Assist. Prof.Surirat Sriswasdi Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University 12 October 2005

Regional Anesthesia Peripheral nerve block Plexus block Neuraxial block

Advantage Less stress response Provide postoperative pain Early ambulation

Local Anesthetic Agents Lidocaine Bupivacaine Ropivacaine Levobupivacaine

Local Anesthetics Toxicity Tissue toxicity Systemic toxicity - Central - Cardiovascular

Central Nervous System Toxicity Metallic taste Light headeness Tinnitus Visual disturbance Numbness of tongue & lips

Central Nervous System Toxicity (cont.) Muscle twitching Loss of consciousness Grand mal seizures Coma

Treatment Stop injection Administration O 2 Anticonvulsant Maintain airway

Cardiovascular toxicity Ventricular contractility Refractory cardiac arrhythmia Loss of peripheral vascular tone

Treatment Oxygen Fluid Vasopressor Amiodarone Prolonged cardiopulmonary resuscitation

Plexus Blockade Interscalene block - Ipsilateral phrenic nerve block (100%)

Supraclavicular block - Pneumothorax ( %) Plexus Blockade (cont.)

Bier’s block - Tourniquet failure (systemic toxicity) Plexus Blockade (cont.)

Neuraxial Block Spinal block Epidural block

Spinal Block Intraoperative complication - Hypotension - Bradycardia - Nausea / vomiting - Dyspnea - Bezold Jarisch reflex (severe bradycardia - hypotension)

- Urinary retention - Post dural puncture headache - Neurological impairment Transient radicular irritation ( TRI) Transient neurological syndrome (TNS) - Infection - Backache Postoperative complication Spinal Block (cont.)

TRI / TNS Subarachnoid injection 5% lidocaine Less with bupivacaine Lithotomy position increase risk Chloroprocaine - Sensory deficit - Motor deficit

Epidural Block Intraoperative complication - Unintentional dural puncture - Subarachnoid injection - Intravascular injection - Local anesthetic overdose

Epidural Block (cont.) Postoperative complication - Direct spinal cord injury - Hematoma - Infection

Epidural Block with Catheter Catheter problem - Insert into epidural vein - Break off or become knotted - Cannulation subarachnoid space - Infection

Thank You