liu CC. Low dose of intrathecal hyperbaric bupivacaine combined with epidural lidocaine for cesarean section - a balance block technique. Anesth Analg 1994;78:474-7
10. Ciccozzi A, Iovinelli G, Varrassi G. Effects of posture on the spread of local anesthetics in CSEA for Caesarean delivery. Reg Anesth 1995;20:S74
11. Mok MS, Tzeng JI. Intramuscular ketoralac enhances the analgesic effect of low dose epidural morphine. Anesth Analg 1993;76:S269
12. Swami A, McHale S, Abbott P, Morgan B. Low dose spinal anesthesia for cesarean section using combined spinal-epidural (CSE) technique. Anesth Analg 1993;76:S423
13. Dickson MAS, Jenkins J. Extension of epidural blockade for emergency Caesarean section. Anaesthesia 1994;94:636-638
14. Westbrook JL, Donald F, Carrie LES. An evaluation of a combined spinal/epidural needle set utilising a 26-gauge pencil point spinal needle for Caesarean section. Anaesthesia 1992;47:990-2
Corning
The first epidural anesthesia done by
1. Marx GF. The first spinal anesthesia: Who deserves the laurels? Reg Anesth 1994;19:429-430
Bier
August Bier (1), on August 24, 1898, asked his assistant, Dr. Hilderbrandt, "to perform a lumbar puncture on me", 8 days after he first performed it on a 34-year-old patient for excision of a tuberculous capsule at the ankle joint. Bier wrote that he did not feel any discomfort "except for a quick flash of pain in one leg at the moment that the needle penetrated the meninges". Unfortunately, the experiment was not successful because of an error (the syringe did not fit the needle tightly... and consequently some CSF ran out and most of the cocaine was lost). No sensory loss ensued. Dr. Hilderbrandt immediately offered to submit himself to the experiment, which was successful. Both of them "went to eat after the experiments were performed on our bodies. We had no physical discomfort, we ate, drank wine, and smoked several cigars". However, next morning, after a one hour morning stroll Bier felt slight headache which increased in intensity during the course of the day. Nine days after the puncture, all the symptoms disappeared. After 3 more days, "I was able to go on a train trip without discomfort and was fit enough to participate in a strenuous 8 day hunting trip in the mountains".
1. Bier AKG, von Esmarch JFA. Versuche uber Cocainisirung des Ruckenmarkes. Dtsch Z Chir 1899;51:361-369
A new
look at the lumbar extradural space pressure
The answer to the questions: Why does not the Macintosh balloon indicator deflate, or why the hanging drop technique is unreliable was given by Shah (1): The epidural space pressure is influenced by many factors. It is raised by jugular venous compression, ventilation with carbon dioxide and positive end-expiratory pressure (PEEP). The lumbar extradural pressure is increased rapidly with stimuli known to increase CSF pressure. However, the next question is what happens in the "normal" condition (without jugular venous compression or CO2 inhalation, etc.)? There is a wave pressure, which is the lumbar CSF wave pressure transmitted to the epidural space. On that subject Shah quoted an article by Hirai et al (2) published in 1982:"The arterial pressure wave in the spinal CSF originates from the choroid plexus... The pulsatile vibration of the brain parenchyma derived from the blood flow in the cerebral arteries may have enough energy to generate the spinal CSF pulse. The amplitude of the pulse wave varies directly with intracranial pressure". This citation is not exactly true in the light of an investigation published by Urayama (3). He performed system analysis on 16 adult mongrel dogs to determine the origin of the lumbar cerebrospinal fluid pulse wave. The descending thoracic aorta was occluded to evaluate the effects of the spinal arterial pulsations, and the thoracic aorta and inferior vena cava were simultaneously occluded to evaluate the effects of the spinal venous pulsations. It was concluded that, in the first harmonic wave, the components of the lumbar cerebrospinal fluid pulse wave are as follows: spinal arterial pulsations - 39.4%; spinal vascular (arteries and veins) pulsations - 77%; venous pulsations in the spinal canal - 37.6%; and the intracranial pressure pulse wave transmitted through the spinal canal from the intracranial space to the lumbar level - 23%. So, from this investigation we can learn that 77% of the lumbar cerebrospinal fluid pulse wave which is directly transmitted to the extradural space as an extradural pressure wave is originated in the vascular system (arteries and veins), and not in the brain . So, any rise in the blood pressure, which is not an infrequent observation during epidural needle insertion, can give a concomitant rise in the extradural pressure with the loss of the "negative" pressure in the extradural space and "unreliable" hanging drop and Macintosh balloon indicator techniques.
1. Shah JL. Positive lumbar extradural
space pressure. Br J Anaesth 1994;73:309-314. 2. Hirai O, Handa H, Ishikawa M.
Intracranial pressure pulse waveform: considerations about its origin and
methods of estimating intracranial pressure dynamics. Brain Nerve (
3. Urayama K. Origin of lumbar cerebrospinal fluid pulse wave. Spine 1994;19:441-445
Do not
rotate the epidural needle
The epidural needle rotation in CSEA
using the needle-through-needle technique was first suggested in 1988 by Rawal
et al. (1). However, Dr. Rawal abandoned this technique of epidural needle
rotation (2) because he was convinced that "180° rotation of the epidural
needle may cause dural tear". Nickalls and Dennison (3) found that the
distance the spinal needle has to be advanced past the end of the Tuohy needle
to just puncture the dura ranges from 0.3 to
1. Rawal N, Schollin J, Wesstrom G. Epidural versus combined spinal epidural block for cesarean section. Acta Anaesthesiol Scand 1988;32:61-6
2. Rawal N. Combined spinal-epidural needle (CSEN) for the combined spinal-epidural block - reply. Acta Anaesthesiol Scand 1989;33:618
3. Nickalls RWD, Dennison B. A modification of the combined spinal and epidural technique. Anaesthesia 1984;39:935
4. Joshi GP, McCarroll SM. Combined spinal-epidural anesthesia using needle-through-needle technique. Anesthesiology 1993;78:406-7
5. Carter LC,
6. Meiklejohn BH. The effect of rotation of an epidural needle. Anaesthesia 1987;42:1180-2
Epidural
rostral augmentation of spinal anesthesia
Suzuki et al. (1) found that spinal
puncture with a 26G spinal needle, with no spinal anesthetic injection, immediately
before epidural injection of 18 ml 2% mepivacaine resulted in rapid caudal
spread of analgesia as compared to an epidural anesthesia alone. They
attributed it to the flow of local anesthetic into the subarachnoid space
through the perforation produced by the spinal needle. Dobson et al. (2)
reported of a sudden asystole 70 min after intrathecal injection of 2.75 ml
hyperbaric bupivacaine 0.5% in a patient whose cardiac output was being
monitored. After successful resuscitation , the height of the block was judged
to be T4. According to the authors of the report, monitoring should continue
for at least 90 min after induction of spinal anesthesia. Bodily et al. (3)
warned that changes in position can alter the spread of sensory blockade for at
least 1 hr after the intrathecal injection of a hypobaric solution. They showed
that 8 ml lidocaine 0.5% (baricity 0.9985±0.0003,
1. Suzuki N, Koyanemaru M, Onizuka S, Takasaki M. Dural puncture with a 26-gauge spinal needle affects epidural anesthesia. Reg Anesth 1995;20:S118
2. Dobson PMS, Caldicott LD, Gerrish SP. Delayed asystole during spinal anaesthesia for transurethral resection of the prostate. Eur J Anaesth 1993;10:41-43
3.
