Dr L. Delaunay Clinique Générale Annecy Vivalto Santé. With the complicity of : C Aveline, O Choquet, JP Estèbe, P Zetlaoui

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1 Dr L. Delaunay Clinique Générale Annecy Vivalto Santé With the complicity of : C Aveline, O Choquet, JP Estèbe, P Zetlaoui

2 Successful spinal anesthesia? Puncture success => CSF back flow No pain, No paresthesia 1 attempt Choose the right local anesthetic Volume Characteristic : Duration Dose Baricity Adjuvants? No complication!

3 Puncture success Incidence of global rate failure is between 3 to 5 % But rate of procedure failure is unknown. Fuzier RAPM 2011 Rate failure : 3,2 % (39/1200 spinal) Total : 59%, partial : 41%

4 Puncture success 1481 spinal & epidural anesthesia More than one attempt Results : One attempt : 65 % Logistic regression : De Filho EJA 2002

5 Puncture success MRI study : 690 patients Kim Anesthesiology 2003

6 Puncture success Landmarks localisation 121 pregnant women 5% 17% 48% 21% 13% 5% 2% L2-L3 L3 L3-L4 L4 L4-L5 L5 L5-S1 X-Ray 163 patients 4% 42% 30% 14% 4% Kettani A et al. AFAR C. Render. Anesthesia 1996 ; 51 :

7 Puncture success 100 patients MRI of lumbar spine One anesthetist draw any inter space on the lower spine Identification by 2 nd anesthetist Then MRI ,5 1% 15,5% 51% 29% 3% C. Broadbent. Anesthesia 2000 ; 55 :

8 Puncture success Sitting or lateral position Patient ability to stay in sitting position Common practice habit Unilateral spinal anesthesia : Lying on side of surgery => hyperbaric solution Lying on contralateral side of surgery => iso/hypobaric solution (hip arthroplasty)

9 Puncture success Lateral decubitus seems more difficult 53% 43% Interest of ultrasound +++! It s important to reduce number of attempts Fernandez RAPM 2010

10 Puncture success Multiple attempts increase the risk of paresthesia The presence of a paresthesia during needle placement significantly increased the risk of persistent paresthesia Auroy Anesthesiology 2003 Horlocker A&A 1997 Rigor during procedure +++

11 Technical aspects : puncture Takiguchi RAPM 2009 Ranger BJA 2008

12 Technical aspects : puncture But even with atraumatic needles

13 Technical aspects : puncture Interest of ultrasound!!

14 Why US?

15 Photos Bertrand Fabre

16 Technical aspects : procedure Landmarks +++ Slow progression of the needle Feel passage of the different layers : Ligamentum Flavum Dura mater Aspiration tests before/during/after Slow injection : Parturient Unilateral spinal anesthesia Elderly, Obesity probably

17 Successful spinal anesthesia? Puncture success => CSF back flow No pain, No paresthesia 1 attempt Choose the right local anesthetic Characteristic : Duration Dose Baricity Adjuvants? No complication!

18 Local anesthetic choice : Duration Double blind randomly study, 106 patients chloroprocaïne n= 53 = 40 mg bupivacaïne n = 53 = 7,5 mg Abdominal surgery Complete block resolution T6 T minutes = 5 hours L2 S1 l l l l l 0 (min) Lacasse Can J Anesth 2011;58:

19 Choice of local anesthetic : Duration Lidocaine 2% HB, 50 mg Prilocaïne 2% HB, 50 mg Max metamer T6 T6 Motor blockade 4 4 Sen block at S2, min 127 ± 33 (76-190) 128 ± 38 (66-213) Deambulation, min 155 ± 40 (91-260) 165 ± 37 (66-235) Voiding, min 238 ± 57 ( ) 253 ± 55 ( ) Bupivacaïne 0.5% HB, 12,5 mg T ± 42 (85-230) 200 ± 48 ( ) 299 ± 85 ( ) Pas de différence entre lidocaine HB et prilocaïne HB Diapo: P Zetlaoui Hampl KH et al. Anesthesiology 1998

20 Choice of local anesthetic : Dose Dose effect N = 60 patients, knee arthroscopy ,5 5 Voiding 428±34 241±14 186±14 163±8 4 groups : 5, 7,5, 10, 15 mg of HB bupivacaïne Length of stay 471±35 269±15 202±14 181±8 Sensory block required pain treament 0/15 0/15 0/15 4/15 Ben David Anesth Analg 1996

21 Choice of local anesthetic : Dose T0 recovery room Retarde la sortie des patients Association à des morphiniques liposolubles Voiding N = 50, Arthroscopie chirurgicale 169±52 177±53 Bupi. 5 mg vs Bupi. 5 mg + fentanyl 10µg Lengh Evaluation of stay : Qualité du bloc 187±51 195±49 Miction Durée d hospitalisation Bupi Bupi Fenta Block failure 6/25* 0/25 Ben David Anesth Analg 1997

22 Choice of local anesthetic : Dose Majority of complication are directly related to the dose of local anesthetic Cardiovascular effects +++ Urinary retention Increase length of stay syndrome of transient neurologic symptoms (TNS) You have to choose the smallest efficient dose!

23 Choice of local anesthetic : Duration 7,5 mg 144±55 10 mg 194±51 15 mg 343±113 < T10 5 mg 123±28 Pain requiring treatment 27% 60 mg 132±34 < T10 50 mg 128±38 40 mg 110±35 Pain requiring treatment 13% < T10 < T10 < T10 40 mg 85±24 30 mg 60±14 50 mg 97±27 Pain requiring treatment 33% Except too short duration 20% Pain requiring treatment 50% Except too short duration 13% Ben David Anesth Analg 1996 Hampl Anesthesiology 1998 Camponovo Anesth Analg 2010 Casati Anesth Analg 2006 Sensory block duration

24 Choice of local anesthetic : Baricity

25 Horizontal position, dorsal decubitus Isobaric solution less extension longest duration Hyperbaric solution longeest extension, less duration Covino BG, Scott DB, Lambert DH. Handbook of Spinal Anaesthesia and Analgesia. Medi Globe. ISBN pp

26 Spinal Anatomy : CSF Density of local anesthetic is increased by glucose Adjuvants reduce density of local anesthetic Temperature modify baricity Negative correlation between temperature and density

27 We control

28 We can take into account

29 We can take into account! n = 129 Motor block Chen M et coll. Anesth Analg 2014;118:863-8

30 We can take into account! Lumbosacral cerebrospinal fluid volume : Adult : 40 ± 10 ml It s reduced by : Obesity Spinal stenosis Pregnancy Abdominal compression Sullivan Anesth Analg 2006

31 We can take into account! During pregnancy Volume variation => 16,7±0,8 % Probably related to epidural venous distention Avant la grossesse 34 semaines Onuki Anesth analg ,2 cm 2 2,0 cm 2

32 We undergo

33 We undergo! Photo JP Estebe Tarlov cysts Not exceptional cause of failure Some suggest that it s an argument for systematic MRI in case of unexplained failure. Popham BJA 2009

34 We undergo!

35 We undergo! Baricity = CSF density / solution density : Plain bupivacaïne 15mg R²= 0,37

36

37 Conclusions Spinal anethesia is a highly technical procedure Too trivialized! Rigourous procedure But 100 % of success Correct rate choice and dose is an unlikely Graal! of LA