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
Preface
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 Corning (1) in
1885 inadvertently. Lumbar dural puncture was introduced
in
1891 by Wynter (2) in England and Quincke (3) in
Germany.
Von Ziemssen (4) in 1894 suggested the feasibility of
injecting drugs by means of lumbar dural puncture. Bier
(5),
a surgeon at the Royal Chirurgical Clinic in Kiel, was
the
first to inject cocaine into the spinal space. It was
between August 16 and 27, 1898.
It took 52 years since Corning`s discovery of the
epidural
analgesia and 39 years since Bier`s spinal anesthesia
that
these two compartments were first combined by Soresi (6)
in
1937. It took another 42 years until Curelaru (7) in
1979
used this combined spinal-epidural anesthesia again.
Even
the discoveries of Corning and Bier are 13 years apart.
However, the first anesthesia (maybe it was combined
spinal-epidural anesthesia - who knows?...) was done by
God
(8) "caused a deep sleep to fall upon Adam" for rib
extraction. The combined approach can also have its
origin
in the Bible: "Two are better than one" (9). Or you can
look
at it from Mark Twain`s point of view: "Name the
greatest of
all the inventors. Accident".
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. Jena 1894
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 Bucharest, Romania,
tested on
150 patients the method of spinal anesthesia with
continuous
epidural block. The punctures of the epidural and
subarachnoid spaces were done through two intervertebral
spaces. The puncture of the epidural space was performed
1-2
intervertebral spaces higher than the subarachnoid.
Anesthesia was always started with the introduction of
an
epidural catheter. After introducing the epidural
catheter,
the puncture of the subarachnoid space was done,
followed by
subarachnoid injection of the anesthetic solution.
Curelaru
concluded its advantages as "the possibility of
obtaining a
high quality conduction anaesthesia, virtually unlimited
in
time, the ability to extend over several anatomical
regions
the surgical field, minimal toxicity, the absence of
postoperative pulmonary complications and the economy".
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 England and Mumtaz, Daz and Kuz (2) from
Sweden, in two separate letters in the same issue of
Anaesthesia, in 1982, first described the insertion of a
long spinal needle through the epidural needle for
performing the combined spinal-epidural anesthesia.
Coates
found the technique "simple, reliable and relatively
quick
to perform". After injecting the anesthetic solution
into
the subarachnoid space, the spinal needle is withdrawn
and
an epidural catheter is threaded through the same lumen
of
the epidural needle, through which the spinal needle was
inserted.
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. Hong Kong, 1986;161-162
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, McGill WA. Do
anesthesiologists prefer a regional or a general
anesthesia
for themselves? Reg Anesth 1986;11:557
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. Greene NM, Brull SJ. Physiology of spinal anesthesia.
4th ed. Baltimore:Williams & Wilkins, 1993, p.IX
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, White DC. Topography of the lumbar
epidural
space. A study in cadavers using injected polyester
resin.
Anaesthesia 1980;35:7-11.
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 11 in the general anesthesia group.
These benefits of continuous spinal anesthesia can be
obtained also in the combined spinal-epidural
anesthesia,
while the spinal injections can be done in incremental
doses
of 0.5 ml plain bupivacaine through the spinal needle or
at
a reduced dose of 1-1.5 ml injected slowly into the
spinal
space, and then supplemented by the epidural route, if
necessary.
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 Groves (1) pinponted again the low public
image
of anaesthesiology and anaesthesiologists. Their paper
was
commented by anaesthesiologists from other countries who
showed the same trend (2,3). Keep and Jenkins (4) showed
in
1978 the same finding that only 67% (65% in Swinhoe and
Groves` report) of the patients thought an
anaesthesiologist
was a medical doctor. Their conclusion was that there is
a
need to give information sheets to patients
preoperatively
on the ward.
It is possible to attack this genuine problem from
another
point of view: In 1973, Katz (5) surveyed American
anesthesiologists and found that 68% preferred regional
anaesthesia for their own anaesthetic during an
unspecified
elective surgical procedure. In 1986, Broadman et al (6)
confirmed that a majority of anaesthesiologists still
preferred regional over general anaesthesia for their
own
extremity surgery. In their survey, 92% of the
anaesthesiologists preferred regional over general
anaesthesia for their own hypothetical emergency
surgery,
while 74% preferred a regional technique for their own
elective extremity surgery. It is possible that if most
anaesthetics are done by the regional techniques there
will
be much time for the awakened patient to learn that the
person at the top of the operating table is not less
important than the person who stands behind the sterile
curtain... and both of them are medical doctors.
So, anesthesiologists have to treat their patients as
they
would like to be treated while they are patients - and
they
have already chosen : Regional anaesthesia. This shift
in
the anaesthetic profession towards the regional
techniques
will be also a shift in the public recognition and
appreciation of anesthesiology and anesthesiologists.
1. Swinhoe CF, Groves ER. Patient`s knowledge of
anaesthetic
practice and the role of anaesthetists. Anaesthesia
1994;49:165-6.
2. Gajraj NM, Bala AS. Patient`s knowledge of
anaesthetists.
Anaesthesia 1994;49:559.
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, McGill WA. Do
anesthesiologists prefer a regional or a general
anesthetic
for themselves? Regional Anesthesia 1986;11:S57.
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 7 inches (18 cm) in length which lied beneath the
lumbar
portion of the spinal column when the patient was lying
on
the mattress.
Three years later, on March 1944, Tuohy (3) described an
alternative method in lieu of a malleable needle for
continuous spinal anesthesia: Use of an ureteral
catheter.
The idea of using an ureteral catheter for continuous
spinal
anesthesia came to Captain Tuohy, who served then in the
Medical Corps, Army of the United States, from the
reports
of the use of the ureteral catheter for caudal
anesthesia
(4,5) and for continuous subarachnoid drainage of
meningitis
advocated by Love (6). On June 14, 1944, Major Tuohy (7)
who
was then the chief of anesthesia and operative section,
Percy Jones General Hospital, Battle Creek, Mich.,
described
this technic before the section on Anesthesiology at the
Ninety-Fourth Annual Session of the American Medical
Association in Chicago. In the following article
published
on May 26, 1945 in JAMA Tuohy (7) said that "the
direction
(cephalad or caudad) which the catheter will advance in
the
subarachnoid space after the tip of the catheter leaves
the
end of the guiding needle cannot be predicted
positively;
however, if the round tip of the catheter is bent
slightly
before it is introduced into the lumen of the needle, I
have
found that the catheter will advance cephalad in most
cases".
In a later article published in 1945 Tuohy (8) mentioned
for the first time a 15 gauge needle with Huber point.
Using
this kind of needle he could "direct the catheter either
cephalad or caudad as desired". No reference was given
by
Tuohy to the use of the name of Huber. Cousins and
Bridenbaugh (9) in their textbook on Neural Blockade
mentioned that Tuohy "performed continuous spinal
anesthesia
by means of a ureteral catheter introduced in the
subarachnoid space through a needle with a Huber point".
No
reference is given to the "Huber point", besides that of
Tuohy, who also did not give any reference, as noticed
before. Ronald Miller (10) in his textbook of Anesthesia
gives a nice photograph of an "18-gauge Huber needle for
continuous spinal catheter insertion", but with no
reference. No other textbook in anesthesia tells us who
was
Huber whom his needle or his "point" revolutionized
regional
anesthesia. Medline search gave only articles on
Huber-point
needle in the port-a-cath implantable device, but with
no
reference to the question of who was Huber or when did
he
first describe his needle or his "point". The point is
that,
there is no reference in the medical literature of
Huber`s
description of his needle.
A search in U.S. patents brought to U.S. patent No.
2,409,979 applied on March 14, 1946 by Ralph L. Huber
from
Seattle, Washington. He described there an hypodermic
needle
with a "transversely curved wall...end portion".
In a recent correspondence said Winnie AP (11) that
"history
will recall what is published, not what is patented; and
no
subsequent publication will make up for failure to
describe
a new piece of technology in the medical literature".
Winnie
is right, at least for the last 50 years concerning
Huber`s
contribution to anesthesia. However, there is some
injustice
in the history of anesthesia on that subject. Every
anesthesiologist knows what is the Tuohy needle. No
anesthesiologist till now knows that the Tuohy needle is
the
Huber needle. Tuohy only used it for the introduction of
the
Tuohy catheter. I do not believe that all the companies
which sell these "Tuohy needles" will change now its
name to
Huber needles, but maybe in the year 2,045...
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. Adams RC, Lundy JS, Seldon TH. Continuous caudal
anesthesia or analgesia: a consideration of the technic
,
various uses and some possible dangers. JAMA
1943;122:152-158.
5. Manalan SA. Caudal block anesthesia in obstetrics. J
Indiana M. A. 1942;35:564-565.
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 PO. Neural Blockade in
Clinical
Anesthesia and Management of Pain. J.B. Lippincott Co.,
2nd
ed. 1988;p.11.
10. Miller RD. Anesthesia. 3rd ed., Churchill
Livingstone
1990;Fig. 45-8.
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 Brussels,
Thomas
Jonnesco (2) from Bucharest, described his new method of
general spinal anesthesia and reported 14 cases operated
upon by his method. Bier, who 10 years ago established
the
first human surgical spinal anesthesia, rejected it (2).
In
a later paper in 1910 Jonnesco wrote: "It is an error to
confuse lumbar rachianesthesia, conceived by Corning and
popularized by Bier, with my method. As I have many
times
emphasized , my method is a new one and altogether
distinctive, because I have generalized spinal
anaesthesia ,
adopting it to all operations on any part of the body"
(3).
Patients given high spinal anesthesia frequently either
lapse into what appears to be normal sleep or may
actually
lose consciousness (4-7). If patients with high spinal
anesthesia are given an inhalational anesthetic such as
nitrous oxide-oxygen , very low concentrations of
anesthetic
gases are required to maintain unconsciousness (8).
Reduction in the strength of nociceptive input may
contribute to loss of consciousness by diminishing the
strength of arousing stimuli arriving at cortical
structures
(9). Studies with C14 labeled lidocaine in dogs have
shown
that the foramen magnum is not a physiological barrier,
for
autoradiographs and tissue samples reveal the presence
of
radioactivity in intracranial parts of the CNS after a
relatively modest epidural dose (10).
