CONTINUOUS SPINAL. Prof. Dr. Armando Fortuna, TSA

Transcription

1 CONTINUOUS SPINAL Prof. Dr. Armando Fortuna, TSA

2 CONTINUOUS SPINAL History: Dean, 1907, needle. Lemmon, 1940, malleable needle. Tuohy, 1944, Rubber Uretheral catheter, 15G needle. Hingson and al: polyethylene, later vinyl, nylon. Needles 16, 17, and finally, 18G, Tuohy or Crawford. 80 s: micro catheters, 32 e 28, abandoned in 91 (FDA).

3 CONTINUOUS SPINAL

4 CONTINUOUS SPINAL

5 CSA - INDICATION: (1/2) Individuals over 60 years (none or minimum incidence of PSPH: post spinal puncture headache) Poor risk cases: Especially over 60 years of age Surgery below T10, in patients over 60 years, in the following conditions: Procedures scheduled for over 2 hours Classified with risk equal or over ASA III, not counting the duration of surgery CSA = Precise doses. Emergency surgery, full stomach (over 60) Long duration Intervention. Consider awake intubation Patients with metabolic problems: diabetes, kidney insufficiency and hepatic disease.

6 CSA - INDICATION: (2/2) Upper Abdomen - procedure below T4: stomach, intestines, spleen, liver, gyn, urological or vascular interventions. Some demand Narcoanalgesia. Perineum and lower limbs, especially orthopedics, hip and femur prosthesis Patients under 60 years, ASA III or higher, where the benefits surpass the risks (hypotension, post-dural puncture headache, etc). CSA as a Combined Method: (GA complementation) Intra or extra abdominal surgery, below T10, long duration at uncomfortable decubitus (Sedation, Narcoanalgesia) Intra-abdominal surgery over T10, in any duration, it is a must

7 CSA CONTRAINDICATION: Patient refusal Diseases of the CNS Cardio-vascular instability (shock, hypovolemia, dehydration) Chronic Back Pain (risk of exacerbation, malpractice), Skin and tissue infection at the puncture level Abnormality of Blood Clotting Mechanisms use of anticoagulants drugs Gross spinal deviations (relative) Lack of experience with the CSA technique Lack of standard resuscitation equipment Poor aseptic technique. LA ampoules not sterilized

8 CSA - TECHNIQUE (1/7) a) Basic care before the procedure: Monitoring of Vital Signs - Monitors on: Oximeter, Cardioscope. Vital Signs Noted. Precordial stethoscope. Thermometer. Automatic blood pressure device. Two venous lines/arterial line, poor risk. 500 to ml preload infusion, Ringer 1/6M. Routine use of O 2 in all procedures (face mask, endotracheal tube)

9 CSA - TECHNIQUE (2/7) b) For the Block: 1) Needle: Tuohy or its modification (Halstead), 18G or 19G. TAYLOR Technique: longer Tuohy needle 2) Puncture: lateral or sitting - L3-L4, L4-L5, L5-S1 (Taylor). 3) Type of catheter: 20 or 21G, nylon, without guide 4) Orientation: cephalic, threaded up to 2 cm in the subdural space 5) Continuous epidural kits are satisfactory

10 CSA - TECHNIQUE (3/7) 6) Local Anesthetic: isobaric bupivacaine 0,5% (recent with good results) lidocaine at 2%: dilute 5% hyperbaric lidocaine (7,5% glucose), in CFS 7) Dorsal decubitus - 0,5% isobaric bupivacaine, 2,5 to 5 mg through the spinal catheter 3-5 min: evaluate spread and autonomic block: If BP falls about 40 mmhg systolic: Metaraminol 0,5 to 1 mg I.V. (bradycardia) Ephedrine 5 to 10 mg. Phenylephrine 10 mg in 250 ml of Ringer (tachycardia)

11 CSA - TECHNIQUE (4/7) c) Maintenance: Interval between injections: # 90 min (bupivacaine) Increases in BP, muscular tonus or signs of discomfort, are indications for a further dose of the agent 1) Sedation: 0 2 by face mask (50%) Fentanyl (10 a 20 mcg) Midazolam ( 0,75 to 1,5 mg IV)

12 CSA - TECHNIQUE (4/7) 2) Narcoanalgesia: IV Induction (Thiopental, Ketamine, Propofol) plus succylcholine to facilitate endotracheal intubation, 2 or 3 min. after the block. Awake intubation in high risk cases (topical + transtraqueal) Traqueal Intubation: procedures expected to last over two hours or for the ones requiring uncomfortable decubitus, upper abdominal procedures or emergency Controlled Ventilation: Intra abdominal procedures or at decubitus that impairs spontaneous ventilation. Low doses of muscular relaxants to help setting the patient, if necessary Even for short cases, when in doubt about the airway patency or ventilation, Intubation or LM is a must. LM - Laryngeal Mask in selected cases (empty stomach, with no other contraindication for its use)

