Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics

 Some are missed wantonly and some are missed unknowingly  Drugs ______

Procaine Chlorprocaine Tetracaine Dibucaine Lignocaine Bupivacaine Ropivacaine levo bupivacaine

 700 cases of epidural series  3- 5 % solution  Upto 20 ml of 5%  pseudocholinesterase  Short and safe  But weak

Ester Pseudocholinesterase Short and safe 3 % upto 33 ml used 1.5 % - 2 % for short analgesia

Ester but a long butyl chain 0.5 % upto 20 ml used More motor block Sensory block ?? Not for post op pain relief Brutal suddenness of récession ,3 % also used

 Ester but not hydrolysed by pseudocholisterase  Slow latency for epidural use 30 – 40 minutes  0.3 % 30 ml used

 Amide  Fast onset  Reliable effect  Stable – autoclavable  1.5 ml /segment at 18 years at lumbar space but 0.75 ml /segment – 80 years of age  1.5 – 2 % reliable onset --5 minutes  1 % infusion used for analgesia

 Ease of destruction  Used when adrenaline is not to be used along with lignocaine  3 % solution = 2 % lignocaine  Break down product – o- toluidine  600 mg of prilocaine – steep rise of methemoglobin upto 1-3 gm / 100 ml.

 it is used in 0.5% and 0.75% concentrations for surgical anesthesia.  Analgesic techniques can be performed with concentrations from 0.125% to 0.25%.  Cardiotoxic  % deepens and creeps caudally after subsequent injections

 is increasing in use as an epidural agent.  It is used in 0.5% to 1.0% concentrations for surgical anesthesia  0.1% to 0.3% concentrations for analgesia  Vasoconstriction  Less cardiotoxic  Less motor block - but clinical ??  More ideal for analgesia, labour and post op

 epidural local anesthetic in 0.5% to 0.75% concentrations for surgical anaesthesia, analgesic techniques can be performed with concentrations of 0.125% to 0.25%.  In an individual patient, the clinical anesthetic effect from the drug is indistinguishable from that of racemic bupivacaine  Less cardiotoxic

 2-Chloroprocaine 2–3% 45–60  Lidocaine 1.5–2% 60–100  Mepivacaine 1.5–2 % 60–100  Bupivacaine 0.5–0.7% 120–240  Levobupivacaine 0.5–0.75% 105–290  Ropivacaine 0.5–1% 90–180

 Block Height  Upper abdominal surgery T4–5  Cesarean section  Lower abdominal (appendectomy, T6–8  inguinal herniorrhaphy)  Pelvic procedures-TURP T10  Obstetric vaginal delivery  Hip and lower extremity L2–3  (with thigh tourniquet)  Lower extremity  Perineal procedures (limited S1–2  to exterior)

 Adrenaline – 1 in 2 lakh  Prepared solutions contain 0.1 % sodium bisulfite –Acidity,Painful,Slow onset  Freshly prepared solutions better –action ??  But  Thyrotoxicosis, MAO inhibitors, fixed cardiac output, severe arteriosclerosis

 Lignocaine hydrochloride  Lignocaine carbonate  Fast onset,dose,quality, missed segments  But preparation – difficult

 Laparotomy, adult, midparamedian incision  Level ??  Drugs ??  T 6-- Bupi 0.5 % ml

 LSCS  Level ?? drugs ?? T6 – T7 Lignocaine with adrenaline – ml Bupi 0.5 % ml

 Hip surgery  IHD patient  Level ??  Drugs ??  L1  10 ml bupi with narcotics

 Fracture ribs 4 to 6  Pain relief  Thoracic catheter  Drugs ??  0.25 % bupi  Opioids

 Life maths  A woman worries about the future until she gets the husband  A man never worries about the future until she gets a wife

 Anaesthesia  Analgesia  Pain relief  malignant  nonmalignant  Trauma

 Immediate technical complications  Neurological complications

 Accidental dural puncture  Less than 1 %  Sometimes a nuisance with headache  Four options  1. abandon  2. proceed in the same space  3. proceed in the different space  4. change to continuous catheter