Total spinal anesthesia has been used as a method of
general
anesthesia for abdominal surgery (11) and for the
treatment
of intractable pain (12). Gillies and Morgan (13)
described
a patient in whom a total spinal anesthesia resulted
after
18 ml of inadvertent subarachnoid injection of 0.5%
bupivacaine. Spontaneous respiration was noted 120
minutes
later and consciousness regained after further 65
minutes.
Return of respiration after 17 ml 1.5% lignocaine which
resulted in total spinal analgesia occurred after 45
minutes
and consciousness after further 80 minutes (14).
Four patients with intractable pain were treated by
total
spinal anesthesia. Power spectral analysis of heart rate
and peripheral blood flow variations were studied. Vagal
activity was depressed as well as the sympathetic
activity
innervating the cardivascular system, so the heart rate
and
peripheral blood flow variations were totally eliminated
(15). Total spinal block can be elicited even after an
epidural test dose like the 36 year old parturient of
Palkar
et al. (16) who developed hypotension and extensive
sensory
and motor block including respiratory paralysis and
aphonia
after injection via the epidural catheter of 3 ml
lidocaine
1.5% (45 mg) with 1:200,000 epinephrine (15 microgram).
The
patient remained fully conscious and alert and
spontaneous
respiration recommenced in five minutes.
Three patients were studied to determine the changes in
regional skin temperature and blood flow during
extensive
sympathetic blockade following total spinal anesthesia.
The
temperature of the truncal area, arm and leg decreased
by 1
degree C, whereas the temperature of the hand and foot
increased by 3 degrees C (17).
Total spinal block was induced by 2% lidocaine in adult
mongrel dogs. Heart rate, mean arterial pressure,
cardiac
index and left ventricle dp/dt max decreased
significantly
(18). Ephedrine 0.5 mg/Kg elevated HR, MAP, LV dp/dt max
and
SVR (19).
Total spinal anesthesia blocks the vagus as well as the
sympathetic nervous system and decreases heart rate
variation, suggesting that neural control of the heart
via
the autonomic nervous system is abolished after total
spinal
anesthesia (17).
Matsuki et al. (20) described a patient with primary
aldosteronism who was anesthetized by total spinal
anesthesia using an epidural catheter inserted at L3-4
into
the subarachnoid space. The trachea was intubated after
intravenous injection of thiopentone 250 mg and
suxamethonium 40 mg, and oxygen 3 liters/minute and
nitrous
oxide 2 liters/minute inhaled. The intraoperative course
was
smooth and intraoperative muscle relaxation excellent.
Adrenaline, noradrenaline and dopamine in the plasma
remained within normal ranges.
Mets et al (21) described a case of an unplanned
version of CSEGA: A 24 year old parturient received an
epidural analgesia during labor. Then she was scheduled
for
cesarean section for failure to progress. A total dose
of 30
ml 0.5% bupivacaine was administered incrementally via
the
epidural catheter which resulted in a patchy block that
was
inadequate for surgery. Twenty minutes after the last
injection of epidural local anesthetic a spinal
anesthesia
was done which resulted in a high block that
necessitated
tracheal intubation and ventilation. Controlled
ventilation
maintained with 50% N2O and 0.5% isoflurane in oxygen
until
delivery of the baby after which the isoflurane was
stopped
and 70% N2O in oxygen was administered. No further
muscle
relaxation was required for the remainder of the
operation
which lasted 45 minutes. The patient was extubated at
the
end of the operation uneventfully.
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. St Louis : The C.V. Mosby Co., 1934.
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, Brown AR. Is spinal anesthesia
after
failed epidural anesthesia contraindicated for cesarean
section? Anesth Analg 1993;77:629-31.
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
±1.95 mm (at the level of T12). Westbrook et
al. (9) found even a smaller ligamentum flavum-dura
mater
depth at the L2-3 level: 3.95±1.1 mm by using the
magnetic
resonance imager of 39 subjects.
Pitkin (10) describing spinal anesthesia in 1928 wrote
that
"in 1912, its use was confined to very elderly people,
those
considered as `bad risks` and to whom we were afraid to
give
ether". Koster (11) described in 1928 his experience of
spinal anesthesia also in operations of the head, neck
and
thorax. He wrote: "Any one who can do a lumbar puncture
can
induce spinal anesthesia; the method is reasonably `fool
proof` ". Babcock (12) in 1928 summarized his experience
of
24 years with spinal anesthesia: "In no other known way
can
so profound and extensive an anesthesia be produced by
so
small a dose of a drug and with so little general
toxicity".
Bromage (13) stated in 1967 that "the beautiful
precision
and economy of a subarachnoid block is lacking in
epidural
anesthesia". Greene and Brull (14) in their preface to
the
fourth edition of "Physiology of Spinal Anesthesia" have
written: "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. Prys-Roberts C. Anaesthesia: a practical or
impractical
construct? Br J Anaesth 1987;59:1341-5.
2. Eger EI. What is general anesthetic action? Anesth
Analg
1993;77:408-9.
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. Greene NM, Brull SJ. Physiology of spinal
anesthesia.
Williams & Wilkins, 4th ed., 1993.
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. New York, The Macmillan Co., 1941, p.1383.
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 (20 in the sitting position and 20 in the
left
lateral position). Supine position after the spinal
injection was achieved in 7.5±4.3 min in the
sitting
position group and in 7.7
±4.9 min in the left lateral group.
One patient (5%) in each group received a single shot
spinal
because of technical difficulties in the epidural
catheter
placement. Five patients (25%) of the left lateral group
showed poor spinal analgesia and then required epidural
supplementation. Mok and Tzeng (11) demonstated that 2
mg
epidural morphine combined with 30 mg ketoralac IM
provided
a better pain relief after cesarean section than using
the 2
mg epidural morphine alone.
Swami et al. (12) studied the effect on the blood
pressure
of a spinal dose of 7.5 mg vs 12.5 mg hyperbaric
bupivacaine
in 90 parturients for cesarean section. Using the
combined
spinal-epidural technique, 23% of the 7.5 mg group
needed an
epidural top-up, while none in the 12.5 mg group.
Hypotension occurred in 40% of the 12.5 mg and only in
22%
of the 7.5 mg hyperbaric bupivacaine spinal injection.
Dickson and Jenkins (13) assessed the efficacy of a
bolus
dose of bupivacaine 0.5% 10 ml following an infusion of
0.1%
for extension of epidural blockade for emergency
cesarean
section. In only 11 patients out of 18 was the analgesic
block of labour successfully converted to a block
adequate
for cesarean section using 10 ml bupivacaine 0.5%. Five
patients required an additional top-up (range 3-10 ml).
A
general anesthetic was necessary in two patients with
blocks
which had initially appeared to be adequate.
Westbrook et al. (14) induced combined spinal-epidural
anesthesia in the lateral position in 150 women
presenting
for cesarean delivery. They saw CSF after the first pass
of
the spinal needle through epidural needle in only
86%-92% of
the time.
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 CO. Spinal anesthesia for obstetrics.
International
Anesthesiology Clinics 1989;27:26-30
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 Corning, a New
York
city neurologist, in 1885 was a "walking" epidural. He
injected twice 2 ml of a 3% solution of the
hydrochlorate of
cocaine into the epidural space of a man "addicted to
sexual
abuse". While standing with eyes closed, the man
experienced
some dizziness, but no incoordination or motor
impairment
was discernible in his gait. He left the office an hour
or
more after the injection and seemed "none worse for the
experience" (1).
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
(Tokyo) 1982;34:1059-1065.
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 1.05 cm.
Joshi and McCarroll (4) described two sets of
needle-through-needle techniques to perform the combined
spinal-epidural anesthesia. They were concerned to find
cerebrospinal fluid in the Tuohy needle after removal of
the
spinal needle.
Carter et al. (5) abandoned this technique of epidural
needle rotation because it increased the chance of
inadvertent dural puncture by a factor of 5.6: there was
also a 16.6% incidence of the epidural catheter
protruding
through the hole made previously by the spinal needle.
Meiklejohn (6) found that "postmortem dura mater
demonstrated that rotation of the epidural needle
significantly decreases the force required to puncture
the
dura". He concluded that "once the needle has been
inserted
into the epidural space... it should not be moved for
any
reason other than to remove it".
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, Popat MT, Wallace DH. Epidural needle
rotation and inadvertent dural puncture with catheter.
Anaesthesia 1992;47:447-8
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,
25°C)
produced effective spinal anesthesia for perirectal
surgery
in the jack-knife position. Dermatomal levels remained
low
(T11-L5) while the patients were in the head-down
position during surgery, but rose two to six dermatomes
if
the patient`s head was elevated after surgery.
Fast rate of injection (0.5 ml/sec) of 5 ml 0.3%
bupivacaine
into the subarachnoid space results in a higher maximum
sensory level than slow rate injection (0.02 ml/sec)
(4).
Serpell et al. (5) recorded intrathecal pressure after
instillation of saline boluses into the epidural space
in
adult ewes. Mean baseline CSF pressure was 28.5±5.5
mmHg.
Five ml saline boluses (1 ml/sec) were injected at
5-minute
intervals until CSF pressure exceeded 100 mmHg.
Initially, a
rapid increase in CSF pressure accompanied each saline
bolus
with a gradual return to baseline. Up to a cumulative
volume
of 20 ml (range 5-60), the mean value of peak CSF
pressure
was 53±12 mmHg and the resting pressure would
return to
baseline. After a cumulative injection volume of
50.5±39.5
ml (range 15-115) saline, the resting pressure
progressively
rose to 64.1
±17.4 mmHg to coincide with a peak CSF pressure
exceeding 100 mmHg, indicating that the compliance of
the
spinal space had been compromised. Radiographic contrast
injected into the caudal sheath revealed that initial
decompression occurred via leakage into the large sacral
root foramina and sheaths.