13 CSA - TECHNIQUE (5/7) Maintenance with N 2 0/0 2, reinforced by low concentration of halogenated agent, associated to opioids or Midazolam, when necessary Controled Ventilation should be stopped 15 to 20 minutes before the end of the surgery. Anesthetic agents, except N 2 0 interrupted at this point Hypotension: vasopressors immediately Bradycardia: ephedrine or atropine

14 CSA - TECHNIQUE (7/7) Extubation only with all laryngeal reflexes present Usually the patient is awake, up to 15 minutes after the surgery is over Careful control of BP with vasopressors and IV fluids in the PACU 0 2 by facial mask (Venturi type 50% ) Depending on the PACU facilities, consider injection of 5 micrograms of Sufentanyl or 100 to 200 micrograms of morphine, before taken out the catheter

15 CSA COMPLICATIONS (1/2) # PER-OPERATIVE: From the Sympathetic Blockade: hypotension, bradycardia Nausea and Vomiting (risk of aspiration) Possibility of hypoventilation (Intercostals nerve paralysis) Minor: Backache, Urinary Retention

16 CSA COMPLICATIONS (2/2) # POST-OPERATIVE: Neurologic Sequelae Risk of meningeal infections Headache (PSPH): very unusual in older age. Lombalgia: position at the table. Air cushion or pillow. Neurological sequela: rare Cauda equina: withdraw of the micro-catheters. (FDA 91) Hematomas extra or intradural.

17 CSA ADVANTAGES (1/2) Regional anesthesia tailored to the patient s needs: duration and for the needed metameres. Decrease of the surgical stress - Anoci-association (Crile 1914), Stress free anesthesia (Kehlet,H 1982) Less bleeding sympathetic block (Scott, 1969) Airway protection, Effective ventilation (Narcoanalgesia) Absence of toxic reactions to the local anesthetic (low dose). Avoids the mandatory use of muscular relaxants and its needed reversion. (Aitkenhead 1982) Awake and fast recovery, pain free.

18 CSA ADVANTAGES (2/2) Reduction of thromboembolism (Modig 1982) Conscience present, except when sedation or hypnosis are indicated. Sedation or Narcoanalgesia to avoid problems with uncomfortable position at the surgical table and fatigue due to the procedure duration. Careful of the sedation trap. Possibility of postoperative analgesia (filter), opioids or local anesthetics. Early ambulation and less incidence of embolism.

19 CSA - DISADVANTAGES Potential Hazards of Severe HYPOTENSION Postdural Puncture HEADACHE (young patients) Potential Hazards of NEUROLOGICAL SEQUELAE Potential Hazards of INFECTIONS More time consuming: two techniques required. Potential Hazards of INTRA or EXTRADURAL BLEEDING in patients receiving anti-coagulant medication. Special attention to low molecular heparin May need SUPPLEMENTATION: NARCOANALGESIA (specially in mid-upper abdominal procedures)

20 CSA - RESULTS 1. No deaths due exclusively to this technique in over cases (820 + recent cases) in our Anesthesia Department 2. No severe headaches in patients over Blood transfusions cut by 1/3. 4. Fast recovery, with the patient alert and with no mental impairment.

21 CONTINUOUS SPINAL Local Anesthetic: Tetracaine 0,5% Distr. in 820 cases Lidocaine 2 to 3,3% Bupivacaine 0,5% % Tetra Lidoc Bupi - 9% - 90% - 1% 0 patients

22 CONTINUOUS SPINAL Intercurrences: (in 820 cases) 54% 12% 34% Hypotension (systolic) Use of Vasopressor 66% < > 50 mmhg Bradicardia (below 50 bpm) % 2% %

23 CONTINUOUS SPINAL Associated Methods to CSA: (820 cases) # NONE (CSA as a single technique) [ 33%] # INTRAVENOUS (sedation) [ 11%] # INHALATION: [ 56%] Endotracheal tube ( 89%) Awake Intubation ( 2%) Facial Mask ( 4%) Laryngeal Mask ( 5%) * MECHANICAL Ventilation [ 85%] assisted/controlled ( 76%) low doses muscle relaxant to facilitate controlled ventilation ( 24%) * SPONTANEOUS Ventilation [ 15%]

24 Dr. ZHEN-GANG ZHAN 5034 Pediatric Epidurals World Congress HAIA 1992 BEIJIN, CHINA

25 Spinals in Children Wilms tumor: 2yrs old girl Spinal (tetracaine 3mg) Narcoanalgesia (Intub)

26 Spinals in Children Direct approach

27 Difficult Punction: The TAYLOR Approach

28 The TAYLOR Approach (L5/S1)

29 The TAYLOR Approach (L5/S1)

30 CSA Hip Replacement 85yr (1986)

31 SANTOS BRAZIL