5. Serpell MG, Coombs DW, Colburn RW, Deheo JA, Twitchell BB. Intrathecal pressure recordings due to instillation in the epidural space. International Monitor on Regional Anaesthesia 1993;52
6. Dell RG, Orlikowski CEP. Unexpectedly high spinal anaesthesia following failed extradural anaesthesia for caesarean section. Anaesthesia 1993;48:641
7. D`Angelo R,
8. Barclay DL, Renegar OJ, Nelson EW. The influence of inferior vena cava compression on the level of spinal anesthesia. Am J Obstet Gynecol 1968;101:792-800
9. Furst SR, Reisner LS. Risk of high spinal anesthesia following failed epidural block for cesarean delivery. J Clin Anesth 1995;7:71-74
10. Gamil M. Combined spinal/epidural anaesthesia for caesarean section. Anaesthesia 1994;49:545-6
11. Carrie LES. Epidural versus combined spinal epidural block for Caesarean section. Acta Anaesthesiol Scand 1988;32:595-596
12. Rawal N, Schollin J, Wesstrom G. Epidural versus combined spinal epidural block for Caesarean section. Acta Anaesthesiol Scand 1988;32:61-66
13. Rawal N. Single segment combined subarachnoid and epidural block for Caesarean section. Can Anaesth Soc J 1986;33:254-255
14. Bromage PR. Mechanism of action of extradural anaesthesia. Br J Anaesth 1975;47:199-212
15. Blumgart CH, Ryall D, Dennison B, Thompson-Hill LM. Mechanism of extension of spinal anaesthesia by extradural injection of local anaesthetic. Br J Anaesth 1992;69:457-460
Metallic
particles in the needle-through-needle technique
The Tuohy needle was not originally
intended to be an introducer for a spinal needle. Tuohy (1) in 1944, used a
needle with a curved Huber tip for continuous spinal anesthesia, and Curbelo
(2) in 1949, adapted this needle for continuous epidural block. Coates (3) and
Mumtaz et al. (4) were the first to publish the possibility of inserting a long
spinal needle through a Tuohy epidural needle. They encountered only two
potential hazards, "possible passage of the epidural catheter through the
hole in the dura mater and the possibility of subarachnoid effects from
epidurally injected drugs by passage through the hole in the dura". Evans
(5) applied for a patent for this instrument a year later. The long spinal
needles have been available in the British market since 1985 (6). The forward
end of the spinal needle is inclined at an angle of about 30° to its length
when it projects by about
1. Tuohy EB. Continuous spinal anesthesia: Its usefulness and technique involved. Anesthesiology 1944;5:142-143
2. Curbelo MM. Continuous peridural segmental anesthesia by means of a ureteral catheter. Curr Res Anesth Analg 1949; 28:13
3. Coates MB. Combined subarachnoid and epidural techniques. Anaesthesia 1982;37:89-90
4. Mumtaz MH, Daz M, Kuz M. Another single space technique for orthopaedic surgery. Anaesthesia 1982;37:90
5. Evans JM. Instrument for epidural and
spinal anaesthesia:
6. Desira WR. A special needle for combined subarachnoid and epidural block. Anaesthesia 1984;39:308
7. Kumar B, Messahel FM. Evaluation of epidural needles. Acta Anaesthesiol Scand 1987;31:96-99
8. Wigle RL. The reaction of copper and other projectile metals in body tissues. J Trauma 1992;33:14-18
Superselective
spinal anesthesia
Veneziani et al. (1) described a technique of superselective spinal anesthesia for the surgical treatment of saphenectomy. The block has been performed at L2-3 with the patients laying in omolateral decubitus with respect to surgical side and injecting slowly 1% hyperbaric bupivacaine 0.5-0.6 ml and maintaining such a position for about 10-15 minutes. The 24G Sprotte spinal needle was used with an incidence of only 0.4% postspinal headache.
1. Veneziani A, Santagostino G, Matera D, Tulli G. Superselective spinal anaesthesia for the surgical treatment of saphenectomy. Acta Anaesthesiol Scand 1995;39:A430
CSEA in
uncommon disease
Cherng et al. (1) described a case report of combined spinal and epidural anesthesia for abdominal hysterectomy in a 34-year-old woman with myotonic dystrophy. Patients with myotonic dystrophy have a high risk of anesthetic complications, and the anesthetic technique should aim to prevent any stimulation (chemical, mechanical or thermal), and avoid any drugs that would induce uncontrollable muscular contraction (myotonic crisis) (2).
1. Cherng YG, Wang YP, Liu CC, Shi JJ, Huang SC. Combined spinal and epidural anesthesia for abdominal hysterectomy in a patient with myotonic dystrophy. Reg Anesth 1994;19:69-72
2.
CSEA for
laparoscopic operations
Ciofolo et al. (1) evaluated the respiratory effects of laparoscopy under epidural anesthesia in seven female patients scheduled for a gamete intrafallopian transfer procedure. No significant changes in the ventilatory variables were observed in the Trendelenburg position. In contrast, CO2 insufflation significantly increased minute ventilation (from 9.1±1.0 L/min to 11.8 ±2.6 L/min) and respiratory rate (from 16.9±1.9 breaths/min to 23.1 ±3.3 breaths/min), whereas CO2 output remained unchanged. PaCO2 remained constant throughout the study. They concluded that epidural anesthesia may be a safe alternative to general anesthesia for outpatient laparoscopy, as it is not associated with ventilatory depression. Epidural analgesia for minilaparotomy cholecystectomy improves pain relief in the immediate postoperative period, compared to intramuscular morphine (2). Reduction of the surgical stress response can be achieved by two techniques: One is to reduce the degree of tissue trauma and thereby the injury response using the "minimal invasive surgery concept"; the other is "stress-free anesthesia and surgery" providing effective pain relief, including afferent neural block (3,4), together with block of various humoral mediator cascade systems (arachidonic cascade metabolites, cytokines, etc.) as well as a maintenance of nutritional status by provision of unspecific nutrients (glutamine, arginine) or growth factors (growth hormone, etc.) (5).
1. Ciofolo MJ, Clergue F, Seebacher J, Lefebvre G, Viars P. Ventilatory effects of laparoscopy under epidural anesthesia. Anesth Analg 1990;70:357-61
2. Dahl JB, Hjortso N-C, Stage JG, Hansen BL, Moiniche S, Damgaard B, Kehlet H. Effects of combined perioperative epidural bupivacaine and morphine, ibuprofen, and incisional bupivacaine on postoperative pain, pulmonary, and endocrine-metabolic function after minilaparotomy cholecystectomy. Reg Anesth 1994;19:199-205
3. Kehlet H. Modification of responses
to surgery and anesthesia by neural blockade: Clinical implications. In:Cousins
MJ, Bridenbaugh PO, eds. Neural blockade in clinical anesthesia and management
of pain.
5. Kehlet H. Postoperative pain relief. A look from the other side. Reg Anesth 1994;19:369-377
Postoperative
epidural analgesia
Albert Schweitzer said that "pain is a more terrible lord of mankind than even death itself". Bonica (1) wrote that "acute and chronic pain afflicts millions upon millions of persons annually, and in many patients with chronic pain and a significant percentage of those with acute pain, it is inadequately relieved". In the 1980s, surveys of patients` subjective well-being revealed an incidence of moderate or severe pain after surgery of 31-75% (2,3). De Leon-Casasola et al. (4) compared the effect on postoperative myocardial ischemia of epidural versus intravenous patient-controlled analgesia. 198 patients received either technique for 5-7 days postoperatively. Patients in the epidural group had a lower incidence of tachycardia (14% vs. 65%), ischemia (5% vs. 17%), and infarction - 0% vs. 20% of patients with ischemia in the intravenous patient-controlled analgesia group. Postoperative ileus is an undesirable response to injury and is predominantly caused by an increase in inhibitory afferent sympathetic activity (5). Postoperative continuous epidural analgesia may improve gastrointestinal motility and reduce ileus (6-9). Early oral feeding reduced the risk of septic complications (10). The positive effect of epidural local anesthetic analgesic techniques on gastrointestinal paralysis may facilitate early oral nutrition as well as reducing fatigue and convalescence.
1. Bonica J.J. History of pain concepts and pain therapy. Mt Sinai J Med 1991;58:191-202
2. Kuhn S, Cooke K, Collins M, Jones JM, Mucklow JC. Perceptions of pain relief after surgery. Br Med J 1990;300:1687-1690
3. Owen H, McMillan V, Royowski D. Postoperative pain therapy: A survey of patients` expectations and their experiences. Pain 1990;41:303-307
4. De Leon Casasola OA, Lema MJ, Karabella D, Harrison P. Postoperative myocardial ischemia: Epidural versus intravenous patient-controlled analgesia. Reg Anesth 1995;20:105-112
5. Wattwill M. Postoperative pain relief in gastrointestinal motility. Acta Chir Scand 1988;550(Suppl):140-145
6.
7. Sheinin B, Asantila R, Orku R. The effect of bupivacaine on pain and bowel function after colonic surgery. Acta Anaesthesiol Scand 1987;31:161-164
8. Ahn H, Bronge A, Johansson K, Ygge H, Lindhargen J. Effect of continuous postoperative epidural analgesia on intestinal motility. Br J Surg 1988;75:1176-1178 9. Wattwill M, Thoren T, Hennerdal S, Garvill J-E. Epidural analgesia with bupivacaine reduces postoperative paralytic ileus after hysterectomy. Anesth Analg 1989;68:353-358
10.
Unilateral
spinal anesthesia
Using the needle-through-needle technique in 80 patients for cesarean section Fan et al. (1) noted the occurrence of a unilateral spinal block with the hyperbaric 0.5% bupivacaine, "because keeping the patient in the lateral position was necessary to accomplish the epidural procedure".
