Controversies - Neuraxial blocks question answer session Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD (physio), FICA

Laparoscopy under spinal !! Possible and done – chole, ectopics, hernias hysterectomy, ovarian cyst, appendix Less pain, less cost, better post op period Safe and adequate : GA conversion is < 1 % No respiratory compromise Arch Surg. 2008;143(5): Rev Bras Anestesiol 2010;60(3): JOACP Oct-Dec; 26(4): 475–479. Egyptian Journal of Anaesthesia (2013) 29, 375–381

Technique Dose adjuvant – usually 3 to 3.4 ml of hyperbaric with 15 mic. Clonidine keta (personal) Shoulder pain – few cases – settles with IV fentanyl (200 mic. Buprenorphine) and IV clonidine Hypo severe with chole ( head up ) but acceptable with head low positions – allow after ten minutes Get experience with routine spinals, understand how it works and its side effects and then use it with caution

Segmental spinal anesthesia Something like segmental epidural !! Give spinal at thoracic level, 1.2 or 1.8 ml !! Nephrectomy, chole, lap chole, hernias done Sacrum spared, hypo and brady – same Anesth Essays Res Jul-Dec; 6(2): 236–238. British Journal of Anaesthesia 96 (4): 464–6 (2006)

Then we must be using it left and right ??- but ?? Technically difficult Spinal cord injury Expert hands Think when indication is very absolute Caution - - Caution

Kyphoscoliosis or rods !!

CAN J ANAESTH 1993 / 40:7 / pp Anesth Analg 1985; 64: 843. Regional Anesthesia 1993; 18: Epidural is more difficult Spread in epidural may be unpredictable Spinal has end point Usually fusion not beyond L4 – so taylor s approach –OK Fusion of vertebrae – less levels Scarring of ligaments – up or down Old age L5 S1 may be more operated than young patients where L234 more frequent Check X’ray LS

Sepsis Frank sepsis – no Controlled – eg. Hemodynamics stable, decreasing Total counts increasing platelets, antibiotics started – just ok The haemodynamic effects of these techniques in the setting of sepsis-induced cardiovascular compromise may be difficult to reverse Recent blood tests confirming normal coagulation are essential. Br J Anaesth. 2010;105(6):

operations in the prone or jackknife position Lower limb, perianal Laminectomy, lipomas Less blood loss, cost Cardiac patients ?? stretcher spinal Obese patients can have levels ?? No additional sedatives or narcotics I will keep proseal LMAJ Neurosurg Spine Jan;2(1): Anesthesist 1999 Apr;48(4): Large doses of LA with fentanyl get a high level – bolsters -duration ?? Surgeon ??

Caesarean section under spinal anaesthesia for a patient with pustular psoriasis. Anaesthesia 2009;64: Infective skin lesions Local – strict NO If indicated, go for segmental spinal Non infective Eg. Psoriasis – sometimes pustular – better avoid But avoiding the area to give spinal is proved Can we give ??

Myelocele repair done Coming for some other pelvic surgery after 15 years Tethered cord Low lying conus Get the prick well below – as far as possible

Diabetic peripheral neuropathy The patho physiology of diabetic neuropathy is unclear Local anesthetics are not proven to increase the damage Note down the deficits – less drugs Think of other damages by DM ( ANS, angio) - RA – OK 2 / 375 patients worsened - same as nondiabetics Reg Anesth Pain Med 2005;29:A66 Progressive neurological disease – no to regional May be 0.04 %

Can a child be given ??

Consider facial dysmorphia difficult intubation, muscular dystrophy, family history of malignant hyperthermia full stomach with aspiration risk

Clinical pearls !! Spinal cord and level of insertion Heavy bupivacaine is recommended in a dose of mg/kg = mL/kg of 0.5% solution. Straight needle BP fall ?? – sympathetics not well developed Short action duration Neck flexion ? Sedatives – ok distance in millimeters = (age in years x2) Skill

Thank you all