Dell and Orlikowski (6) described a 26-year-old patient
who
received 45 ml of bupivacaine 0.25% (including a 3 ml of
bupivacaine 0.5% as a test dose) within 3 hours of
labour
analgesia. One hour after the last dose of epidural
bupivacaine, with the patient in the left lateral
position,
2.5 ml of hyperbaric bupivacaine 0.5% was injected
through a
25 gauge Whitacre needle into the subarachnoid space for
cesarean section, because the epidural sensory block was
patchy. Two minutes later, there was profound motor
block of
the lower limbs. At 5 min she developed paresthesias and
weakness in the upper limbs and experienced difficulty
in
breathing. At 8 min she complained of nasal stuffiness
and
her trachea was intubated following rapid sequence
induction
of general anesthesia. The reduced CSF volume following
epidural injection of a relatively large volume (45 ml)
was
suggested as an explanation for this high spinal
anesthesia
following 2.5 ml hyperbaric bupivacaine spinal
injection.
D`Angelo et al. (7) found a rapid cephalad spread of
intrathecal sufentanil 10 æg combined with 12 ml
epidural
saline injection for labor analgesia. However, they have
"blamed" this phenomenon only on the opioid
pharmacokinetics
and not the epidural saline rostral augmentation of
intrathecal sufentanil.
Barclay et al. (8) showed that compression of the vena
cava
by an abdominal binder decreases the volume of the
subarachnoid space and heightens the level of spinal
anesthesia.
Furst and Reisner (9) described two cases of high spinal
anesthesia following failed epidural blockade. They
found
its incidence to be 11% versus fewer than 1% in patients
undergoing spinal anesthesia alone. In light of these
findings, they changed their practice by reducing the
dose
of spinal bupivacaine by 20% in those patients in whom
epidural anesthesia has proved inadequate. They also
perform
the spinal block in the sitting position, allowing it to
"set" for 60-90 seconds prior to placing the patient
supine.
Gamil (10) reported a case of a parturient for cesarean
section who received spinal anesthesia with 2.5 ml of
0.5%
heavy bupivacaine in the sitting position. The patient
was
maintained in this position whilst an epidural catheter
was
sited in a cephalad direction. It took 15 min. Before
threading the epidural catheter, the epidural space was
primed with 20 ml of saline. Then the patient positioned
for
surgery, supported under the shoulders by three pillows.
75
min from the insertion of the spinal, at the end of
surgery,
50 ml of saline was injected to the epidural space as
prophylaxis against headache. 5 min later the block
extended
from L1 to T1.
The injection of a relatively small amount of 0.5%
bupivacaine into the extradural space after a
subarachnoid
injection of a standard dose of bupivacaine results in
rapid
extension of the block (11,12). Several hypotheses have
been
advanced to explain this enhancement of the subarachnoid
block. These include leakage of extradural bupivacaine
into
the subarachnoid space via the hole created by the
subarachnoid puncture, the existence of a "subclinical"
analgesia at a higher level which is enhanced and
becomes
evident by perineural or transdural spread of the
extradural
solution, or the continuing spread of the initial
subarachnoid injection independent of the extradural
injection (11-14).
Blumgart et al. (15) 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.
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. Bodily MN, Carpenter RL, Owens BD. Lidocaine 0.5%
spinal
anaesthesia: A hypobaric solution for short-stay
perirectal
surgery. Can J Anaesth 1992;39:770-773
4. Horlocker TT, Wedel DJ, Wilson PR. Effect of
injection
rate on sensory level and duration of hypobaric
bupivacaine
spinal anesthesia for total hip arthroplasty. Anesth
Analg
1994;79:773-7
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, Anderson MT, Philip J, Eisenach JC.
Intrathecal sufentanil compared to epidural bupivacaine
for
labor analgesia. Anesthesiology 1994;80:1209-1215
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 10
mm
from the forward end of the epidural needle (5). At that
inclination the spinal needle scratches the inner
surface of
the epidural needle tip when moving forward and
backward.
This friction must cause metallic microparticles.
Spectral analysis of the 18-gauge epidural needle
(Portex)
at 20 KV (7) revealed 18.96±0.28% chromium and
68.75
±0.82%
iron. The other components were: nickel,
9.35±0.57%;
manganese, 1.85
±0.07%; silicone, 0.67±0.16%; and molybdenum,
0.31
±0.23%. For example, nickel implanted in rats produced a
necrotic, abcesslike reaction (8).
In the clinical setting, an epidural catheter is pushed
through the shaft after the spinal needle is withdrawn,
so
the microparticles produced by the friction between the
two
needles can be pushed forward by the force exerted to
insert
the catheter into the epidural space.
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:
UK patent application, 1983: GB 2124503A
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. Paterson RA, Tousignant M, Skene DS. Caesarean
section
for twins in a patient with myotonic dystrophy. Can
Anaesth
Soc J 1985;32:418-421
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.
Philadelphia,
Lippincott, 1987:145-188
4. Kehlet H. General vs regional anesthesia. In: Rogers
MC,
Tinker JH, Covino EG, Longnecker DE (eds.). Principles
and
practice of anesthesiology. St Louis, C.V. Mosby,
1993:1218-1234
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. Bredtmann RD, Herden RN, Teichmann W, Moecke HP,
Kniesel
B, Batdgen R, Tecklenburg A. Epidural analgesia in
colonic
surgery: Results of a randomized prospective study. Br J
Surg 1990;77:638-642
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. Moore FA, Philiciano DV, Andrassy REJ, McArdle AH,
Booth
FVM, Morgenstein-Wargnen TB, Kellum JM, Welling RE,
Moore
EE. Early enteral feeding, compared with parenteral,
reduces
postoperative septic complications: The results of a
meta-analysis. Ann Surg 1992;216:172-183
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. Greene NM, Brull SJ. Physiology of spinal anesthesia.
4th
ed. Baltimore: Williams & Wilkins, 1993:61-8
3. Kehlet H. Modification of responses to surgery by
neural
blockade: clinical implications. In: Cousins MJ,
Bridenbaugh
PO, eds. Neural bloclkade. Philadelphia: JB Lippincott,
1988:145-188
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 (Moscow) 1960;46:1230-5
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, Stanton Hicks M, Stuhmeier KD.
Peridural anesthesia and the distribution of blood in
supine
humans. Anesthesiology 1985;63:616-623
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 USA (1).
Finucane (2) in an editorial on the dosage dilemma of
spinal
anesthesia for cesarean delivery wrote that "the era of
the
microcatheter technique was short lived... The combined
spinal-epidural technique is an excellent alternative
and
addresses many of the issues raised. One does not have
to
commit to a large initial subarachnoid dose of local
anesthetic, supplementation may be administered
epidurally,
and opioids may be administered in this fashion for
postoperative pain relief".
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, Anderson MT, Philip J, Eisenach JC.
Intrathecal sufentanil compared to epidural bupivacaine
for
labor analgesia. Anesthesiology 1994;80:1208-1215
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; 2. A congenital
median
epidural septum or acquired midline adhesion may act as
a
diffusion barrier; 3. The epidural catheter tip may pass
through an intervertebral foramen resulting in
production of
a unilateral paravertebral block; 4. The epidural
catheter
tip may be in the anterior epidural space resulting in
longitudinal and ipsilateral transverse spread of local
anesthetics, instead of circumferential spread around
the
dura.
Unilateral epidural block is more common in women
receiving
repeat epidurals (6.6% vs. 18.3%) (10).
Crawford (11) reported an incidence of two cases of
inadequate epidural block (one unilateral block; one
missed
segment) in 17 women who received epidural analgesia
after a
blood patch. In a further woman the sensory level could
not
be extended above T10 for cesarean section.
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. Withington DE, Weeks SK. Repeat epidural analgesia
and
unilateral block. Can J Anaesth 1994;41:568-71
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 Royal Adelaide Hospital revealed that
only
3% received regional anesthesia (4). In contrast, in a
review of 1-year prospective analysis (5), the Hospital
for
Special Surgery in New York City used regional
anesthesia in
89% of their orthopedic outpatient population.
The incidence of spinal anesthesia in an orthopedic
institute in Firenze increased from 22% in 1989 to 42%
in
1993 (6). However, the incidence of epidural anesthesia
decreased from 20% to 4% during that period. The overall
incidence of regional anesthesia (spinal and epidural)
increased only in 2%. This was due to the introduction
of
the 25G Quincke needle in 1990, and the blunting needles
in
1993 (Sprotte 24G; and Whitacre 25, 27G).The selective
spinal anesthetic technique also contributed to this
increase in spinal anesthesia.
Valia et al. (7) evaluated patient attitudes towards
regional anesthesia in Valencia, Spain. The following
advantages during surgery under regional anesthesia were
referred to by 82.7% of patients: possibility of
speaking
with relatives during the immediate postoperative period
(72.7%), the maintaining of consciousness during surgery
(71.8%) and the absence of pain during the immediate
postoperative interval (37.3%).
Carson et al. (8) compared the use of spinal anesthesia
with
that of general anesthesia in 100 young adults (aged
18-45
years) scheduled for lower body minor surgery. The
spinal
anesthesia group took longer than the general anesthesia
group for surgical readiness (13±0.6 vs. 9
±0.5 min), but
much less time in recovery (57.7±3.1 vs. 72.5
±3.6 min).
Spinal anesthesia patients were quicker to drink fluids
(3.4±0.3 vs. 5.1
±0.7 hr), required less narcotic analgesia
(0.6
±1 vs. 1.2±0.2 intramuscular injections) and had a lower
incidence of vomiting (0.2±0.09 vs.
1.07±0.34).
In a survey performed at the 1993 meeting of the Society
for
Obstetric Anesthesia and Perinatology (SOAP), 52% of the
conference attendees reported using spinal anesthesia as
their technique of choice for elective cesarean delivery
(9).
Regional anesthesia offers safe, effective and cheap
anesthesia when performed by trained personnel. The
Kilimanjaro Christian Medical Center in Tanzania (10)
produces its own lidocaine and crystalloid intravenous
fluids. Volatile and intravenous anesthetic agents are
often
unavailable and considered expensive. Supplies of oxygen
are
also unreliable. Hence, spinal and epidural anesthesia
are
frequently performed for lower abdominal and lower
extremity
procedures.