1. Fan SZ, Susetio L, Wang YP, Cheng YJ, Liu CC. Low dose of intrathecal hyperbaric bupivacaine combined with epidural lidocaine for cesarean section - a balance block technique. Anesth Analg 1994;78:474-7
CSEA for
abdominal operations
Guedj et al. (1) compared between spinal anesthesia and combined spinal-epidural anesthesia (CSEA) in 63 patients undergoing gynecological surgery. Spinal anesthesia (n=34) was carried out in the L3-4 interspace with the patients sitting using 15 mg of hyperbaric 0.5% bupivacaine with adrenaline. In the CSEA group (n=29) an epidural catheter was inserted through the L2-3 interspace and the spinal anesthesia in the L3-4 interspace, while the patients were sitting. In the CSEA group, excellent analgesia was obtained in all patients. In the spinal group, general anesthesia was required in 3 patients (8.8%), as anesthesia only reached the T12 level in 2 cases, and as surgery lasted longer than the spinal in the third one. Moiniche et al. (2) described a case of colonic resection with early discharge after combined subarachnoid - epidural analgesia, preoperative glucocorticoids, and early postoperative mobilization and feeding in a 59-year-old pulmonary high-risk woman. They have introduced an epidural catheter between T9-10 and a spinal catheter between L3-4. During the operation the patient was fully awake. At one time during intestinal traction, visceral pain was treated vith intravenous 100 æg fentanyl. Surgery lasted for 70 minutes. The spinal catheter was removed at the end of surgery, while the epidural catheter provided postoperative analgesia for 72 hours. Luchetti et al. (3) used the combined spinal-epidural anesthesia in 20 patients undergoing surgery for hernioplasty, saphenectomy, hemorroidectomy and varicocelectomy. The subarachnoid injection consisted of hyperbaric bupivacaine 1% 1 ml and the epidural catheter injection - bupivacaine 0.5% 3 ml + fentanyl 50 µg. Analgesia was excellent in 17 patients and good in 3. No patient needed further analgesic medication intraoperatively. Mihic and Abram (4) compared five groups of patients undergoing abdominal hysterectomy with or without appendicectomy with regional anesthesia. Two hundred patients were divided as follows: Group 1 - spinal anesthesia with hyperbaric 0.5% bupivacaine; Group 2 - as group 1 with the addition of 0.06 mg of IV buprenorphine and 2.5 mg of IV midazolam; Group 3 - epidural block with 0.75% bupivacaine; Group 4 - as group 3 with the addition of epidural morphine 1%; Group 5 - combined spinal-epidural block (as in groups 1 and 4). No case of unsuccessful blockade occurred in the combined spinal-epidural anesthesia, compared to 3-4 cases of failed block in the other groups. Four patients whose analgesia was considered to be unsuccessful had to be intubated to obtain satisfactory surgical conditions. The combination of subarachnoid and epidural block provided the best analgesia.
1. Guedj P, Eldor J, Gozal Y. Conventional spinal block versus combined spinal-epidural anaesthesia for lower abdominal surgery. Ann Fr Anesth Reanim 1992;11:399-404
2. Moiniche S, Dahl JB, Rosenberg J, Kehlet H. Colonic resection with early discharge after combined subarachnoid-epidural analgesia, preoperative glucocorticoids, and early postoperative mobilization and feeding in a pulmonary high-risk patient. Reg Anesth 1994;19:352-356
3. Luchetti M, Palomba R, Liardo A, Bardari G, Sica G. Combined spinal-epidural anaesthesia (CSEA) is effective and safe for minor general surgery. Int Monitor Reg Anaesth 1994;A97
4. Mihic DN, Abram SE. Optimal regional anaesthesia for abdominal hysterectomy: Combined subarachnoid and epidural block compared with other regional techniques. Eur J Anaesthesiol 1993;10:297-301
CSEA for
thoracic operations
Kowalewski et al. (1) reported on the use of spinal anesthesia with hyperbaric bupivacaine (20-30 mg) and/or lidocaine (150 mg) with morphine (0.5-1 mg) combined with general anesthesia with alfentanil 97 ±22 µg/Kg and midazolam 0.04±0.02 mg/Kg supplemented with a muscle relaxant and maintained with isoflurane (0.25-0.5%) in oxygen in 18 patients for coronary artery bypass surgery (CABG). They suggested that general anesthesia combined with spinal anesthesia may be an effective technique for CABG. Very low concentrations of inhalational agents are required to maintain unconsciousness during high spinal anesthesia (2). Epidural anesthesia attenuates the endocrine-metabolic responses to surgical stress (3), reduces intestinal paralysis (4,5) and decreases perioperative morbidity (6,7). Thoracic epidural anesthesia decreases heart rate, mean arterial pressure, cardiac output and left ventricular contractility (8,9). Dopamine effectively counters cardiovascular depression during thoracic epidural anesthesia (10,11). Dopamine effectively and dose-dependently counters cardiovascular depression induced by the anesthetic technique of combining isoflurane and thoracic epidural anesthesia (12). Animals` experiments demonstrated that spinal cord section (13) or its cooling at the T1 level (14) resulted in behavioral and electrophysiological evidence of sleep. Subarachnoid bupivacaine blockade decreased the hypnotic dose of thiopental from 3.40 ±0.68 mg/Kg to 2.17±0.48 mg/Kg. The ED50 value of midazolam also decreased with bupivacaine blockade, from 0.23 mg/Kg to 0.06 mg/Kg. It was suggested that the reduction in hypnotic requirements was due to the decrease in afferent input induced by spinal anesthesia (15). Extension of the segmental block to involve the cardioaccelerator fibers (above T4) is commonly advanced as a reason to explain the bradycardia that may accompany epidural analgesia (16), however, central volume depletion may have a greater cardioinhibitory vasodepressor influence (16,17).
1. Kowalewski RJ, MacAdams CL, Eagle CJ, Archer DP, Bharadwaj B. Anaesthesia for coronary artery bypass surgery supplemented with subarachnoid bupivacaine and morphine: a report of 18 cases. Can J Anaesth 1994;41:1189-95
2.
3. Kehlet H. Modification of responses
to surgery by neural blockade: clinical implications. In: Cousins MJ,
Bridenbaugh PO, eds. Neural bloclkade.
4. Scheinin B, Asantila R, Orko R. The effect of bupivacaine and morphine on pain and bowel function after colonic surgery. Acta Anaesthesiol Scand 1987;31:161-164 5. Ahn H, Bronge A, Johansson K, Ygge H, Lindhagen J. Effect of continuous postoperative epidural analgesia on intestinal motility. Br J Surg 1988;75:1176-1178 6. Yeager MP, Glass DD, Neff RK, Brinck-Johnson T. Epidural anesthesia and analgesia in high-risk surgical patients. Anesthesiology 1987;66:729-736
7. Scott NB, Kehlet H. Regional anaesthesia and surgical morbidity. Br J Surg 1988;75:299-304
8. Reiz S, Nath S, Ponten E, Friedman A, Backlund U, Olsson B, Rais O. Effects of thoracic epidural block and the beta-1-adrenoreceptor agonist prenalterol on the cardiovascular response to infrarenal aortic cross-clamping in man. Acta Anaesthesiol Scand 1979;23:395-403
9. McLean APH, Mulligan GW, Otton P, MacLean LD. Hemodynamic alterations associated with epidural anesthesia. Surgery 1967;62:79-87
10. Lundberg J, Biber B, Henriksson BA, Martner J, Raner C, Werner O, Winso O. Effects of thoracic epidural anesthesia and adrenoreceptor blockade on the cardiovascular response to dopamine in dog. Acta Anaesthesiol Scand 1991;35:359-365
11. Lundberg J, Norgren L, Thomson D, Werner O. Hemodynamic effects of dopamine during thoracic epidural analgesia in man. Anesthesiology 1987;66:641-646
12. Raner C, Biber B, Lundberg J, Martner J, Winso O. Cardiovascular depression by isoflurane and concomitant thoracic epidural anesthesia is reversed by dopamine. Acta Anaesthesiol Scand 1994;38:136-143
13. Ho T, Wang YR, Lin TAN, Chang YF. Predominance of electrocortical sleep patterns in the "encephale isole" cat and new evidence for a sleep center. Physiol Bohemosloven 1960;9:85-92
14. Oreshchuk FA. The development of
sleep on local cooling of the spinal cord. Fiziol Z (
15. Tverskoy M, Shagal M, Finger J, Kissin I. Subarachnoid bupivacaine blockade decreases midazolam and thiopental hypnotic requirements. J Clin Anesth 1994;6:487-490
16. Bromage PR. Physiology and pharmacology of epidural anesthesia. Anesthesiology 1967;28:592-608
17. Arndt JO, Hock A,
Anesthetic
risk factors
In a survey
among 1,152 Australian and New Zealand anesthetists Kitching et al. (1)
evaluated the percentage of anesthetists who warn patients before operation
about "material risks" like death, neurological injury, awareness,
failed intubation, failed block, seizures, etc. Only 1-9% have discussed and
documented these items to their patients. 55% discussed but not documented the
subject of failed block compared to 2% - for failed intubation. 36-97% did not
discuss these matters at all pre-operatively. 1. Kitching A, Love J, Donnan G.
