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Regional Anesthesia

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Ashley Lamb

on 16 August 2015

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Transcript of Regional Anesthesia

Regional Anaesthesia
What is a Spinal block?
Clinical use

Adverse effects
Implications for Physiotherapy
Local anaesthetic injected through the dura into the cerebrospinal fluid

Single injection = single dosage
Small dose of 1.5 - 3mL
Below L2 to avoid damage to the spinal cord
Onset ~ 5 minutes, within 10 minutes complete anaesthesia of the injected distribution
Lasts ~ 2 hours
Total numbness of the spinal levels above and below the injection sight
How does it work?
Lower limb orthopaedic surgery
Laprascopic bowel surgery
Lower limb vascular surgery
Abdominal or vaginal hysterectomies
May be used in conjuction with a general anaesthetic, or in isolation.
Useful for patients with severe respiratory distress e.g. COPD
Cephalad spread of local anaesthetic
Cauda equina
Cardiac arrest
Spinal canal haemotoma
Epidural abscess
An increase in injection sight of one spinal level can have a significant increase the cephalad spread of the local anaesthetic

Females have a lower density CSF
At extremes of age there is an increase in the maximum spread
Higher level of block in obese patients
Lower abdomen and below;
What is a TAP block?
Peripheral nerve block designed to
the nerves supplying the anterior abdominal wall (T6-L1)
Blind landmark technique OR ultrasound guided technique
Injection of local anaesthetic into the deep fascial plane between the internal oblique and the transversus abdominus
Clinical use
Benefits of TAP block;
Implications for Physiotherapy
Used as an adjunct for post operative pain control
Surgery in the T6 - L1 distribution
Bilateral TAP blocks are used for midline incisions
Placement of a catheter for a continuous TAP block
Decreased need for post operative opioid use
Less adverse effects
No invasion of the spinal cord; no risk of CNS adverse effects
Longer term pain relief with or without the use of ongoing TAP block
Can be injected pre, intra or post operatively
Adverse Effects
Variable effectiveness of TAP block
Transient femoral nerve palsy
Haemotoma and infection
Peritoneal puncture
Local anaesthetic toxicity
Laceration to liver, kidney, spleen
Decreased need for opioids
= less nausea, respiratory depression, drowsiness

Effective pain management
= Greater compliance with PT Rx

Better outcomes for your patient
Ineffective pain management
Pt less likely to mobilise, cough, exercise secondary to high pain levels
Greater opioid use for pain management
The pt will either have little/no pain OR have high levels of pain

Clinical studies
Sinah et al. 2013;
The efficacy of ultrasound-guided transversus abdominis plane block after laparoscopic bariatric surgery
Median VAS at 1, 3, 6, 12 & 24 hours post op at rest and with movement was lower in the USG-TAP group compared to the control group
Time to ambulate was 6.3 (+/- 1.8) in the USG-TAP group, compared to 8 (+/- 1.8) in the control group
Calle et al. 2014;
Transversus abdominus plane block after ambulatory total laprascopic hysterectomy: Randomized controlled trial
What is an epidural?
Injection of local anaesthetic via a catheter inserted into the epidural space
In dwelling catheter allows an infusion of local anaesthetic over a prolonged period of time (usually 2-3 days)
Initial dose 10 - 20mL
May be performed anywhere in the vertebral column
Onset ~ 5 minutes, anywhere from 15 - 25 minutes to reach full anaesthetic effect to the dermatomes immediately surrounding the injection site
How does it work?
Preferentially acts on afferent sensory receptors
E.g. In labour the female may not feel pain but will feel the pressure
However, an epidural will block other types of nerve fibers in a dose dependent manner
Clinical Use
May be combined with spinal anaesthetic
Initally used as an anaesthetic intra-operatively, and then analgesic post operatively
Obstetrics - During child birth
Abdominal surgeries
Orthopaedics - Lower limb
Vascular surgery - Lower limbs,
Gynecology and Urology surgeries
Adverse Effects
CNS complications: Damage to neural structures, epidural haemotoma, epidural abcess, dural puncture, cerebral ischemia (CSp), meningitis
CV effects: Cardiac arrest, tachycardia, hypotension
Respiratory effects: Respiratory compromise if phrenic nerve is blocked
The Bromage Score for motor blockade
Clinical Studies