Patients in Canada and Scotland were asked to complete a
pre-operative questionnaire examining their desire for
information relating to anesthesia. Details of dangerous
complications of anesthesia and surgery were
consistently
rated of low priority, with high priority going to
postoperative landmarks such as eating and drinking.
Both
countries rated meeting the anesthetist before surgery
as
the highest priority of all (11).
In the second edition of Principles and Practice of
Obstetric Analgesia and Anesthesia edited by Bonica and
McDonald (12) and published in 1995, there are 1,344
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 and
analgesia 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, neither its
future...
Rawal (13) mailed a questionnaire in April 1993 to 105
European anesthesiologists in 5-10 hospitals from each
of
the 17 European countries. Data requested was for 1992.
A
total of 102 (96.2%) completed questionnaires. Except
for
Ireland, combined spinal-epidural anesthesia was used in
every participating country. It was used in 53% of
participating hospitals. During 1992, 835,986 in-patient
surgical procedures were performed in the participating
European hospitals, 141,444 (17%) of those procedures
were
performed under central blocks (epidural,spinal,
combined
spinal-epidural). A total of 5,348 combined
spinal-epidural
blocks were performed during 1992, which constitutes
only 4%
of the central blocks (spinal - 56%; epidural - 40%;
combined spinal-epidural - 4%). The commonest indication
for
combined spinal-epidural block 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%). Special combined spinal-epidural
sets
were used by 31% respondents; the remaining used their
own
combinations of epidural needles and extra long spinal
needles.
1. Rawal N. Epidural and intrathecal opioids for
postoperative pain management in Europe - A 17-nation
survey. ASRA Annual Meeting 1995:45
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. Osborne GA, Rudkin GE. Outcome after day-care surgery
in
a major teaching hospital. Anaesth Intensive Care
1993;21:822-827
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 10 cm segment of four epidural catheters to be tested
was
suspended vertically from a stand, and weights were hung
from it until it broke to investigate the comparative
strengths of 19 gauge epidural catheters. The concord -
Portex`s weight at break was 2,042±67 gm while that
of
Kendall - 1,674
±67 gm, Arrow (Flex Tip Plus with spiral wire
reinforcement) - 1,370±16 gm and Becton-Dickinson
only
1,284±149 gm were needed for its breakage.
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
(Kendall) - 15.16%, and the 20 gauge Polymide, open tip,
Perifix (Braun) - 32.24%. It was concluded that the
softer
tip epidural catheters like Flex Tip Plus (Arrow) were
least likely to cause transient paresthesias during
epidural
catheter placement.
Spriggs et al. (3) compared between Arrow`s wire
reinforced
epidural catheter (Flex Tip Plus; 19 gauge; open tip)
and
Braun`s Perifix (18 gauge; open tip). They found that
the
wire reinforced catheter was inferior than the Perifix
in
its inability of insertion (8/50 vs. 0/51) and the
incidence
of catheter related transient paresthesias (5/42 vs.
0/51).
Huhtala et al. (4) examined the incidence of transient
radicular irritation after spinal anesthesia with
hyperbaric
5% lidocaine compared to 0.5% hyperbaric bupivacaine and
0.5% plain bupivacaine. 10.2% of patients anesthetized
with
hyperbaric lidocaine complained of radicular irritation
compared to 1% of patients anesthetized with hyperbaric
bupivacaine and none of the patients in the plain
bupivacaine group.
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, Sih IL. Epidural analgesia and
anticoagulant
therapy. Experience with one thousand cases of
continuous
epidurals. Anaesthesia 1983;38:254-259
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 UK, 30% of 272 obstetric units surveyed by Davies
et
al. (4) stated that they used opioids in routine
epidural
analgesia for normal labor, but only when an infusion
technique was employed.
Scott et al. (5) in 1980, first reported the use in
labor
of "single-shot" intrathecal morphine.
Abouleish et al. (6) suggested that the use of combined
spinal-epidural analgesia in labor "avoids the
requirement
for setting up infusion devices, tubing, and solutions
routinely used for continuous epidural infusion
techniques"
since all of their patients delivered with only the
original
intrathecal dose, or a small amount of epidural local
anesthetic as a supplemental bolus.
Columb et al. (7) found that the minimum local analgesic
concentration of epidural bupivacaine in labor is
0.065%.
Breen et al. (8) compared two regimes of epidural
anesthesia
for labor in ambulatory parturients: epidural fentanyl
bolus
of 75 µg diluted to 15 ml with normal saline with
an
epidural infusion of fentanyl 2.5 µg/ml at 15 ml/hr
vs.
epidural bolus of bupivacaine 0.04% 15 ml, epinephrine
1.7
µg/ml and fentanyl 1.7 µg/ml, following by an
infusion
of
this combination at 15 ml/hr. Patients experiencing
inadequate analgesia at any time were given one 10 ml
bolus
of the study drug. Any patient not made sufficiently
comfortable by the study drug, including the additional
10
ml bolus, was given 10 ml of bupivacaine 0.125% with
fentanyl 150 µg added, followed by an infusion of
bupivacaine 0.125% with fentanyl 2 µg/ml. 48% in
the
bupivacaine-epinephrine-fentanyl group and 79% in the
fentanyl group needed these bolus augmentations.
Justins et al. (9) first published in 1982 the use of
fentanyl-bupivacaine mixtures for epidural analgesia in
labor.
Since the continuous infusion epidural analgesia needs
supplementary top-ups in many cases it should be termed
more
accurately a continuous infusion - intermittent bolus
epidural analgesia. However, intermittent low-dose
epidural
injections every approximately 90 minutes will avoid the
need for the patient to be connected to an infusion set,
and
on the other hand will allow the "walking epidural" due
to
the low dose injections at equal times, without waiting
for
the analgesic effect to wear off.
Enever et al. (10) believed that "infusions rather than
intermittent technique... are safer and more effective".
However, in their study of epidural infusion of
diamorphine
with bupivacaine in labor 63.2% - 66.8% required top-up
injections of bupivacaine during the epidural catheter
infusion technique.
Wlodarski et al. (11) found that adding 250 µg
nalbuphine to
a 10 µg sufentanyl in 1 ml saline mixture for the
spinal
injection in the combined spinal-epidural analgesia for
labor reduced significantly the incidence of pruritus:
62%
in the sufentanyl group compared to only 20% in the
sufentanyl-nalbuphine group.
Using an extradural mixture, in labor, of 0.1%
bupivacaine
with fentanyl 30 µg in 15 ml, the initial test dose
of
0.5%
bupivacaine 3 ml is unnecessary, as the single bolus of
15
ml of the extradural mixture serves equally to detect
accidental subarachnoid injection without producing a
total
spinal block (12). It is the total amount of local
anesthetic drug which determines the extent of a
subarachnoid block and not its volume (13).
Ewen et al. (14) have been shown in parturient women
that
analgesia obtained by infusing 0.25% bupivacaine 8 ml/hr
is
inferior to that obtained by giving the same mass of
drug as
0.07% bupivacaine 25 ml/hr.
Eddleston et al. (15) found no advantage to either
mother or
fetus in using an extradural infusion of 0.125%
bupivacaine
compared with intermittent injections of 0.25%
bupivacaine.
In the intermittent group, the majority of fetal
decelerations (73.8%) were recorded as transient,
whereas in
the infusion group 61.1% of episodes lasted in excess of
10
min.
Silva and Popat (16) described a 34-year-old parturient
with
Harrington rods in whom they have done a combined
spinal-epidural analgesia for labor. Using the
needle-through-needle technique they injected 1 ml 0.25%
bupivacaine and 25 µg fentanyl through the spinal
needle.
The epidural catheter was not tested after insertion.
Two
hours after the spinal injection the patient requested a
top
up. 15 ml 0.1% bupivacaine with 2 µg/ml fentanyl
were
injected epidurally without success. Further 10 ml of 2%
lidocaine 1:200,000 epinephrine injected epidurally
produced
a dense motor block in both legs but did not reduce the
pain. Another combined spinal-epidural procedure was
done at
the same interspace and a similar spinal dose of
bupivacaine
and fentanyl again resulted in excellent pain relief for
two
hours. Because of a high breech with cervical dilatation
of
9 cm the patient needed a cesarean section. However, she
declined regional anesthesia and had a cesarean delivery
under general anesthesia.
Sufentanil 5, 10 and 15 µg and fentanyl 25, 37.5
and 50
µg
as intrathecal solutions for labor analgesia were
compared
in 36 parturients using the combined spinal-epidural
analgesia. Duration of analgesia or pruritus were not
affected by drug dosage, but rather by drug choice. Both
the
duration of analgesia and pruritus were longer for
sufentanil than for fentanyl (17).
In a review of analgesia for labor Crowhurst (3) stated
that "with the advent of `pencil-point` spinal needles,
the
simpler technique of subarachnoid blockade will almost
certainly continue to supplant other methods, especially
for
late first stage and second stage labour".
Joos et al. (18) used a combined spinal-epidural
analgesia
technique in 620 parturients. The spinal injection
consisted
of 1 mg 0.5% bupivacaine, 25 µg adrenaline,and 5
µg
sufentanil. When pain returned bolus doses of 10 ml
saline
containing 12.5 mg bupivacaine 0.125%, 12.5 µg
adrenaline
and 12.5 µg sufentanil were injected. Spinal
analgesia
was
perfect in 94%. The mean duration of the spinal
analgesia
was 134 min. All parturients were able to move perfectly
both legs. Transient pruritus occurred in 48% of women,
drowsiness in 12%. The postspinal headache rate was
0.8%.
The injections were made by a 16G Tuohy epidural needle
and
a 29G 113 mm Quincke spinal needle inserted through it.
Caldwell et al. (2) used the combined spinal-epidural
analgesia in 26 parturients. Subarachnoid injection
consisted of morphine 0.25 mg with fentanyl 25 µg.
In
cases
where additional analgesia was requested, epidural
analgesia
was initiated with 10 ml of bupivacaine 0.25%, followed
by
an infusion of bupivacaine 0.125%, with fentanyl 1
µg/ml.
76% of patients requested additional epidural analgesia.