Mishap or negligence. Br J Anaesth 1995;74:110-111
Medico-legal
aspects of CSEA
Reports of cauda equina syndrome
associated with micro-bore spinal catheter use, resulted in their removal from clinical
practice in the
1. FDA Safety Alert; 29.5.92 2. Finucane BT. Spinal anesthesia for cesarean section: The dosage dilemma. Reg Anesth 1995;20:87-89
Spinal
opioid pruritus and emesis
Larger doses of spinal morphine result in a greater incidence of pruritus (1). Knudsen and Lisander (2) decreased the incidence of emesis post subarachnoid morphine from 58% to 17% by 20 mg metoclopramide given intramuscularly before and after the surgery. Combined use of intrathecal sufentanil and bupivacaine can reduce the incidence of pruritus due to the sole use of intrathecal sufentanil for labor analgesia. Abouleish et al. (3) used spinal injection of bupivacaine 2.5 mg and sufentanil 10 µg in the combined spinal-epidural analgesia (CSEA) and found an incidence of 21%. However, D`Angelo et al. (4) used only intrathecal sufentanil 10 µg in CSEA with an incidence of pruritus of 84%.
1. Fuller JG, McMorland GH, Douglas MJ, Palmer L. Epidural morphine for analgesia after caesarean section: A report of 4880 patients. Can J Anaesth 1990;37:636-40
2. Knudsen K, Lisander B. Metoclopramide decreases emesis after spinal anesthesia supplemented with subarachnoid morphine. Reg Anesth 1994;19:390-394
3. Abouleish A, Abouleish E, Camann W. Combined spinal-epidural analgesia in advanced labour. Can J Anaesth 1994;41:575-8
4. D`Angelo R,
Endocrine
responses to spinal or epidural anesthesia
The endocrine response measured by plasma cortisol and glucose levels was not abolished by thoracic epidural etidocaine (1). Studies have failed to dampen the endocrine metabolic response to surgical trauma by thoracic epidural anesthesia unless this has been combined with spinal anesthesia (2).
1. Dahl JB, Rosenberg J, Kehlet H. Effect of thoracic epidural etidocaine 1.5% on somatosensory evoked potentials, cortisol and glucose during cholecystectomy. Acta Anaesthesiol Scand 1992;36:378-382
2. Dahl JB, Rosenberg J, Dirkes WE, Mogensen T, Kehlet H. Prevention of postoperative pain by balanced analgesia. Br J Anaesth 1990;64:518-520
Epidural
unilateral blockade
The incidence of unilateral blockade in
continuous lumbar epidural anesthesia is 5.9% (1). There have been four
etiologic factors described for the development of unilateral epidural blockade
(2-9):1. Slow injection of small volumes, patient position, and baricity of
local anesthetic solution may cause anesthetic solutions to pool on the lower
side during injection;
1. Asato F, Hirakawa N, Oda M, Iyatomi I, Nagasawa I, Katekawa Y, Totoki T. A median epidural septum is not a common cause of unilateral epidural blockade. Anesth Analg 1990;71:427-9
2. Singh A. Unilateral epidural analgesia. Anaesthesia 1967;22:147-9
3. Shanks CA. Four cases of unilateral epidural analgesia. Br J Anaesth 1968;40:999-1002
4. Usubiaga JE, Dos Reis A, Usubiaga LE. Epidural misplacement of catheters and mechanisms of unilateral block. Anesthesiology 1970;32:158-61
5. Bozeman PM, Chandra P. Unilateral analgesia following epidural and subarachnoid block. Anesthesiology 1980;52:356-7
6. De Rosayro AM. A case of unilateral analgesia following epidural and subarachnoid block revisited. Anesthesiology 1981;55:478
7. Bailey PW. Median epidural septum and multiple cannulation. Anaesthesia 1986;41:881-2
8. Nunn G, Mackinnon RP. Two unilateral epidural blocks. Anaesthesia 1986;41:439-40
9. Hehre FW, Sayig JM, Lowman RM. Etiologic aspects of failure of continuous lumbar peridural anesthesia. Anesth Analg 1960;39:511-7
10.
11. Crawford SJ. Epidural blood patch. Anaesthesia 1985;40:381
Combined
spinal-epidural anesthesia: The anesthesia of choice
In 1992 (1) only 6.6% of patients
operated in 17 European countries received epidural or spinal opioid analgesia.
89.2% received epidural opioids, while 10.8% intrathecal opioids (ratio 8:1).
In a recent review on regional anesthesia and analgesia for same-day surgery in
adults Wurm (2) stated that "regional anesthesia continuous to remain
under-utilized for same-day surgery. Reasons for this include uncertainty of
success, prolonged preparation time, and special skills required by the
anesthesiologist". Lyons et al. (3) found a "demonstrable lack of
enthusiasm for the sequential separate punctures amongst women who had previous
experience of regional anesthesia for caesarean section. An additional skin
breech, while seeming trivial in itself, may have had a greater impact on
patient acceptance". There is a considerable variation in the frequency
with which regional anesthesia is used. A review of 6,000 patients at the
1. Rawal N. Epidural and intrathecal
opioids for postoperative pain management in
2. Wurm WH. Regional anesthesia and analgesia for same-day surgery in adults. Current Opinion in Anaesthesiology 1994;7:436-440
3. Lyons G, Macdonald R, Mikl B. Combined epidural/spinal anaesthesia for Caesarean section: Through the needle or in separate spaces? Anaesthesia 1992;47:199-201
4.
5. Urmey WF, Stanton J, Sharrock NE. Initial one-year experience of a 97.3% regional anesthesia ambulatory surgery center. Reg Anesth 1993;18:69
6. Florio R, Sassu B, Cianciullo A. Selective spinal technique and atraumatic needles increase the incidence of spinal anesthesia. Acta Anaesthesiol Scand 1995;39:A432
7. Valia JC, De Andres J, Gil A, Bolinches R. Analysis of patient attitudes towards regional anaesthesia. Int Monitor Reg Anaesth 1993:57
8. Carson D, McLead G, Serpell M, Bannister J. Minor surgery for young adults: general or spinal anaesthesia? Int Monitor Reg Anaesth 1993:51
9. Riley ET, Cohen SE, Macario A, Desai JB, Ratner EF. Spinal versus epidural anesthesia for cesarean section: A comparison of time efficiency, costs, charges, and complications. Anesth Analg 1995;80:709-12
10. Smith J, Egan E. Regional anaesthesia in a developing country. Int Monitor Reg Anaesth 1993:57
11. Lonsdale M, Hutchison GL. Patient`s desire for information about anaesthesia: Scottish and Canadian Attitudes. Anaesthesia 1991;46:410-412
12. Bonica JJ, McDonald JS, eds. Principles and practice of obstetric analgesia and anesthesia. 2nd ed, Williams & Wilkins, 1995
13. Rawal N. European trends in the use of combined spinal epidural technique - A 17-nation survey. Reg Anesth 1995;20(Suppl):162
Epidural
catheter strength
A
1. Blum S, Sosis M. An investigation of the comparative strengths of 19 gauge epidural catheters. Reg Anesth 1995;20(Suppl):157
Epidural
catheter paresthesias
Rolbin et al. (1) reported a 24-44%
incidence of transient paresthesias during epidural catheter insertion. Juneja
et al. (2) compared the incidence of transient paresthesias among three types
of epidural catheters. The Flex Tip Plus (19 gauge; open tip; Arrow) produced
only 2.16% paresthesias, while the 20 gauge Copolymer Bullet tip (
1. Rolbin SH, Hew E, Olgilvie G. A comparison of two types of epidural catheters. Can J Anaesth 1987;34:459-461
2. Juneja M, Kargas GA, Miller DL, Perry EA, Gupta B, Garcia E, Pajel V, Botic Z, Rigor B. Comparison of epidural catheter`s induced paresthesias in parturients. Reg Anesth 1995;20(Suppl):152
3. Spriggs LE, Vasdev GM, Leicht CH. Clinical evaluation of wire impregnated epidural catheters with standard epidural catheters for labor analgesia. Reg Anesth 1995;20(Suppl):154
4. Huhtala J, Tarkkila P, Tuominen M. Transient radicular irritation after spinal anaesthesia with hyperbaric 5% lidocaine. Acta Anaesthesiol Scand 1995;39:A426
CSEA and
anticoagulation
Intraoperative anticoagulation with heparin appears relatively safe if epidural catheters are inserted prior to anticoagulation (1,2).
1. De Angelis J. Hazards of subdural and epidural anesthesia during anticoagulant therapy: A case report and review. Anesth Analg 1972;51:676-679
2. Odoom JA,
Combined
spinal-epidural analgesia in labor
Pain during the first stage of labor is
attributed to uterine contractions that contribute to dilation of the lower
uterine segment and cervix. During this stage, neural transmission of painful
sensation to the neuroaxis travels via sympathetic fibers that enter at the
10th, 11th, and 12th thoracic and 1st lumbar spinal segments (1). These fibers
synapse with ascending and descending fibers in the dorsal horn of the spinal
cord. As labor progresses to the second stage, additional pain is produced by
stretching and distention of the vagina and perineum. This pain is more somatic
in nature and is conveyed by the pudendal nerve that arises from 2nd, 3rd, and
4th sacral nerves (2). Interactive computer questioning of 218 delegates at the
meeting of the Society for Obstetric Anesthesiology and Perinatology in 1993
revealed that only 4.2% clinicians did not add opioids to bupivacaine for
epidural analgesia in labour. Fentanyl and sufentanil were chosen by 97% (3).