 Massive injection – wrong space  Subdural  Intravenous  Subarachnoid

 Hypotension  Unconsciousness  Apnoea.  Treatment  Support circulation and respiration till block wears off  Increased epidural spread ??  Arteriosclerosis, DM,pregnancy,tumors

 Vasopressors, resp. support, anticonvulsants  Avoidance  1. gentle insertion of the catheter  2. aspirate before  3. test dose  4. aspirate again

 Potential space between dura and pia arachnoid  Subdural injection is confirmed by observing the typical “railroad track” or “honeycomb” pattern after injection of contrast material  Massive spread  How to Avoid  Steady movement  No change in bevel direction  Subdural and total spinal – difference ??  Test dose is negative for subdural

 previous back surgery (due to widened subdural space),  with repeated dural puncture(s) at the same or an adjacent site,  and with rotation of an epidural needle 180 degrees once the epidural space  The cervical subdural space is larger than the lumbar space,  accidental subdural injection may be higher during attempts at cervical epidural injection

 If inadvertent bloody tap due to trauma to a vessel  Options  1. abandon  2. later insertion problem  But infection and hematomas – unheard of

 2%  Similar incidence to GA  More in OBG epidurals  Usually disappears 36 hours  Solution leakage before ligamentum flavum

 30 % incidence after pelvic surgeries if not catheterized  Epidural for postop pain relief also – more common  Lumbar epidural more common

Relatively tolerant to abuse Paraplegia reported after hypertonic saline Inadvertent injection of KCL What happened Steroids ??

 A) shearing at the needle tip  --- goes for 1 cm stops. Withdraw as a whole (i e needle and catheter )  B) Brittle catheters  plastic catheters were hard and brittle  Teflon are better  Fibrin reaction by tissues  Every 4 th day change in a different space

 C) laminar pincer :  In some postures, the laminae of some osteoarthritc patients may trap the catheter  Difficult to remove – break  Back to flexion – left or right lateral  Change and remove slowly D)Knotted catheters – rare – 1 in 30,000  Too much insertion more than 4 cm  Gentle, firmness with persistence

 Patient informed  Decisions  1. masterly inactivity  2. enthusiastic exploration

 Life maths again  A successful man is one who makes more money than his wife can spend  successful woman ??  A successful woman is one who can find such a man

 Damage to spinal cord – if above L1  Nerve roots otherwise  Rare but avoidance is the best  Withdraw if root pain  Stop if root pain on injection  The problem is when epidural administered in a very sedated patient  Gentleness precision and dexterity of hands

 Hypotension ◦ Level ◦ Drugs ◦ Additives ◦ Status of patient ◦ we shall Leave it to discuss later

 Epidural hematomas – prevention  avoiding the use of epidural catheters in patients with  clotting abnormalities, such as severe liver disease, uremia, thrombocytopenia, or in patients on heparin  PIH  Stick to evidence based protocols

 severe back pain and rapid onset of neurologic deficits  progressive motor/sensory block with bladder and bowel dysfunction  TREATMENT  Once MRI confirms --  emergent laminectomy  and decompression

 1 in general  But anaesthesia – in 5,00,000

 epidural hematoma that becomes secondarily infected.  possible routes of infection  inoculation of bacteria in the subcutaneous tissue during catheter placement,  contamination of the injectate,  infection by migration of bacteria from the exit site alongside the catheter.

 back pain and nuchal rigidity  Fever  Later  Root pain, bowel bladder dysfunction  MRI – abscess – drainage  Localizing – no root involvement, non spreading  conservative management is practiced by a few.

 meningitis,  spinal tumor,  hematoma,  transverse myelitis,  spinal cord infarction,  and intervertebral disc prolapse.

 Femoral  Sciatic  Lateral femoral cut. N  obturator  Factors Pregnant  Obesity  Position