Side effects were nausea and vomiting (50%) and pruritus
(50%). One patient developed postdural puncture
headache,
following unintentional dural puncture with the 18 gauge
Tuohy needle. Bonica and McDonald (19) referred to their
double-catheter technique (lumbar epidural catheter and
caudal catheter) as "the ultimate in
analgesia/anesthesia
for labor and vaginal delivery, and is often referred to
by
anesthesiologists as the `Rolls Royce` of obstetric
analgesia and anesthesia". In comparison, the combined
spinal-epidural analgesia and anesthesia is the
"Mercedes
Benz"...
Hill et al. (20) compared the efficacy of intrathecal
250 µg
alfentanil and 400 µg diamorphine in combination
with
0.5 ml
of 0.5% bupivacaine (2.5 mg) in the combined
spinal-epidural
analgesia in labor. If labour continued beyond the
duration
of the subarachnoid block analgesia was maintained with
a
top-up of 15 ml of 0.125% bupivacaine followed by an
infusion of 0.125% bupivacaine at 8 ml/hr.
Abdominal analgesia was inadequate in 8% in the
alfentanil
group and in 44% in the diamorphine group. Sympathetic
block
occurred in 20% of the alfentanil group and none of the
diamorphine group. 32% of the women in the alfentanil
group
were unable to walk after 20 min due to motor block.
Transient fetal bradycardia was seen in 20% of the
alfentanil group and none of the diamorphine group.
Pruritus
was common in both groups (over 90%).
Arkoosh et al. (21) compared the subarachnoid injection
of
fentanyl 2.5 µg with morphine 0.25 mg to sufentanil
10
µg
with morphine 0.25 mg for labor analgesia using the
combined
spinal-epidural analgesia. Both fentanyl and morphine
and
sufentanil and morphine provided adequate labor
analgesia
for about 2 hours. However, patients who received
sufentanil
experienced more severe pruritus.
Norris et al. (22) compared epidural versus combined
spinal-epidural (CSE) technique for maternal pain relief
during labor in 1022 laboring parturients. 9.6% of the
women
chose not to receive neuroaxial labor analgesia; 38%
chose
epidural while 52.4% received combined spinal-epidural
analgesia. The CSE was done by a long spinal needle (27G
Whitacre or 24G Sprotte) passed through a 18G epidural
needle. After withdrawing the spinal needle the epidural
needle was rotated cephalad and a 20G epidural catheter
inserted through it. In 94.4% of the CSE group the
epidural
and subarachnoid spaces were successfully identified. In
4.9% of them no CSF was obtained and only epidural
analgesia
was induced. There was an incidence of 0.2% of the
epidural
catheter entering subarachnoid space after dural
puncture
with a 24G Sprotte spinal needle. In 0.8% an accidental
dural puncture occurred while rotating the epidural
needle.
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 United Kingdom. Anaesthesia
1993;48:63-65
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. Columb MO, Lyons G, Vail A. Estimation of the minimum
local analgesia concentration (MLAC) of epidural
bupivacaine
hydrochloride in labour. International Monitor on
Regional
Anaesthesia 1994;A89
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, Campbell A, Tunstall
ME.
Continuous infusion epidural analgesia in obstetrics. A
comparison of 0.08% and 0.25% bupivacaine. Anaesthesia
1986;41:143-147
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
Hamburg, since 1989 till 1994 there were over 13,602
cases
of combined spinal-epidural anesthesia (1).
Urmey et al. (2) compared the use of 40, 60 or 80 mg
isobaric lidocaine 2% injected subarachnoidally in the
needle-through-needle technique for ambulatory knee
arthroscopy in 90 patients aged 18-60 years. 24.5% of
patients required separate spinal injections due to
inadequate protrusion length of the 120 mm 27G Whitacre
spinal needle through the 3 inch Weiss epidural needle.
Seven patients required epidural reinforcement doses
intraoperatively. Motor recovery onset was at
82.3±20.3
minutes in the 40 mg lidocaine 2% group, 108.2
±25.6 - in the
60 mg and 122.8±25 in the 80 mg spinal injection.
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 USA are of
the
single terminal hole, while most of those used in the UK
are of the three lateral holes with a blunted end (1).
A new epidural catheter was designed which is claimed to
combine the benefits of these two different types of
catheters: Combined end-multiple lateral holes epidural
catheter (CEMLH).
Curbelo (2) in 1947 was the first to use an epidural
catheter for epidural anesthesia. It was of the end hole
type.
Lee (3) in 1962 described an epidural catheter which its
"tip is non-patent and smooth, to facilitate insertion,
solution enters the space from a small opening 1 cm from
the
tip".
Skinner (4) in 1966 described another epidural catheter
with
"the tip of the cannula...is blunt...and has a hole in
its end. There is a second hole, 3 mm from the distal
end".
He said that "with the hole in this position, kinking is
impossible with the stresses involved in normal use".
Collier and Gatt (5) described an epidural catheter,
with a closed end and three holes spaced at
approximately
2, 3 and 4 mm from the smooth closed tip. They suggested
that the close spacings of the holes will eliminate the
complication of multicompartment block (epidural, spinal
or
intravenous), as seen with earlier multihole epidural
catheters.
The CEMLH epidural catheter has 7 holes within its 1.5
cm head: One at the tip; the first 3 lateral holes are
arranged circumferentially at 1 mm from each other; the
other 3 holes have a 4 mm distance from one to the
other.
All the holes are within the 1.5 cm from the tip. The
area
of the 6 lateral holes is the same , so the anesthetic
solution stream is the same from each hole, depending on
the
correct pressure elicited upon the syringe plunger.
While introducing the epidural catheter for 3 cm into
the
epidural space there is a proximal 1.5 cm with 7 holes
and a
distal 1.5 cm which is "blind". The epidural catheter
(CEMLH) has the following possible claimed advantages:
The
end hole can recognize an intravascular or intrathecal
insertion of the epidural catheter tip, which a blunted
tip
cannot, but an open-end catheter can; The six lateral
holes
spaced at 1.5 cm from the tip allow anesthetic solution
injection into the epidural space in case that the end
hole
or one of the lateral holes is obstructed by a blood
clot or
tissue; The chance that all the 7 holes will be blocked
is
six times less than the one open-end hole and 4 times
less
than the three lateral holes closed-end catheter; The
CEMLH
epidural catheter gives a better distribution of the
anesthetic solution due to its 7 holes, avoiding a
partial
block; The CEMLH epidural catheter also afford the use
of a
lesser amount of anesthetic solution to achieve an
anesthetic level than the present used catheters, due to
its
even distribution, without preferrence to any side;
Because
of its small end hole the CEMLH catheter will give less
paresthesias than the bigger end hole catheter. The
terminal
hole catheter elicits more paresthesias than the rounded
closed end side hole catheter (6).
Michael et al. (7) compared between the open-end (single
hole) and closed-end (three lateral holes) epidural
catheters. They found that the open-end catheters
"caused an
unacceptably high incidence of unsatisfactory sensory
blockade". Collier and Gatt (5) also found the incidence
of
unsatisfactory blocks with terminal hole catheter to be
"unacceptably High" (32%) when compared with the three
lateral holes catheter (12%).
Ward et al. (8) found that the pressure elicited upon a
lateral double-orifice epidural catheter (orifices 180
degrees opposed 5 mm and 12 mm from the closed end tip)
is
important whether it will exit fluid from the proximal
or
the distal holes. In order to achieve injection through
the
two holes at the same time they needed to exceed the
pressure of 900 torr. With a pressure of 700 torr,
ejection
was only from the proximal port.
If one of the three lateral holes epidural catheter is
obstructed the injection through the catheter can miss
this
direction and result in partial block. If the end hole
epidural catheter is obstructed you need to replace it.
Just to remind us: Before Lee (3) described in 1962 his
prepackaged epidural catheter anesthetists had employed
polyvinyl chloride tubing and nylon infant`s ureteric
catheters and cut it by themselves. Lee himself said
that
his epidural catheter "will also withstand autoclaving
several times without deterioration". It seems that we
have
already passed the point of epidural catheter
autoclaving.
However, other problems confronting us: Inadvertent
intrathecal or intravascular insertion; partial
blockade;
unreliability of the present used epidural catheters
with
need to supplement it by a prior anesthetic solution
injected through the epidural needle, etc.
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, Richmond MN, Birks RJS. A comparison
between
open-end (single hole) and closed-end (three lateral
holes)
epidural catheters. Anaesthesia 1989;44:578-580
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 1926 a needle with a point that
is
"round, tapering, and sharp". This was the result of
experiments made by him during 1923 (2) and his
experience
since then that brought him to the conclusion that
"postpuncture headache is caused by trauma to the spinal
dura sufficient to result in excessive leakage of
cerebrospinal fluid to the point at which the brain is
left
without a water cushion". His experiments demonstrated
that
a greater trauma was produced by the use of a needle
with a
blunt cutting point than by a needle of the same caliber
with a point rounded, tapering and sharp. He found also
that
it was possible to pass a small sharp, round, tapering
pointed instrument between the fibers of a spinal dural
sac,
suspended and filled with water, without cutting any of
them. He performed 215 consecutive punctures with his
needle, with a headache incidence of two in the series.
In
many instances the puncture was done during the noon
hour,
and the patient resumed his work for the remainder of
the
day...
Kirschner (3) in 1931 described a needle for spinal
anesthesia with an opening in the shaft just proximal to
the
beveled closed end. Such a needle was recommended to aid
in
the more accurate control of the duration and extent of
anesthesia, since it could be manipulated to permit the
injection of solution in the stream flowing parallel to
the
long axis of the spinal fluid column rather than against
the
side of the canal opposite puncture.
Hart and Whitacre (4) described in 1951 their
pencil-point
spinal needle, known since as the Whitacre needle.
Sprotte, Schedel and Pajunk (5) in 1987 modified the
Whitacre needle, known since as the Sprotte needle.
The FDA approves only the use of the pencil-point spinal
needle in the needle-through-needle or the Eldor needle
techniques for the combined spinal-epidural anesthesia.
However, the long orifice of 24 gauge Sprotte spinal
needles
may result in failed spinal anesthetics when they are
used,
since this length exceeds the 1 mm thickness of human
lumbar
dura (6). Sprotte has modified this device by reducing
the
length of the orifice. Sosis et al. (6) compared in
vitro
the 1.8 mm long laterally placed orifice of the original
version of the Sprotte spinal needle with the 1.0 mm
long
new Sprotte needle. They found that the flow of water
through the needle was not reduced after the orifice
length
was reduced by 44%.