In the
1. Shnider SM, Levinson G, Ralston DH. Regional anesthesia for labor and delivery. In: SM Shnider, G. Levinson, eds. Anesthesia for obstetrics, 3rd ed., Baltimore, Williams & Wilkins, 1987, p.135
2. Caldwell LE, Rosen MA, Shnider SM. Subarachnoid morphine and fentanyl for labor analgesia: Efficacy and adverse effects. Reg Anesth 1994;19:2-8
3. Crowhurst JA. Analgesia for labour. Curr Opin Anaesthesiol 1994;7:224-228
4. Davies M, Harrison J, Ryan T. Current
practice of epidural analgesia during normal labour. A survey of maternity
units in the
5. Scott PV, Bowen FE, Cartwright P, Mohan Rao BC, Deeley D, Wotherspoon HG, Sumrein IMA. Intrathecal morphine as sole analgesia during labour. Br Med J 1980;278:351-353
6. Abouleish A, Abouleish E, Camann W. Combined spinal-epidural analgesia in advanced labour. Can J Anaesth 1994;41:575-578
7.
8. Breen TW, Shapiro T, Glass B, Foster-Payne D, Oriol NE. Epidural anesthesia for labor in an ambulatory patient. Anesth Analg 1993;77:919-924
9. Justino DM, Francis D, Houlton PG, Reynolds F. A controlled trial of extradural fentanyl in labour. Br J Anaesth 1982;54:409-414
10. Enever GR, Noble HA, Kolditz D, Valentine S, Thomas TA. Epidural infusion of diamorphine with bupivacaine in labour: A comparison with fentanyl and bupivacaine. Anaesthesia 1991;46:169-173
11. Wlodarski JC, Tanck EN, Newman LM, Ivankovich AD. Nalbuphine added to intrathecal sufentanyl ameliorates the pruritus in laboring patients. Anesth Analg 1994;78:S483
12. Morgan BM, Kadim MY. Mobile regional analgesia in labour. Br J Obstet Gynaecol 1994;101:839-841
13. Van Zundert AA, Wolf AM, Vaes L, Soetens M. High volume spinal anesthesia with bupivacaine 0.125% for cesarean section. Anesthesiology 1988;69:998-1003
14. Ewen A, McLeod DD, MacLeod DM,
15. Eddleston JM, Maresh M, Horsman EL, Young H, Lacey P, Anderton J. Comparison of the maternal and fetal effects associated with intermittent or continuous infusion of extradural analgesia. Br J Anaesth 1992;69:154-158
16. Silva TSS, Popat MT. Combined spinal-epidural anesthesia in parturient with Harrington rods. Reg Anesth 1994;19:360
17. Gaiser R, Adams H, Cheek TG, Gutsche BB. Comparison of three different doses of intrathecal fentanyl and sufentanyl for labor analgesia. ASRA Annual Meeting 1995;75
18. Joos S, Servais R, Van Steenberge A. Sequential spinal-epidural analgesia for pain relief during labour. International Monitor on Regional Anaesthesia 1994;A88
19. Bonica JJ, McDonald JS. Epidural analgesia and anesthesia. In: Bonica JJ, McDonald JS. eds. Principles and Practice of Obstetric Analgesia. 2nd ed., Williams & Williams, 1995, p.442
20. Hill DA, McAuley DM, Clarke RSJ. Randomised double blind comparison of intrathecal alfentanil or diamorphine with bupivacaine in a single space, needle through needle, combined spinal-epidural for analgesia in labour. International Monitor on Regional Anaesthesia 1994;A94
21. Arkoosh VA, Sharkey SJ, Norris MC, Isaacson W, Honet JE, Leighton BL. Subarachnoid labor analgesia: Fentanyl and morphine versus fentanyl and morphine. Reg Anesth 1994;19:243-246
22. Norris MC, Grieco WM, Borkowski M, Leighton BL, Arkoosh VA, Huffnagle HJ, Huffnagle S. Complications of labor analgesia: epidural versus combined spinal epidural techniques. Anesth Analg 1994;79:529-537
Combined
spinal-epidural anesthesia for orthopedic operations
In some hospitals the combined
spinal-epidural anesthesia is the method of choice in all surgical
interventions of the lower extremities. For example, in the Endo-Clinic in
1. Schleinzer W, Hook D, Reibold JP, Schmalz B. Combined spinal/epidural anaesthesia (CSE) - An appropriate procedure. Acta Anaesthesiol Scand 1995;39:A424
2. Urmey WF, Stanton J, Sharrock NE. Combined spinal-epidural (CSE) technique to assess dose-response of isobaric lidocaine spinal anesthesia. Anesth Analg 1993;76:S441
Combined
end-multiple lateral holes (CEMLH) epidural catheter
Most of the epidural catheters used in
the
1. Collier CB, Gatt SP. Epidural catheter for obstetrics: Terminal hole or lateral eyes? Reg Anesth 1994;19:378-385
2. Curbelo MM. Continuous peridural segmental anesthesia by means of an ureteral catheter. Anesth Analg 1949;28:13-23
3. Lee JA. A new catheter for continuous extradural analgesia. Anaesthesia 1962;17:248-250
4. Skinner BS. A new epidural cannula. Can Anaesth Soc J 1966;13:622-623
5. Collier CB, Gatt SP. A new epidural catheter: Closer eyes for safety? Anaesthesia 1993;48:803-806
6. Segal S, Eappen S, Datta S.
Comparison of single-orifice and multi-orifice epidural catheters for labor
analgesia and cesarean delivery. ASRA Annual Meeting 1995:149 7. Michael S,
8. Ward CF, Osborne R, Benumof JL, Saidman LJ. A hazard of double-orifice epidural catheters. Anesthesiology 1978;48:362-364
Double-hole
pencil-point spinal needle
Greene (1) described in
1. Greene HM. Lumbar puncture and the prevention of postpuncture headache. JAMA 1926;86:391-392
2. Greene HM. A technic to reduce the incidence of headache following lumbar puncture in ambulatory patients with a plea for more frequent examinations of the cerebrospinal fluids. Northwest Med 1923;22:240
3. Kirschner M. Versuche zur Herstellung einer gurtelformigen Spinal-anasthesie. Arch Klin Chir 1931;167:755-760
4. Hart JR, Whitacre RJ. Pencil-point needle in prevention of postspinal headache. JAMA 1951;147:657-658
5. Sprotte G, Schedel R, Pajunk H. Eine atraumatische Universalkanule fur einzeitige Regionalanaesthesien. Reg Anaesth 1987;10:104-108
6.
7. Lipov EG,
Epidural
catheter test dose in the combined spinal-epidural anesthesia
The epidural test dose was first
recommended by Dogliotti (1) in 1933. He suggested a small volume of local
anesthetic through the epidural needle to insure that a subarachnoid placement
had not occurred prior to injecting the full epidural dose. Scott (2) in 1988
wrote in an editorial that "many anaesthetists do not use (epidural test
dose) unless they have serious doubts on the correct position of the needle or
catheter". Brown (3) in the 4th edition of Miller`s textbook Anesthesia
wrote that "in spite of an adequately positioned catheter during first use
of local anesthetic, each subsequent injection should be preceded by aspiration
and an epidural test dose, since catheter migration into vessels and
subarachnoid or subdural spaces does occur."
1. Dogliotti AM. Segmental peridural anesthesia. Am J Surg 1933;20:107-18
2. Scott DB. Test doses in extradural block. Br J Anaesth 1988;61:129-130
3. Brown DL. Spinal, epidural, and
caudal anesthesia. In: Anesthesia,
4.
5. Shnider SM, Levinson G. Anesthesia
for cesarian section. In: Anesthesia for obstetrics; 2nd ed.; Shnider SM,
Levinson G (eds.);
6. Galloon S. Test doses in extradural analgesia. Br J Anaesth 1978;50:304
7. Rees GAD, Rosen M. Test-dose in extradural analgesia. Br J Anaesth 1979;51:70-71
8. Crawford JS. Some maternal complications of epidural analgesia for labour. Anaesthesia 1985;40:1219-1225
9.
10. Kumar CM, Dennison B, Panchal HI. Epidural test dose. Anaesthesia 1985;40:1023
11.
12. Soresi AL. Episubdural anesthesia. Anesth Analg 1937;16:306-10
13. Rawal N. Single segment combined subarachnoid and epidural block for caesarean section. Can Anaesth Soc J 1986;33:254-5
14. Myint Y, Bailey PW, Milne BR. Cardiorespiratory arrest following combined spinal epidural anaesthesia for caesarean section. Anaesthesia 1993;48:684-686
15. Thoren T, Holmstrom B, Rawal N, Schollin J, Lindeberg S, Skeppner G. Sequential combined spinal epidural block versus spinal block for cesarean section: Effects on maternal hypotension and neurobehavioral function of the newborn. Anesth Analg 1994;78:1087-92
16. Kumar CM. More on combined subarachnoid and epidural techniques. Anaesthesia 1986;41:90-91
17. Cheng PA. The anatomical and clinical aspects of epidural anesthesia. Part 1. Anesth Analg 1963;42:398-406
18. Westbrook JL, Renowden SA, Carrie LES. Study of the anatomy of the extradural region using magnetic resonance imaging. Br J Anaesth 1993;71:495-498
19. Ravindran RS, Bond
20. Reisner LS, Hochman BN, Plumer MH. Persistent neurologic deficit and adhesive arachnoiditis following intrathecal 2-chloroprocaine injection. Anesth Analg 1980;59:452-4
21.
