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

2. Regional Anesthesia Peripheral nerve block Plexus block Neuraxial block

3. Advantage Less stress response Provide postoperative pain Early ambulation

4. Local Anesthetic Agents Lidocaine Bupivacaine Ropivacaine Levobupivacaine

5. Local Anesthetics Toxicity Tissue toxicity Systemic toxicity - Central - Cardiovascular

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

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

8. Treatment Stop injection Administration O 2 Anticonvulsant Maintain airway

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

10. Treatment Oxygen Fluid Vasopressor Amiodarone Prolonged cardiopulmonary resuscitation

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

12. Supraclavicular block - Pneumothorax (0.5-0.6%) Plexus Blockade (cont.)

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

14. Neuraxial Block Spinal block Epidural block

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

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

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

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

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

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

21. Thank You