Lipov et al.(7) examined whether the window design of
Sprotte pencil point needles leads to deformation under
lateral or axial loading conditions. They examined the
22-
and 24-gauge Sprotte, 22- and 25-gauge Whitacre and 22-
and
25-gauge Quincke needles. The force needed to bend the
Sprotte needles was less than needed for the Whitacre
and
Quincke needles of similar size when lateral or axial
pressure was applied. Examination of the needle tips
demonstrated that the Sprotte needles were most likely
to
bend at the needle window, while the Quincke and
Whitacre
needles deformed at the point of clamping. They
concluded
that the Sprotte needles have an inherent design
weakness to
lateral and axial pressure, which may result in a
greater
number of needle tip deformations upon needle insertion.
The
nature of this deformation may result in difficulty in
needle withdrawal and possibly fracture of the needle
tip.
A new pencil-point spinal needle is described: It is
named
double-hole pencil-point (DHPP) spinal needle, and is
composed of a blunt ogival tip and two circular holes
opposing each other just proximal to the tip. The area
of
the two holes is almost the same as of the single hole
Sprotte needle`s area, which enables more rapid CSF
reflux.
The anesthetic solution injection spreads through both
holes. There is a possible advantage of a more diffuse
anesthetic distribution and less anesthetic solution
dosage.
The DHPP spinal needle allows anesthetic solution
injection
when one of the holes is obstructed by a tissue
fragment,
through the opposite hole. Using the DHPP spinal needle
is
like inserting two Whitacre needles in the same
interspace,
from the point of view of the hole`s area. There is a
possibility to avoid the risk of needle deformation due
to
bending at the window, as it is the case with the
Sprotte
needle. In this respect it is more like the Whitacre
needle.
However, unlike the Whitacre needle there is a
possibility
of a two times rapid CSF reflux, because of a double
orifice
area. There is also a possibility for a more even
distribution of the anesthetic solution through the
opposite
holes of the DHPP spinal needle as compared to the
Whitacre
or Sprotte one-sided orifice spinal needles. On account
of
that there is a possibilty to reduce the anesthetic
solution
dosage with less untoward effects due to a larger spinal
anesthetic dose needed in the Whitacre or Sprotte spinal
needles.
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. Sosis MB, Braverman B, Toppses A. An in vitro
evaluation
of the new shorter orifice Sprotte spinal needle. Anesth
Analg 1994;78:S410
7. Lipov EG, Sosis MB, McCarthy RJ, Ivankovich AD. Does
the
design of the Sprotte spinal needle reduce the force
needed
to deform the tip? J Clin Anesth 1994;6:411-413
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." Moore (4) in his handbook on regional block
advocates the use of "2 cc of the local anesthetic
solution"
to be injected "at the rate of 1 cc per 6 to 8 seconds"
as
an epidural catheter test dose. An epidural test dose is
considered mandatory (5).
Albright (6) suggested that the test dose should consist
of
3 ml 0.5% bupivacaine with 1:200,000 epinephrine. This
kind
of test dose should be adequate to detect intravascular
placement as it produces a rapid increase in pulse rate.
This test dose is also adequate to detect a subarachnoid
injection because a significant motor or sensory block
will
occur within 5 minutes.
Some authors recommend that every top-up should be
preceded
by a test dose or given in fractions (6,7). Crawford (8)
in
his review of 27,000 lumbar epidural blocks concluded
that
"the requirements for safety are that all top ups are
given
in divided doses, with an interval of approximately 5
minutes between the two increments."
The epidural catheter test dose consists of either 1 ml
of
hyperbaric lidocaine with adrenaline or 2 ml of 0.5%
bupivacaine with adrenaline (9). A volume of 1.5 ml has
also been recommended (10).
The epidural catheter test dose is a must maneuver,
because as Moore (11) said on the epidural needle, none
of
us has "an eye on the end of the needle", neither on the
end
of the catheter introduced through that needle.
Soresi (12) was the first to describe the combined
spinal-epidural anesthesia in 1937.He called it
"episubdural
anesthesia" and thought it is "the safest procedure
giving
perfect surgical anesthesia, ideal relaxation and
eliminating practically all postoperative pain and
distress". Soresi first injected 7-8 ml of 20 centigrams
novocain into the epidural space and then insert the
spinal
needle further into the spinal space and injected there
2 ml
of 10-15 centigrams novocain. These 7-8 ml injected into
the
epidural space can be looked now as the first "test
dose" in
the combined spinal-epidural technique. He recommended
"to
inject only 7 to 8 cc of fluid in the epidural space
because
large amounts of fluid will make the pressure in the
epidural space positive. This increased pressure being
contrary to natural conditions is the reason for the
troubles noticed in the ordinary epidural anesthesia".
Soresi also stated that "to make episubdural anesthesia
safer the anesthesiologist must be absolutely certain of
the
position of the needle".
Rawal (13) injected into the subarachnoid space 1.5-2 ml
0.5% hyperbaric bupivacaine through a 26-27G spinal
needle
in 24 parturients scheduled for cesarean section.
Fifteen
minutes later he injected fractional doses of 5 ml 0.5%
bupivacaine through the epidural catheter (range: 5-10
ml).
Myint et al. (14) 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 into the spinal space 2 ml 0.5% bupivacaine in
8%
dextrose through 24G Sprotte needle. 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 breathe 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
i.v. Then she received two doses of naloxone 0.4 mg i.v.
The
patient started breathing and regained consciousness
within
2 min of the first administration of intravenous
naloxone.
Her recovery was complete with no neurological deficit.
She
also 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 would occur at the first place, i.e.,
the
epidural catheter test dose injected 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 three lateral
holes. Their inability to recognize it was caused by the
technique of the needle-through-needle in which you need
first to inject the anesthetic solution into the spinal
space and then to insert the epidural catheter into the
epidural space.
Thoren et al.(15) used the combined spinal-epidural
technique in 21 parturients scheduled for cesarean
section.
Hyperbaric bupivacaine 0.5% was injected intrathecally.
Additional bupivacaine was injected through the epidural
catheter in fractionated doses. After an initial "test
dose"
of 2 ml 0.5% bupivacaine, an additional 2 ml per
unblocked
segment was given through the epidural catheter until a
T4
level was achieved.
Kumar (16) observed that when an epidural catheter is
threaded after a spinal block was performed in the
needle-through-needle technique, "a minute quantity of
clear, or slightly red-tinged fluid sometimes comes back
through the catheter". The source of this minute
quantity of
fluid is either CSF or local anesthetic agent. He
advocated
an aspiration test before giving the epidural medication
to
extend the spinal block.
Spinal dura mater thickness at the lumbar region is 0.5
mm
(17). Using magnetic resonance imaging (MRI) in 39
patients
Westbrook et al. (18) found that the depth of the
extradural
space at the level of T12 is 0.83 ± 0.195 cm.
There are many reports of failed aspiration tests for
both
subarachnoid and intravascular epidural catheter
placement
(19-21). Aspiration test through an epidural needle was
suspected as a cause for dural puncture. In eight of 31
patients (25.8%) aspiration produced CSF flow. It was
not
possible to say whether the aspiration caused puncture
of
the dura or just revealed it, but "the suspicion remains
that aspiration of a Tuohy needle may cause dural
puncture
by increasing the transdural pressure gradient" (22).
In the first 1,000 epidural cases reported by Crawford
(23),
of 71 dural taps, nine were with the catheter. In his
second
series of 1,000, Crawford reported 33 dural taps, four
of
which were caused by the catheter (24).
Epidural catheter migration has been shown to be
relatively
common, occurring in approximately one-third of the
patients
in one study (25). Hogan (26) suggested another
mechanism
for the "migration" of an epidural catheter: the
membrane
which separates the lateral epidural spaces from the
anterior venous confluence ruptures, allowing local
anesthetic to pour from the epidural space into the
circulation. Another mechanism of epidural catheter
"migration" is rupture of subdural bleb of local
anesthetic
into the CSF (27).
The incidence of epidural needle/catheter unintentional
dural puncture range from 2.5% (28) to 0.6% (29) and
even
0.26% (30).
Recognized intravascular placement or migration of an
epidural catheter occurs in 5.2% of obstetric epidural
anesthetics (31).
Chadwick et al. (32) reviewed the malpractice claims
filed
against anesthesiologists in USA in 1985. There were 190
claims for care involving obstetric anesthesia (OB) and
1,351 of claims not involving obstetric anesthesia
cases.
Sixty five percent (124) of the OB claims were
associated
with regional anesthesia. Of the 17 claims for newborn
brain
injury attributed to an anesthetic cause, 13 had
regional
anesthesia as the primary technique. Of the 13
associated
with regional anesthesia, 9 involved a convulsion, 8 of
which appeared due to intravascular local anesthetic
injection. Convulsions were much more common in the OB
claims (10%). Eighteen of 19 convulsions occurred in
patients having epidural anesthesia. Seventeen of the
convulsions appeared to be due to local anesthetic toxic
reactions. In 10 of these cases, epinephrine containing
test
doses were not used; in 7 others, data were not
sufficient
to determine if epinephrine-containing test doses were
used
or not. The local anesthesia used in 15 cases was
bupivacaine, and in 2 other cases was not specified. Two
of
the convulsions appeared to be eclamptic. Eighty three
percent of the convulsions resulted in neurologic injury
or
death to the mother, newborn, or both.
Dain et al. (43) in 1987 distinguished in their review
on
the epidural test dose in obstetrics between "what is
medically safe and what is legally safe. The authors
have
the impression that in order to be `legally safe` one
must
perform a test dose".
In conclusion, it seems that the needle-through-needle
technique for the combined spinal-epidural anesthesia
has an
inherent risk because of its inability to perform
properly
the epidural catheter test dosing. This can result in
intravascular or subarachnoid local anesthetic or opioid
inadvertent injections. Using the Eldor needle technique
for
the combined spinal-epidural anesthesia the epidural
catheter can be inserted before the spinal local
anesthetic
is injected, allowing a proper epidural catheter test
dosing, as it is done in a regular epidural anesthesia.