22. Hollway TE,
23. Crawford JS. Lumbar epidural block in labour: A clinical analysis. Br J Anaesth 1972;44:66-74
24. Crawford JS. The second thousand epidural blocks in obstetric hospital prctice. Br J Anaesth 1972;44:1277-1287
25. Bishton IM, Martin PH, Vernon JM, Liu WH. Factors influencing epidural catheter migration. Anaesthesia 1992;47:610-2
26. Hogan QH. "Migration" of an epidural catheter? Anesth Analg 1993;76:910-911 27. Reynolds F, Speedy HM. The subdural space: the third space to go astray. Anaesthesia 1990;45:120-3
28. Dawkins CJM. An analysis of the complications of extradural and caudal block. Anaesthesia 1969;24:554
29. Tanaka K, Watanabe R, Harada T, Dan K. Extensive application of epidural anesthesia and analgesia in a university hospital: incidence of complications related to technique. Reg Anesth 1993;18:34-38
30. Macdonald R. Unintentional dural puncture. Anaesthesia 1988;43:705
31.
32. Chadwick HS, Posner K, Caplan RA, Ward RJ, Cheney FW. A comparison of obstetric and nonobstetric anesthesia malpractice claims. Anesthesiology 1991;74:242-249
33. Dain SL, Rolbin SH, Hew EM. The epidural test dose in obstetrics; is it necessary? Can J Anaesth 1987;34:601-5
Spinal
and epidural opioid analgesia
Epidural
bolus injection of opioid, morphine and fentanyl, can produce good analgesia in
doses of 2-4 mg and 0.1-0.2 mg, respectively (1). In animal studies, it has
been demonstrated that intrathecal or epidural coadministration of opioid and
local anesthetics produced synergistic analgesia (2-5). The use of continuous
epidural opioid infusions may obviate the need for redosing, but it may
obligate the patient to receive more opioid than is required (6) and increase
the risk of respiratory depression (7). Drug dose is the important determinant
of efficacy, rather than concentration or volume (8). Torda et al. (9) found
that in patients who had undergone major abdominal surgery, analgesia after
thoracic extradural injection of fentanyl 50 µg did not differ significantly
from analgesia after 0.5% bupivacaine 10 ml, or the fentanyl-bupivacaine
mixtures. Bupivacaine alone caused a greater decrease in arterial pressure and
a higher incidence of hypotension than fentanyl or the fentanyl-bupivacaine
mixtures. Badner et al. (10,11) reported that after abdominal, thoracic or knee
replacement surgery, there was no advantage in using a mixture of 0.1%
bupivacaine with fentanyl 10 µg/ml compared with fentanyl alone by continuous
extradural infusion. Rudolph Matas (12), on November 10, 1899, was the first in
the
1. De Castro
J, Meynadier J, Zenz M. Regional opioid analgesia.
2. Akerman B, Arwestrom E, Post C. Local anesthetics potentiate spinal morphine antinociception. Anesth Analg 1988;67:943-948
3. Penning JP, Yaksh TL. Interaction of intrathecal morphine with bupivacaine and lidocaine in the rat. Anesthesiology 1992;77:1186-1200
4. Maves TJ, Gebhart GF. Antinociceptive synergy between intrathecal morphine and lidocaine during visceral and somatic nociception in the rat. Anesthesiology 1992;76:91-99
5. Kaneko M, Saito Y, Kirihara Y, Kosaka Y. Effects of epidural morphine and lidocaine on somatic and visceral pain. Neuroscience Abstracts 1991;17:294
6. Marlowe S, Engstrom R, White PF. Epidural patient-controlled analgesia (PCA): an alternative to continuous epidural infusions. Pain 1989;37:97-101
7. Boudreault D, Brasseur L, Samii K, Lemoing J. Comparison of continuous epidural bupivacaine infusion plus either continuous epidural infusion or patient-controlled epidural injection of fentanyl for postoperative analgesia. Anesth Analg 1991;73:132-137
8. Laveaux MMD, Hasenbos MAWM, Harbers JBM, Liem T. Thoracic epidural bupivacaine plus sufentanyl: High concentration/low volume versus low concentration/high volume. Regional Anaesthesia 1993;18:39-43
9. Torda TA, Hann P, Mills G, DeLeon G, Persman D. Comparison of extradural fentanyl, bupivacaine and two fentanyl-bupivacaine mixtures for pain relief after abdominal surgery. Br J Anaesth 1995;74:35-40
10.
11.
12. Matas R. Local and regional anesthesia with cocaine and other analgesic drugs, including the subarachnoid method, as applied in general surgical practice. Phil Med J 1900;6:820-843
13. Vandam LD. On the origins of intrathecal anesthesia. International Anesthesiology Clinics 1989;27:2-7
14. Moreno LA, Sinche M, Balust J, Izquierdo E, De Jose Mana B, Sala X, Galard JJ, Nalda MA. Total spinal block (TSB) treated by means of cerebrospinal fluid rechange (CSFR). International Monitor on Regional Anesthesia 1993;68
15. Kaiser KG, Bainton CR. Treatment of intrathecal morphine overdose by aspiration of cerebrospinal fluid. Anesth Analg 1987;66:475-477
16. Liu S, Carpenter RL, Neal JM, Pollock JE, Gerancher JC. Effects of addition of 20 µg of fentanyl to lidocaine spinal anesthesia. Reg Anesth 1995;20:S112
17. Sosis M, Braverman B, Ivankovich A. Growth of Candida albicans and staphylococcus aureus in Fentanyl/Bupivacaine mixtures for epidural administration. Society of Obstetric Anesthesia and Perinatology (SOAP), 25th Annual Meeting, 1993:92
18. Hansdottir V, Woestenborghs R, Nordberg G. The cerebrospinal fluid and plasma pharmacokinetics of sufentanil after thoracic or lumbar epidural administration. Anesth Analg 1995;80:724-729
19. Nordberg G, Hansdottir V, Bondesson U, Boreus LO, Mellstrand T, Hedner T. CSF and plasma pharmacokinetics of pethidine and norpethidine in man after epidural and intrathecal administration of pethidine. Eur J Clin Pharmacol 1988;34:625-631 20. Famewo CE, Naguib M. Spinal anaesthesia with meperidine as the sole agent. Can Anaesth Soc J 1985;5:533-537
21. Swayze C, Sherman JH, Walker EB. Efficacy of subarachnoid meperidine for labor analgesia. Reg Anesth 1991;16:309-313
22.
Sangarlankarn S, Klaewtanong V, Jonglerttrakool P, Khankaew V. Meperidine as a
sole anesthetic agent: A comparison with lidocaine-glucose. Anesth Analg
1987;66:235-240
The
choice of the anesthesiologists
Gantt et al. (1) evaluated whether anesthesiologists will still prefer spinal or epidural anesthesia over general anesthesia after they will experience these regional techniques. Twelve anesthesiologists underwent two procedures (spinal and epidural anesthesia) on the same day. All but one anesthesiologist (91.6%) did not change their preference for regional over general anesthesia. In a survey among 558 Canadian surgeons they have been asked which anesthesia they would choose for themselves for a hernia repair. The results were: local - 38%; general - 30%; epidural - 15%; spinal - 10%; other - 6% (2). The choice was somewhat surprising, because surgeons rarely perform local anesthesia on patients for hernia repair. It was also interesting to note that the the method of anesthesia selected by the surgeons for themselves was not necessarily the method they would choose for their patients.
1. Gantt R, Beardsley D, Lindsey J, Setzer V, Stevens RA. Subjective preferences of twelve anesthesiologists undergoing two major neuroaxial blockades: spinal and epidural. Anesthesiology 1994;81:A990
2. Klassen N, Grace M, Finucane BT. Surgeons` attitudes towards regional anesthesia: a Canadian perspective. ASRA Annual Meeting 1995;107
Epidural
catheter malposition
In a survey (1) conducted in 218
obstetric units in the
1. Sajjad T, Ryan TDR. Current
management of inadvertent dural taps occurring during the siting of epidurals
for pain relief in labour: A survey of maternity units in the
2. Ravindran RS, Bond
3. Reisner LS, Hochman BN, Plumer MH. Persistent neurologic deficit and adhesive arachnoiditis following intrathecal 2-chloroprocaine injection. Anesth Analg 1980;59:452-4
4.
5.
