Continuous Spinal Anaesthesia

Transcription

1 Continuous Spinal Anaesthesia Ph. Biboulet Department of Anesthesiology and Critical Care Medicine, Lapeyronie University Hospital, Montpellier France

2 CSA story : 1906 Dean 1944 Tuohy 1991 CSA revisited catheter in the subarachnoid space

3 Catheter in the subarachnoid space 1- Reinjection of LA during maintenance : «continuous spinal anesthesia» 2- Titration of LA during induction : «titrated spinal anesthesia»

4 The spinal anesthesia limit Interdependance between : LA dose Hemodynamic Duration of anesthesia Spread of anesthesia

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6 The subarachnoid catheter release the interdependance between dose / level / duration LA dose Hemodynamic Duration of anesthesia Spread of anesthesia

7 The indications of CSA are the indications of spinal anesthesia in elderly patients with severe comorbidities.

8 CSA vs Single shot spinal anesthesia SDSA : mg bupi hyperbare CSA : 5 mg bupi hyperbare Favarel - Garrigues et al. Anesth Analg 1996 ; 82:312-6

9 CSA vs Single shot spinal anesthesia Favarel - Garrigues et al. Anesth Analg 1996 ; 82:312-6

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16 Spinal Sonography 1. Puncture level L5 2. Needle direction Articular process 3. Depth of the dura mater Dura mater

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19 Pencil point needle 18 gauge, multi-holed catheter 23 gauge

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23 Cephalad direction, 2 cm maximum

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26 Feasibility of CSA in a University Hospital 100 CSA 94 success 6 «failures» N of attempts 1 or 2 3 or more 64 % 36 % Time to punction ( sec ) N of catheterization 1 or 2 3 or more Time to catheter insertion ( sec ) 140 [ ] 79 % 21 % 84 [ ] Van Gessel et al. Anesth Analg 1995;80:880-5

27 CSA vs epidural anesthesia in elderly patients CSA n = 457 CEA n = 274 Age (years ) 82 +/ /- 6 * ASA 3 and ( 76 % ) 104 ( 38 %)* Failures 8 ( 1.7 % ) 25 ( 9 % )* GA before surgey GA during surgery Sutter et al Anaesthesia 1989; 44:47-50

28 CSA : 5 mg bupivacaine in supine position Patient number nombre de patients hypotension isobaric hyperbaric T 11 0 L5 L4 L3 L2 L1 T12 T11 T10 T9 T8 T7 T6 T5 T4 T3 T2 Reg Anesth 1993 ;18 :170-5 Sensory level niveau sensitif

29 Minville V. et al. Anesth Analg 2006; 102 :

30 MLAD :1.25 mg ED 95 : 2.15 ± 1.95 mg (0,43 ml)

31 CSA : 5 mg bupivacaine in supine position Patient number nombre de patients isobaric hyperbaric L5 L4 L3 L2 L1 T12 T11 T10 T9 T8 T7 T6 T5 T4 T3 T2 Reg Anesth 1993 ;18 :170-5 Sensory level niveau sensitif

32 Maldistribution of LA in the CSF by sacral trapping cathéter Experimental study Rigler et al. Anesthesiology 1991 ; 75:684-92

33 Maldistribution of LA : caudal direction of the catheter L3 L4 L5 Biboulet et al. Anesthesiology 1998;88:

34 Maldistribution of LA : lumbar canal stenosis L1 L2 L3 L4 L5 Biboulet et al. Anesthesiology 1998;88:

35 Homogenous distribution of LA during CSA bupivacaine L3 catheter The catheter allows : - Titration of the minimal dose to reach the target sensory level - Reinjections of LA if necessary

36 Neurotoxicity of local anesthetics sensory deficit 70% 60% 50% 40% 30% 20% 10% 0% 5% Lidocaine HB 5% Lidocaine 0,75% Bupivacaine HB 0,5% Tetracaine HB 10% Glucose Saline Drasner et al. Anesthesiology 1994 ; 80: Sakura et al. Anesthesiology 1995 ; 82: Hashimoto et al. Reg Anesth 1998 ; 23:444-50

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38 Maldistribution treatment Hyperbaric solution + Trendelenburg postion Biboulet et al. Anesthesiology 1998 ; 88:

39 Maldistribution and patient postion : injection in lateral decubutus position Van Gessel et al. Anesth Analg 1993;76:1004-7

40 Maldistribution and patient position In lateral decubitus position the ventro dorsal curves of the spine does not affect the LA distribution.

41 CSA : catheter direction cranial horizontal caudal 20 gauge 4cm 28 gauge >4cm 28 gauge 3cm 71% 20% 9% (14%) 61% 8% 31% 28% 62% 10%* Quincke 40% 25% 35% Sprotte 60% 40% 0%* Standl et al. Can J Anaesth 1995;42:701-5 Standl et al. Br J Anaesth 1993;71:803-6

42 CSA and postdural puncture headache Age ( years ) PDPH Macrocathéter ( n = 476 ) 72 +/ ( 3.4 % ) Microcathéter ( n = 127 ) 29 +/ ( 33.1 % ) No treatment 6 ( 1.3 % ) 7 ( 5.5 % ) Caffeine 0 6 ( 4.7 % ) Blood patch 10 ( 2.1 % ) 31 ( 24.4 % ) Horlocker et al. Anesth Analg 1997 ; 84:

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44 Easy to perform High success rate Low onset time Sensory level control Duration control Maldistribution of LA Management of antithrombotic therapy Hemodynamic stability Respiratory stability

45 Take - home messages ü The indications of CSA are the indications of spinal anesthesia in elderly patients with severe comorbidities. ü The bupivacaine induction dose is 2.5 mg. ü If after 10 to 15 mg of bupivacaine you don t reach a thoracic level, you have to suspect a maldistribution. ü Prevention of maldistribution is easy : cephalad direction of the hole of the needle, and insert only 2 cm of the catheter.

46 Take - home messages ü Treatment of maldistribution is easy : inject a hyperbaric solution in a patient in trendelenburg position or an isobaric solution in a patient in lateral decubitus position. ü This is a safe and easy technique.