The
comparison between these two techniques (the
needle-through-needle and the Eldor needle) makes the
Eldor
needle technique safer from the epidural catheter test
dose
point of view.
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, Miller RD (ed.); Churchill Livingstone; 4th
ed.;
1994;p.1525
4. Moore DC. Regional block. Charles C. Thomas; 4th ed.;
1981;p.433
5. Shnider SM, Levinson G. Anesthesia for cesarian
section.
In: Anesthesia for obstetrics; 2nd ed.; Shnider SM,
Levinson
G (eds.); Baltimore: Williams and Wilkins; 1987; p.161
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. Moore DC, Batra MS. The components of an effective
test
dose prior to epidural block. Anesthesiology
1981;55:693-6
10. Kumar CM, Dennison B, Panchal HI. Epidural test
dose.
Anaesthesia 1985;40:1023
11. Moore DC. Accidental dural puncture - who has an eye
on
the end of a needle. Anaesth Intensive Care 1986;14:208
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 UK, Tasch MD, Gupta CD, Luerssen
TG.
Prolonged neural blockade following regional analgesia
with
2-chloroprocaine. Anesth Analg 1980;59:447-51
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. Moore DC, Spierdijik J, Vankleef LD, Coleman RL,
Love
GF. Chloroprocaine neurotoxicity: four additional cases.
Anesth Analg 1982;61:155-9
22. Hollway TE, Telford RJ. Observations on deliberate
dural
puncture with a Tuohy needle: depth measurements.
Anaesthesia 1991;46:722-724
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. Kenepp NB, Gutsche BB. Inadvertent intravascular
injections during lumbar epidural anesthesia.
Anesthesiology
1981;54:172-173
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 U.S. to apply the subarachnoid anesthesia. Matas may
have been the first to inject morphine into the
subarachnoid
space (13).
Moreno et al. (14) described three patients treated by
CSF
rechange after total spinal block caused by mistaken
overdosage of local anesthetic in the subarachnoid space
(two after epidural and one after paravertebral blocks).
In
all three patients clinical features of total spinal
block
appeared with severe hypotension, respiratory depression
and
loss of consciousness. After crystalloid perfusion and
epinephrine administration, CSF rechange was performed.
A
22G spinal needle was introduced in a cervical space in
two
patients and in a lumbar space in one patient. Repeated
removal of 5 ml of CSF was followed by replacement of an
equal volume of saline solution up to a volume of 50 ml.
In
less than 5 minutes all three patients recovered normal
blood tension, spontaneous respiration and
consciousness,
while spontaneous movements of the four limbs were
achieved between 20-30 minutes. The method was also used
for
the treatment of subarachnoid morphine overdose (15).
Addition of 20 µg of fentanyl to plain lidocaine 5%
in
dextrose (50 mg) spinal anesthesia improve duration of
sensory anesthesia without prolonging recovery of motor
function or time to micturition (16).
Sosis et al. (17) have shown that staphylococcus aureus
and
candida albicans continue to survive 51 hr after
inoculation
of fentanyl/bupivacaine mixtures.
The fraction of the lumbar epidural dose found in CSF
after
epidural sufentanil 75 µg, diluted in 10 ml saline,
was
2.7%. The time to peak CSF sufentanil concentration was
0.76±0.50 hr in the lumbar area and 2.1±1.4 hr
in the
thoracic area (18).
The availability to CSF of epidural morphine is 2% and
of
epidural pethidine - 10% (19).
Spinal anesthesia has been achieved with meperidine as a
sole agent (20). Meperidine has also been used for
spinal
analgesia during labor and delivery (21) because it
provides
sensory anesthesia with a weak motor block (22).
1. De Castro J, Meynadier J, Zenz M. Regional opioid
analgesia. Dordrecht: Kluwer Academic Publishers, 1991,
p.
198-200
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. Badner NH, Komar WE. Bupivacaine 0.1% does not
improve
postoperative epidural fentanyl analgesia after
abdominal or
thoracic surgery. Can Anaesth Soc J 1992;39:330-336
11. Badner NH, Reimer EJ, Komar WE, Moote CA. Low-dose
bupivacaine does not improve postoperative epidural
fentanyl
analgesia in orthopedic patients. Anesth Analg
1991;72:337-341
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
UK
in 1993, 99% of the units resited the epidural catheter
following an inadvertent dural tap. One percent inserted
the
epidural catheter into the subarachnoid space to provide
continuous spinal analgesia.
There are many reports of failed aspiration tests for
both
subarachnoid and intravascular catheter placement (2-4).
Epidural catheter test dose is a must maneuver, because
as
Moore (5) said on the epidural needle, none of us has
"an
eye on the end of the needle", neither on the end of the
catheter introduced through that needle.
The incidence of inadvertent epidural catheter
intravascular
cannulation range from 5.6% (6) to 4.8% (7) and even
0.67%
(8).
Brown (9), in the 4th edition of Miller`s 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".
Campbell et al. (10) evaluated the spinal injection of
2.5
mg bupivacaine, 10 µg sufentanil and 10 µg
sufentanil
plus
2.5 mg bupivacaine in 52 nulliparous patients using the
needle-through-needle technique in the combined
spinal-epidural anesthesia. After spinal anesthetic
injection the 25G spinal needle was removed and the 20G
epidural catheter inserted but not tested. CSF was not
obtained in 7.7% (4/52) of the patients who subsequently
had
a functioning epidural catheter. 4.2% (2/48) of the
epidural
catheters required replacement.
Rathmell et al. (11) evaluated in 8 healthy volunteers
whether premedication with nalbuphine 0.15 mg/Kg IV has
an
effect on the ability to detect auditory or taste
symptoms
of IV local anesthetic injection (1.5 mg/Kg 2%
chloroprocaine). They found that nalbuphine sedation
does
not interfere with the detection of intravascular
epidural
catheters when 2% chloroprocaine is used as a test dose.
Cantelo and Walsh (12) described a case in which an
epidural
catheter was inserted at the T12-L1 interspace after an
inadvertent dural puncture occurred at the L1-2
interspace.
Aspiration tests revealed 0.2-0.3 ml of CSF, which
leaked
from the subarachnoid space into the epidural space.
Failure to detect inadvertent intravenous injection of a
local anesthetic with epinephrine can result in cardiac
arrest (13) during general anesthesia. In the elderly
(14,15) or in patients with á-adrenergic blockade (16),
systolic blood pressure changes were reported to be more
reliable than heart rate changes.
Tanaka et al. (17) gave 3 ml of 1.5% lidocaine with
epinephrine (1:200,000) IV to 15 patients anesthetized
with
1% end-tidal isoflurane and nitrous oxide. 5 of 15
patients
developed heart rate increments smaller than 20
beats/min.
However, all patients exhibited systolic blood pressure
increases more than 15 mmHg. They concluded that the
systolic blood pressure criterion should be used to
diagnose
suspected intravascular migration of the epidural
catheter
during combined spinal-epidural anesthesia.
Crawford (18) in his review of 27,000 lumbar epidural
blocks
concluded that "the requirements for safety are that all
top
ups are given in divided dose, with an interval of
approximately 5 minutes between two increments". The
inadvertent intravenous administration of local
anesthetic
during "epidural" injection was classified by Crawford
as a
"potentially life threatening complication" (18).
Scott and Hibbard (19) collated 108 nonfatal
complications
from more than 500,000 obstetric epidurals in the UK
from
1982 to 1986 inclusive. One out of three cardiac arrests
and
21 convulsions were associated with inadvertent
intravascular injection.
Michels et al. (20) found that the use of 1 mg/Kg
lignocaine
as a test dose would result in a significantly higher
sensitivity of subjective symptoms for detecting
intravascular injection than the use of 0.5 mg/Kg (95%
vs.
50%).
The incidence of epidural needle/catheter unintentional
dural puncture range from 2.5% (21) to 0.6% (8) and even
0.26% (22).
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
United
Kingdom. Anaesthesia 1995;50:156-161
2. Ravindran RS, Bond UK, Tasch MD, Gupta CD, Luerssen
TG.
Prolonged neural blockade following regional analgesia
with
2-chloroprocaine. Anesth Analg 1980;59:447-51
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. Moore DC, Spierdijik J, Vankleef JD, Coleman RL, Love
GF.
Chloroprocaine neurotoxicity: four additional cases.
Anesth
Analg 1982;61:155-9
5. Moore DC. Accidental dural puncture - who has an eye
on
the end of a needle. Anaesth Intensive Care 1986;14:208
6. Jaucot J. Paramedian approach of the peridural space
in
obstetrics. Acta Anaesthesiol Belg 1986;37:187
7. Kenepp NB, Gutsche BB. Inadvertent intravascular
injections during lumbar epidural anesthesia.
Anesthesiology
1981;54:172-173
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; Miller RD (ed.); Churchill Livingstone; 4th
ed.;
1994;p.1525
10. Campbell DC, Camann WR, Datta S. Combined
spinal-epidural for labor analgesia: Comparison of
intrathecal sufentanil vs bupivacaine vs sufentanil plus
bupivacaine. Anesthesiology 1994;81:A1145
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
á-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 UK, was
probably retarded by 20-25 years (1).
Noble and Murray (2) in a review of 78,746 spinal
anesthetics in Canada, found no permanent neurological
sequelae. Similarly, Moore and Bridenbaugh (3) surveyed
12,386 and Dripps and Vandam (4) - 10,098 spinal
anesthetics, and did not find evidence of permanent
neurological deficits.
In an editorial published in 1975 on spinal anesthesia
Scott and Thorburn (5) wrote that "it has been virtually
ignored in the last 20 years for several reasons,
including
the introduction of muscle relaxants. Since the Woolley
and
Roe cases, reported in 1954, in which two patients
developed
painful and permanent paraplegia following spinal
anaesthesia, the use of the technique in the United
Kingdom
has been confined to a few enthusiasts".
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
US cost of local anesthetic drugs are much cheaper than
those of general anesthetics. For example, bupivacaine
0.5%
30 ml - $1.24; lidocaine 1% 30 ml - $0.35; fentanyl 100
µg -
0.30 compared to midazolam 5 mg - $7.27; atracurium 100
mg -
$39.17; propofol 200 mg - $9.63.