6. Jaucot J. Paramedian approach of the peridural space in obstetrics. Acta Anaesthesiol Belg 1986;37:187
7.
8. Tanaka K, Watanabe R, Harada T, Dan K. Extensive application of epidural anesthesia and analgesia in a university hospital: incidence of complications related to technique. Reg Anesth 1993;18:34-38
9. Brown DL. Spinal, epidural, and
caudal anesthesia. In: Anesthesia;
10.
11. Rathmell JP, Viscomi CM, Roth J, Aladjem E, Williams J. Detection of intravascular epidural catheters using 2-chloroprocaine injection: influence of dose and nalbuphine premedication. Anesthesiology 1994;81:A971
12. Cantelo RA, Walsh GR. Aspiration of cerebrospinal fluid - not always a dural tap. Anaesthesia 1993;48:452
13. Marx GF. Cardiotoxicity of local anesthetics - the plot thickens. Anesthesiology 1984;60:3-5
14. Kahn RL, Quinn TJ. Blood pressure, not heart rate, as a marker of intravascular injection of epinephrine in an epidural test dose. Reg Anesth 1991;16:292-5
15. Vestal RE, Wood AJJ, Shand DG. Reduced adrenoceptor sensitivity in the elderly. Clin Pharmacol Ther 1979;26:181-6
16. Guinard JP, Mulroy MF, Carpenter RL, Knopes KD. Test doses: optimal epinephrine content with and without acute beta-adrenergic blockade. Anesthesiology 1990;73:386-92
17. Tanaka M, Yamamoto S, Ashimura H, Iwai M, Matsumiya N. Efficacy of an epidural test dose in adult patients anesthetized with isoflurane: Lidocaine containing 15 µg epinephrine reliably increases arterial blood pressure, but not heart rate. Anesth Analg 1995;80:310-4
18. Crawford JS. Some maternal complications of epidural analgesia for labour. Anaesthesia 1985;40:1219-1225
19. Scott DB, Hibbard BM. Serious non-fatal complications associated with extradural block in obstetric practice. Br J Anaesth 1991;64:537-41
20. Michels AMJ, Lyons G, Hopkins PM. Lignocaine test dose to detect intravenous injection. Anaesthesia 1995;50:211-213
21. Dawkins CJM. An analysis of the complications of extradural and caudal block. Anaesthesia 1969;24:554-563
22. Macdonald R. Unintentional dural puncture. Anaesthesia 1988;43:705
Woolley
and Roe case
On October 13, 1947, two incidents
occurred which resulted in one of the most famous of all medicolegal actions as
far as the speciality of anesthesia was concerned. Two patients, Cecil Roe and
Albert Woolley who were on the same operative list for relatively minor
surgical procedures, developed permanent, painful, spastic paraparesis
following spinal anesthesia with hypobaric 1:1500 cinchocaine (nupercaine;
dibucaine) administered by the same anesthetist. Both patients sued the
hospital and the anesthetist and the case came to court in October 1953 and
lasted 11 days. This case had a profound effect on the practice of spinal
anesthesia, as anesthetists were fearful of producing permanent neurological
damage and the technique, in the
1. Morgan M. The Woolley and Roe case. Anaesthesia 1995;50:162-173
2. Noble AB, Murray JJ. A review of the complications of spinal anaesthesia with experience in Canadian teaching hospitals from 1959-1969. Can Anaesth Soc J 1971;18:5
3. Moore DC, Bridenbaugh LD, Bagdi PA, et al. Present status of spinal (subarachnoid) and epidural (peridural) block: a comparison of the two technics. Anesth Analg 1968;47:40-9
4. Dripps RD, Vandam LD. Long term follow-up of patients who received 10,098 spinal anesthetics. JAMA 1954;156:1486-1491
5. Scott DB, Thorburn JT. Spinal anaesthesia. Br J Anaesth 1975;47:421-2
Anesthetic
costs
1. Cooper JO. The relative costs of
anesthesia drugs in
2. Bowe EA, Brill VL, Baysinger CL, Brown KL, Longston GM, Chillag KJ. Anesthesia drug costs for total joint replacement: Spinal versus general anesthesia. ASRA Annual Meeting 1995;21
From the
skin to the spinal-epidural spaces
The distribution of distance from the
skin to the epidural space in obstetric patients (n=2,123) was: <
1. Hamza J, Smida M, Benhamou D, Cohen SE. Parturient`s posture during epidural puncture affects the distance from skin to epidural space. J Clin Anesth 1995;7:1-4
2. Leighton BL. A greengrocer`s model of the epidural space. Anesthesiology 1989;70:368-9
3. Cousins MJ. Epidural neural blockade.
In: Neural blockade in clinical anesthesia and management of pain. Cousins MJ,
Bridenbaugh PO (eds.);
4. Cheng PA. The anatomical and clinical aspects of epidural anesthesia. Part 1. Anesth Analg 1963;42;398-406
5. Westbrook JL, Renowden SA, Carrie LES. Study of the anatomy of the extradural region using magnetic resonance imaging. Br J Anaesth 1993;71:495-498
6. Franksson C, Gordh R. Headache after spinal anesthesia and a technic for lessening its frequency. Acta Chir Scand 1946;94:443-454
7. McDonald JS, Mandalfino DA. Subarachnoid block. In: Bonica JJ, McDonald JS, eds. Principles and practice of obstetric analgesia and anesthesia. 2nd ed., Williams & Wilkins, 1995;pp.479-480
8. Viets HR. Domenico Cotugno: his description of the cerebrospinal fluid. Bull Inst Hist Med 1935;3:701-720
9. Meme E, Amici M, Ricci L, Merletti F. Epidural space: anatomical living view. International Monitor on Regional Anaesthesia 1993;96
10. Reina MA, Lopez A, Escriu MN, Del Cano MC, Cascales MR, Delgado MP. Structure of human duramater by a scanning electron microscopy. International monitor on Regional Anaesthesia 1994;A71
Myint
case
Myint et al. (1) published the first case report of cardiorespiratory arrest following combined spinal-epidural anesthesia. using the needle-through-needle technique in a 31 year old parturient scheduled for cesarean section they injected 2 ml 0.5% bupivacaine in 8% dextrose through 24G Sprotte needle into the spinal space. Then they rotated the epidural needle 180° and introduced an epidural catheter with three lateral holes into the epidural space. They made an aspiration test which was negative for blood or CSF. Then they made a test dose of 2 ml 0.5% bupivacaine with adrenaline 1:200,000 given through the epidural catheter. A few minutes later the patient complained of some numbness in her fingers, but her hand grip was strong and she was able to breath deeply and strongly on request. Upper limit of sensory block was T4 bilaterally. At the end of the operation they have given 2.5 mg of diamorphine in 5 ml of 0.25% bupivacaine through the epidural catheter for postoperative analgesia. Forty minutes later she complained of difficulty in breathing which developed rapidly to respiratory and cardiac arrest. Resuscitation started with endotracheal intubation, adrenaline 1 mg and atropine 0.6 mg IV. Then she received two doses of naloxone 0.4 mg IV. She started breathing and regained consciousness within 2 min of the first administration of intravenous naloxone. The patient recovered completely with no neurological deficit and did not develop a postspinal headache. Due to the masking of the epidural test dose by the previous spinal anesthetic injection Myint et al. could not appreciate correctly the patient`s complaint of "some numbness in her fingers". If it occurred at the first place, i.e., the epidural catheter test dose before the spinal anesthetic injection, their suspicion would certainly be of an intravascular or subarachnoid inadvertent placement of the epidural catheter or one of its 3 lateral holes. Their inability to recognize it is blamed upon the technique of the needle-through-needle in which you have first to inject the anesthetic solution into the spinal space and then to insert the epidural catheter into the epidural space. It is in contrast to the Eldor needle technique in which the epidural catheter is first inserted allowing a proper test dose, and then the spinal anesthetic is injected through the spinal needle introduced through its spinal conduit.
1. Myint Y, Bailey PW, Milne BR. Cardiorespiratory arrest following combined spinal epidural anaesthesia for caesarean section. Anaesthesia 1993;48:684-686
Spinal
needles
Slow flowback of CSF through 25 and
26-gauge spinal needles may, particularly in inexperienced hands, lead to
repeated unrecognized dural puncture and this may contribute to post dural
puncture headache. In 1968, Brandus (1) examined 22G spinal needles and
identified tissue fragments ("cores") in 75% of needles in which the
stylet was not removed and CSF not seen. The cores (skin or epidural threads)
were absent when CSF was identified and local anesthetic injected. Campbell et
al. (2) compared the coring effect between the 25G Quincke and 25G Whitacre
spinal needles. Tissue fragments were identified in 80% of the Quincke needles
compared to 41% of the Whitacre needles in which the stylet was not removed and
CSF not seen, and in one of the 25G Quincke needles in which CSF was identified
and local anesthetic injected. All tissue fragments were fat tissue. Westbrook
et al. (3) compared the force required for dural puncture with different spinal
needles and subsequent leakage of cerebrospinal fluid using an in vitro model
of a bovine dura. They found that the pencil-point needles required significantly
more force to pierce the dura than the Quincke needle of the same external
diameter. For example, using the B-D 25G Quincke needle the puncture was 0.04±
1. Brandus V. The spinal needle as a carrier of foreign material. Can Anaesth Soc J 1968;15:197-201
2.