Barash, P. G., Cullen, B. F., Stoelting, R. K., Calahan, M. K., Stock, C. M. (2009).
Clinical Anesthesia (6th ed.).
Philadelphia, PA. Wolters Kluwer
Journal Articles;
Sinha, A., Jayaraman, L., & Punhani, D. (2013).
Efficacy of ultrasound-guided transversus abdominis plane block after laparoscopic bariatric surgery: a double blind, randomized, controlled study.
Obesity surgery, 23(4), 548-553.
Salman, C., Kayacan, N., Ertuğrul, F., Bıgat, Z., & Karslı, B. (2013).
Combined spinal-epidural anesthesia with epidural volume extension causes a higher level of block than single-shot spinal anesthesia
. Revista Brasileira de Anestesiologia, 63(3), 267-272.
Calle, G. A., López, C. C., Sánchez, E., Los Ríos, J. F., Vásquez, E. M., Serna, E., ... & Almanza, L. A. (2014).
Transversus abdominis plane block after ambulatory total laparoscopic hysterectomy: randomized controlled trial
. Acta obstetricia et gynecologica Scandinavica, 93(4), 345-350.
Tummala, V., Rao, L. N., Vallury, M. K., & Sanapala, A. (2015).
A comparative study-efficacy and safety of combined spinal epidural anesthesia versus spinal anesthesia in high-risk geriatric patients for surgeries around the hip joint.
Anesthesia: Essays and Researches, 9(2), 185.
Web pages;
Retrieved on; 13.08.2015
Mukhtar, K. (2009). Transversus abdominis plane (TAP) block. The Journal of New York School of Regional Anesthesia, 12, 28-33.
Wisanen, M. T., (2013). Medscape: Transversus Abdominus Plane Block. Retrieved 14.08.2015, retrieved from; http://emedicine.medscape.com/article/2000944-overview
Military Advanced Regional Anesthesia and Analgesia. (2008).
The Military Advanced Regional Anesthesia and Analgesia Handbook
. Retrieved on 16.08.2015, Retrieved from; http://www.dvcipm.org/clinical-resources/dvcipm-maraa-book-project
(https://en.wikipedia.org/wiki Epidural_administration)

Retrieved on; 13.08.2015
Retrieved on 13.08.2015
Chawla, J., (2013). Medscape: Epidural Nerve Block. Retrieved 14.08.2015, retrieved from; http://emedicine.medscape.com/article/149646-overview#a9
Liou, L. S., (2013). Medline Plus: Spinal and Epidural anesthesia. Retrieved 14.08.2015. retrieved from; http://www.nlm.nih.gov/medlineplus/ency/article/007413.htm
Retrieved on 15.08.2015
Retrieved on 14.08.2015
Tummala, et al (2015).
A comparative study-efficacy and safety of combined spinal epidural anesthesia versus spinal anesthesia in high-risk geriatric patients for surgeries around the hip joint
Combined spiral and epidural anesthesia showed a significantly less incidence of hypotension (p < 0.01)
Combined spinal and epidural anaesthesia showed prolonged analgesia when compared to spinal anaesthesia alone
Salaman, et al (2012).
Combined Spinal-Epidural Anesthesia with Epidural
Volume Extension causes a Higher Level of Block than Single-Shot Spinal Anesthesia
Sensory block had the fastest onset, lasted the longest and was higher in group 2 (combined spinal epidural anaesthesia with saline) compared to group 1 (single shot spinal spinal anaesthesia)
Implications for Physiotherapy
Be aware of the potential complications
Grade I motor block persists; need to consider is this due to neurotoxicity OR is there an underlying CNS complication.
Depending on the level of the epidural need to consider respiratory compromise
Monitor clinical signs and symptoms of CVS complications
What is a paravertebral block?
Unilateral block of the spinal nerve including the dorsal and ventral rami
Clinical Use
Unilateral or bilateral anaesthsia or analgesia
Breast surgery
Open cholecystectomy
Open nephrectomy
Abdominal surgery
Patients where hypotension or sympathetic blockade from epidural would be particuarly detrimental

Paravertebral block is preferbale to epidural in patients with coagulopathy
Adverse effects
3 - 5mL of local anaesthetic (< if bilateral)
10 - 15mL will spread 1 - 2 paravertebral levels above and below the injection site
May require multiple injections for a multisegmental anaestehtic
In dwelling catheter may be used for an ongoing infusion
Hypotension (rare)
Vascular puncture
Pleural puncture
Paravertebral muscle pain
Nerve injury
Implications for Physiotherapy
Zhang et al, 2014.
Single-Dose, Bilateral Paravertebral Block Plus Intravenous Sufentanil Analgesia in Patients With Esophageal Cancer Undergoing Combined Thoracoscopic– Laparoscopic Esophagectomy: A Safe and Effective Alternative

Post operative VAS score lower in the paravertebral block (PVB) group compared to ' conservative Management' - PCA + oral opiods alone
Lower PCA access in the PVB group
Three day post operative pulmonary function better in the PVB group (p <0.05)
Quicker hospital discharge in the PVB group ( p < 0.05)
Respiratory complications
Likely less sedation, nausea, constipation and vomitting than opiod based analgesia
Pt's may progress faster, mobilise earlier and discharge from hospital sooner
Byram, S. W. (2013). Medscape: Nerve Block. retreieved on 16.08.2015. retrieved from; http://emedicine.medscape.com/article/2000541-overview#a3
( http://www.nysora.com/techniques/neuraxial-and-perineuraxial-techniques/landmark-based/3077-thoracic-paravertebral-block.html). Retrieved on 16.08.2015
Tighte. S, M. (2010). Continuing care in anaesthesia, critical care and pain: Paravertebral block. Retrieved 16.08.2015, retrieved from; http://ceaccp.oxfordjournals.org/content/10/5/133.full
Zhang, W., Fang, C., Li, J., Geng, Q. T., Wang, S., Kang, F., ... & Wei, X. (2014). Single-Dose, Bilateral Paravertebral Block Plus Intravenous Sufentanil Analgesia in Patients With Esophageal Cancer Undergoing Combined Thoracoscopic–Laparoscopic Esophagectomy: A Safe and Effective Alternative. Journal of cardiothoracic and vascular anesthesia, 28(4), 978-984.
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