Inhalational anesthetics also cost much more: Isoflurane
100
ml -$70.75; halothane 250 ml - $14.89 (1).
For total hip or knee replacement, the anesthesia
related
drug costs for a spinal anesthetic are approximately one
half that for a general anesthetic (2).
1. Cooper JO. The relative costs of anesthesia drugs in
New
Zealand versus the United States. Anesth Analg
1995;80:850-851
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: < 3 cm -
0.3%; 3
to
< 4 cm - 15%; 4 to < 5 cm - 47.3%; 5 to < 6 cm - 28.6%; 6
to
< 7 cm - 6.9%; 7 to < 8 cm - 1.4%; and > 8 cm - 0.5% (1).
Barbara l. Leighton (2) described her model for initial
instruction in epidural catheterization technique... the
banana. The banana represents the skin, subcutaneous
tissue
and the ligamentum flavum. "An average banana can be
used
for 30 attempts before it becomes mushy". Unripe bananas
need less frequent replacement. In addition, an average
banana`s width (3 cm) is only slightly less than the
distance from the skin to the epidural space in the
average
patient (4 cm) (3). This model does not represent the
vertebrae; however, bony anatomy can be learned from a
skeleton.
The mean value of the distance from skin to the epidural
space in term parturients is influenced by the patient`s
position during epidural needle placement. It is 4.44
± 0.82
cm in the sitting position and 5.03
± 1.05 cm in the lateral
position (1).
Spinal dura mater thickness at the lumbar region is 0.5
mm
(4).
Using magnetic resonance imaging (MRI) of 39 patients
Westbrook et al. (5) found that the depth of the
extradural
space at the level of T12 is 0.83±0.195 cm.
Cerebrospinal fluid is formed at the rate of 400 ml/day
(6).
The average adult has a total of 120 to 150 ml of fluid,
of
which only 20 to 35 ml are in the spinal portion of the
subarachnoid space. In parturients, this volume in the
spinal canal is decreased (7).
Valsalva (8), in 1682, was the first to remark on the
CSF
when he cut open the spine of a dog and noticed the
liquid
"which in all its aspects resembles that which is found
in
the joints".
Meme et al. (9) using an epiduroscope could visualize
the
pulsation of the dura synchronized to heart rate.
The human dura mater shows its fibers neither
longitudinally
nor parallel directed. It has thin collagen fibers and
thick
elastic ones with wavy characteristics, grouped in
ribbons
or sheets (10).
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.); Philadelphia; JB Lippincott,
1980:pp.
184-5
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±0.01 Kg force, while using the B-D Whitacre
needle it
was three times more - 0.12±0.02 Kg force. The CSF
flow
through the Quincke needle was almost twice than that of
the
Whitacre needle (8.30±.9 vs 4.30±.9). This
lesser leak
of CSF of the pencil-point needle compared to the
Quincke
needle, confirms its superiority in reducing the
incidence
of post dural puncture headache.
In a meta-analysis of 450 articles published from
January
1966 till December 1993 Halpern and Preston (4) found a
reduction in the incidence of postdural puncture
headache
when noncutting spinal needles rather than cutting
needles
were used and when a small spinal needle was used
compared
with a large needle of the same type. There was no
difference in the incidence of failure of spinal
anesthesia
or the incidence of back pain between the noncutting and
the
cutting spinal needles.
Garcia et al. (5) found a significantly higher
unsuccessful
dural puncture or inadequate sensory block while using
27G
Whitacre needle as compared to 25G Whitacre needle (10%
vs
2%).
Anderson et al. (6) used either 25G Whitacre or 27G
Quincke
spinal needles to induce combined spinal-epidural labor
analgesia. They were able to obtain CSF in only 28 of 37
patients (75.6%) when using the Whitacre needle but in
all
of 13 patients in whom they used the Quincke-point
needle.
McLeod et al. (7) described two 25G Whitacre needles
which
tips resembled "concorde nose" after it struck bone
while
introduced at the L3-4 interspace.
Using the needle-through-needle technique Pedraza et al.
(8)
found that after dural puncture with 26G Whitacre spinal
needle there were 0.11 ml CSF refluxed through the
epidural
needle within 2 minutes, while with the 24G Sprotte
needle
there were 0.30 ml of CSF.
Using the needle-through-needle technique Joshi and
McCarroll (9) encountered difficulties to feel the
spinal
needle puncturing the dura. "This could be due to the
fact
that the spinal needle has to brush the curved bevel of
the
Tuohy needle".
Turner and Shaw (10) found an increased incidence of
paresthesias (16.6%) while using the long Whitacre
spinal
needles through the epidural needles in the combined
spinal
epidural anesthesia for cesarean section. They
postulated
its long nose cone as an explanation ("before
cerebrospinal
fluid is evident, these needles have to be passed
further
through the dura").
Injection of local anesthetics at the first appearance
of
fluid at the hubs of spinal needles with long orifices
(Sprotte, Quincke, Diamond point) may result in failed
spinal anesthesia due to leakage into the epidural
space. In
that regard the shorter orifice spinal needle (Whitacre)
is
preferred (11).
Failed or incomplete spinal block with Sprotte needles
varies between 1.6% and 11.5% (12,13). This could
possibly
be related to the larger length of the orifice compared
to
the dura. Since the thickness of the dura is from 0.5 to
almost 2.0 mm (14), and the length of the orifice of 22
gauge Sprotte needle is 2 mm and that of the 24 gauge
Sprotte is 1.4 mm, it is possible that CSF aspiration
can
occur while, on injection, some of the local anesthetic
escapes through that part of the orifice outside the
dura
(15).
Coring of the epidermis by a spinal needle with tissue
deposition and proliferation in the subarachnoid space
is a
presumed etiology for iatrogenic intraspinal epidermoid
tumors. These tumors have been reported as a late
complication of lumbar puncture (16,1).
1. Brandus V. The spinal needle as a carrier of foreign
material. Can Anaesth Soc J 1968;15:197-201
2. Campbell DC, Douglas J, Taylor G. Do the newer spinal
needles reduce "coring"? Anesthesiology 1993;79:A478
3. Westbrook JL, Uncles DR, Sitzman BT, Carrie LES.
Comparison of the force required for dural puncture with
different spinal needles and subsequent leakage of
cerebrospinal fluid. Anesth Analg 1994;79:769-72
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. Anderson M, D`Angelo R, Philip J, Hood DD, Eisenach
JC.
Intrathecal sufentanil compared to epidural bupivacaine
for
labor analgesia. Anesthesiology 1993;79:A970
7. McLeod GA, Carson D, Bannister J. "Concorde nose" in
Whitacre spinal needles. Br J Anaesth 1993;70:593
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, Sosis MB, Braverman B, Ivankovich AD. An
in
vitro investigation of the relationship between spinal
needle design and failed spinal anesthetics. Reg Anesth
1993;18:S85
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. Gardner DJ, O`Gorman AM, Blundell JE. Interspinal
epidermoid tumor: late complication of lumbar puncture.
Can
Med J 1987;141:233-235
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 (4°C) for 120 sec) was performed. Conduction
block
attenuated the increase in response to cold pressor test
only in mean arterial pressure (spinal and epidural) and
cardiac index (spinal only). Neither spinal nor epidural
anesthesia blocked the increase in heart rate,
norepinephrine or epinephrine to cold pressor test.
Despite
a more complete motor block during spinal anesthesia,
spinal
anesthesia did not produce a more complete sympathectomy
than epidural anesthesia.
The myocardium and the coronary vasculature are densely
innervated by sympathetic fibers. Sympathetic tone in
the
coronary circulation both at rest and during exercise
may
improve the matching of coronary blood flow and
myocardial
oxygen demand (13). In patients with coronary artery
disease, however, there is evidence for a nonbeneficial
sympathetic influence as this matching capability is
disturbed during sympathetic stimulation (14-18). In
patients with severe coronary artery disease, cardiac
sympathetic block with high thoracic epidural anesthesia
increases coronary artery stenotic diameter at rest
(15),
improves global as well as regional left ventricular
wall
motility, and increases left ventricular ejection
fraction
during exercise stress tests (19). Furthermore, in
patients
with severe coronary artery disease and unstable angina
refractory to maximal medical therapy, thoracic epidural
anesthesia offers efficient pain relief (20), and
decreases
determinants of myocardial oxygen demand - heart rate,
preload and afterload during myocardial ischemia (14).
It
also seems to "stabilize" patients with unstable angina
(20,21). Thoracic epidural anesthesia may beneficially
affect the collateral flow during ischemia. It was
observed
by Klassen et al. (22) that thoracic epidural anesthesia
reduced the coronary vascular resistance 20%-25% for
collateral flow into the ischemic myocardium.
1. Greene NM. Physiology of spinal anesthesia. 3rd ed.
Baltimore: Williams & Wilkins, 1981
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. New York: Pergamon Press,
1990:84-121
3. Bonica JJ. Autonomic innervation of the viscera in
relation to nerve block. Anesthesiology 1968;29:793-813
4. Greene NM, Brull SJ. Physiology of spinal anesthesia.
4th
ed. Baltimore, Williams and Wilkins, 1993, pp. 21-40
5. Greene NM. The area of differential spinal block
during
spinal anesthesia with hyperbaric tetracaine.
Anesthesiology
1958;19:45-50
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, Greene NM. Zones of differential sensory
block
during extradural anaesthesia. Br J Anaesth
1991;66:651-655
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. Columbus, American, 1988
10. Bengtsson M, Loefstroem JB, Malmqvist LA. Skin
conductance responses during spinal anesthesia. Acta
Anaesthesiol Scand 1985;29:67-71
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 1654. In 1689 was
published a collection of his sayings entitled: Table
talk.
One of them is as follows: "Preachers say, Do as I say,
not
as I do. But if the physician had the same disease upon
him
that I have, and he should bid me do one thing, and
himself
do quite another, could I believe him?"
Conclusion
"We shape the architecture of our buildings and then
they
shape us" (Winston Churchill).
You can email me to the following address:
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