3. Westbrook JL,
4. Halpern S, Preston R. Postdural puncture headache and spinal needle design. Anesthesiology 1994;81:1376-1383
5. Garcia J, Arilla MC, Sierra P, Castillo J, Pares N, Escolano F, Castano J. Spinal anaesthesia with 25G and 27G Whitacre spinal needles in patients under 60 years of age. International Monitor on Regional Anaesthesia 1993;23
6.
8. Pedraza I, Riobo MI, Alvarez J. Collection of CSF using a combined spinal epidural needle as an indication of a duramater hole spinal puncture. International Monitor on Regional Anaesthesia 1994;A96
9. Joshi GP, McCarroll SM. Evaluation of combined spinal-epidural anesthesia using two different techniques. Reg Anesth 1994;19:169-174
10. Turner MA, Shaw M. Atraumatic spinal needles. Anaesthesia 1993;48:452
11. Sayeed YG,
12. Brettner J, Wresch KP, Klose R. Does a pencil-shaped spinal needle offer advantages for spinal anesthesia? Reg Anaesth 1990;13:124-128
13. Crone LL, Vogel W. Failed spinal anesthesia with the Sprotte needle. Anesthesiology 1991;75:717
14. Dittman M, Schafer HG, Ulrich J, Bond-Taylor W. Anatomical re-evaluation of lumbar dura mater with regard to postspinal headache: Effect of dural puncture. Anaesthesia 1988;43:635-7
15. Ackerman W, Cases-Cristobal V, Juneja M, Rigor BM. Sprotte needle for caesarean section. Anaesthesia 1991;46:230
16.
Meningitis
post combined spinal-epidural anesthesia
Harding et al. (1) reported on two cases of meningitis which developed after combined spinal-extradural procedures for obstetric analgesia. The first case was thought to be caused by aseptic or chemical meningitis and the second was a case of bacterial meningitis in a patient who also received an extradural blood patch.
1. Harding SA, Collis RE, Morgan BM. Meningitis after combined spinal-extradural anaesthesia in obstetrics. Br J Anaesth 1994;73:545-547
Preemptive
analgesia and combined spinal-epidural anesthesia
Shir et al. (1) compared three groups of patients undergoing radical prostatectomy with general, epidural or combined epidural and general anesthesia. Preemptive analgesia was observed only with epidural anesthesia, because this type of anesthesia allows for even minor discomfort to be noticed and treated during surgery. They concluded that "complete intraoperative blockade of afferent signals to the CNS is fundamental in decreasing postoperative pain".
1. Shir Y, Raja SN, Frank SM. The effect of epidural versus general anesthesia on postoperative pain and analgesic requirements in patients undergoing radical prostatectomy. Anesthesiology 1994;80:49-56
Sympathetic
innervation and CSEA
Sympathetic innervation to the
sinoatrial node exits from the spinal cord between T1 and T4 (1,2). Sympathetic
block below these segments results in arterial and venous vasodilation in the
lower extremities and reflex compensatory increased sympathetic activity above
the block (1). Blocks reaching the T1-4 segments would then interrupt the
sympathetic flow to the heart. Parasympathetic innervation to the heart, on the
other hand, originates in the brainstem, travels via the vagus nerve and should
not be blocked, even during high levels of spinal anesthesia (1). The adrenal
medulla, which is the only known source of plasma epinephrine, receives its
sympathetic innervation from preganglionic fibers having their cell bodies in
spinal segments T6 through L2 (3). For many years, anesthesiologists have
assumed that, when local anesthetic is given to produce a sensory or motor
block, blockade of preganglionic sympathetic fibers would be present (4). In
vivo investigations of spinal (5,6) and epidural (7,8) anesthesia have
concluded that sympathetic denervation is present during sensory and motor
centroneuraxis block and that the level of sympathetic block exceeds the level
of sensory block by at least two dermatome segments. However, these conclusions
are based on a loss of cold sensation (5,9), an increase in skin temperature
(6) or thermography (4). However, studies evaluating sympathetic blockade by
monitoring skin conductance responses (10,11) have reported that spinal
anesthesia (upper level of sensory analgesia T4-T6) produced an incomplete
sympathectomy of the lower extremity. Stevens et al. (12) evaluated ten
subjects who underwent both spinal and epidural anesthesia with plain lidocaine
on the same day with complete recovery between blocks. Before and 30 min after
local anesthetic injection, a cold pressor test (immersion of an hand up to the
wrist into an ice-water bucket (
1. Greene NM. Physiology of spinal
anesthesia. 3rd ed.
2. Lefkowitz RJ, Hoffman BB, Taylor P.
Neurohumoral transmission: the autonomic and somatic motor nervous system. In:
Gilman AG, Rall TW, Nies AS, Taylor P, eds. Goodman and Gilman`s The Pharmacologic
basis of therapeutics. 8th ed.
3. Bonica JJ. Autonomic innervation of the viscera in relation to nerve block. Anesthesiology 1968;29:793-813
4.
5.
6. Chamberlain DP, Chamberlain BDL. Changes in skin temperature of the trunk and their relationship to sympathetic blockade during spinal anesthesia. Anesthesiology 1986;65:139-145
7. Brull SJ,
8. Hopf HB, Weissbach B, Peters J. High segmental thoracic epidural anesthesia diminishes sympathetic outflow to the legs despite restriction of sensory block to the upper thorax. Anesthesiology 1990;73:882-889
9. Gibbons JD. Non-parametric methods
for quantitative analysis. 2nd ed.
10. Bengtsson M, Loefstroem JB,
11. Malmqvist LA, Bengtsson M, Bjoernsson G, Jordfeldt L, Loefstroem JB. Sympathetic activity and hemodynamic variables during spinal analgesia in man. Acta Anaesthesiol Scand 1987;31:467-473
12. Stevens RA, Beardsley D, White JL, Kao TC, Gantt R, Holman S. Does spinal anesthesia result in a more complete sympathetic block than that from epidural anesthesia? Anesthesiology 1995;82:877-883
13. feigl E. Coronary physiology. Physiol Rev 1983;63:1-205
14. Blomberg S, Emanuelsson H, Ricksten S-E. Thoracic epidural anesthesia and central hemodynamics in patients with unstable angina pectoris. Anesth Analg 1989;69:558-62
15. Blomberg S, Emanuelsson H, Kvist H, Lamm C, Ponten J, Waagstein F, Ricksten SE. Effects of thoracic epidural anesthesia on coronary arteries and arterioles in patients with coronary artery disease. Anesthesiology 1990;73:840-7
16. Chierchia S, Lazzari M, Simonetti I, Maseri A. Hemodynamic monitoring in angina at rest. Herz 1980;5:189-98
17. Heusch G, Deussen A. The effects of cardiac sympathetic nerve stimulation on perfusion of stenotic coronary arteries in the dog. Cir Res 1983;53:8-15
18. Heusch G, Deussen A, Thamer V. Cardiac sympathetic nerve activity and progressive vasoconstriction distal to coronary stenoses: feed-back aggravation of myocardial ischemia. J Auton Nerv Syst 1985;13:311-26
19. Kock M, Blomberg S, Emanuelsson H, Lomsky M, Stromblad SO, Ricksten SE. Thoracic epidural anesthesia improves global and regional left ventricular function during stress-induced myocardial ischemia in patients with coronary artery disease. Anesth Analg 1990;71:625-30
20. Blomberg S, Curelaru I, Emanuelsson H, et al. Thoracic epidural anaesthesia in patients with unstable angina pectoris. Eur Heart J 1989;10:437-44
21. Blomberg SG. Long-term home self-treatment with high thoracic epidural anesthesia in patients with severe coronary artery disease. Anesth Analg 1994;79:413-21
22. Klassen G, Bramwell R, Bromage P, Zborowska-Sluis D. Effect of acute sympathectomy by epidural anesthesia on the canine coronary circulation. Anesthesiology 1980;52:8-15
The
politics of anesthesiology
Bridenbaugh (1) in his 1994 Gaston Labat Award Lecture recalled "visiting our congressman in the late 1980`s when we were fighting against legislation that proposed the radiology, anesthesiology, and pathology specialities should be reimbursed by the hospital and not our patients. In spite of our rational and logical protests, the congressman reminded us that our groups had little impact on the voting public. His comment was `All of your group`s patients are either in the dark, asleep, or dead`".
1. Bridenbaugh PO. Anesthesiology and pain management: Medical practice or perception. Reg Anesth 1994;19:301-306
Preconclusion
John Selden was an English historian,
jurist, antiquary and statesman. He lived between 1584 and
Conclusion
"We shape the architecture of our buildings and then they shape us" (Winston Churchill).