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Regional anaesthesiaRegional anaesthesia is anaesthesia affecting only a large part ofthe body, such as a limb or the lower half of the body. Regionalanaesthetic techniques can be divided into central and peripheraltechniques.The central techniques include so called neuraxial blockade(epidural anaesthesia, spinal anaesthesia). The peripheral techniquescan be further divided into plexus blocks such as brachial plexusblocks, and single nerve blocks.Regional anaesthesia may be performed as a single shot or with acontinuous catheter through which medication is given over aprolonged period, e.g. continuous peripheral nerve block.Regional anaesthesia can be provided by injecting local anaestheticsdirectly into the veins of an arm, i.e. intravenous regionaltechniques
Regional anaesthesia...Neck Surgeries, which can be performed under regional anaesthesia…-Carotid Artery Surgeries, including endarterectomy-Percutenous Carotid Baloon Angioplasty-Thyroidectomy-Parathyroidectomy-Excision of thyroglossal and branchial cysts and thyroglossal fistula-Radical Neck Dissection-Cervical Node Biopsy-Stenomastoid release for torticolis-Chemodectoma-Tracheostomy and repair-Laryngectomy-Superficial Neck Procedures-Plastic repairs on the neck-Plastic procedure like liposuction, platysmoplasty etc.
Interesting FactTait and Caglieri suggested the use of cervical intrathecalinjections for operating on the upper extremities and neck.A. W. Morton reported success with total spinal anesthesiaafter lumbar puncture for operations on all parts of the body.Thomas Jonnesco reported no adverse effects from 398spinal anesthetics administered between vertebrae at thethoracic and lumbar levels with a novocaine and strychninemixture. Jonnesco called the method General SpinalAnesthesia.
IntroductionUses Of Regional Anaesthesia in Neck Surgeries...-Post operative analgesia-Operative analgesia with GA-Operative anaesthesia.
Advantages Of Regional Anaesthesia Over GA- Patient remains conscious- Maintain airway- Aspiration unlikely- Earlier recovery of bowel function- Reduction in surgical stress because of better intraopanalgesia- Reduced opioid requirements, so low incidence of PONV- Smooth recovery requiring less skilled nursing care- Postoperative analgesia- Earlier discharge for outpatientsIntroduction...
- Less expensive- Patients unfit for GA can be operated if emergency is expected.- Reduced intra-operative blood loss.- Decreased chances DVT- Decreased metabolic changes, ie. for severe respiratory impairment.- Excellent muscle relaxation.- Avoidance of rare complications like malignant hyperthermiaIntroduction...
Introduction...Disadvantages of RA compared to GA- Patient may prefer to be asleep- Practice and skill is required for the best results- Some blocks require up to 30 minutes or more to be fullyeffective- Analgesia may not always be totally effective - patient mayrequire additional analgesics, IV sedation, or a light generalanesthetic( this will blunten the advantages of RA)- Toxicity may occur if the local anesthetic is givenintravenously or if an overdose is injected- Patient discomfort from long operation- Patient discomfort during eliciting paresthesia- Contraindicated in confused patients.- Potential for nerve damage(although rare)- Some operations are unsuitable for regional anesthetics.
Advantages of GA over Regional- A patent airway may be assured.- Adequate oxygenation possible.-Cardiovascular effects are usually titrable.-Familiarity for most anaesthesists.-Patient preference.Disadvantages of GA compared to RA- Higher prevalence of cardiovascular depression.- Depressed protective reflexes- Prolonged psychomotor impairment- Possibility of inadvertent awareness during the surgery- PONV, headache etc.Introduction...
Introduction...Specific advantages of Regional Anesthesia of Neck..-Identification of intra-operative laryngeal nerve injurySpecific disadvantages of Regional Anesthesia of Neck..- Intraoperatively Airway manipulation if required may be moredifficult than Preoperative manipulation.- Incase of tracheal injury, aspiration of the blood and secretions- Inadvertent Stellate Ganglion Block- Injury to important surrounding structures, like vessels andnerves.- Effects on heart rate and hemodynamic stability- Cardiacsympathectomy, which in turn depresses phasic and tonic dynamicmodulation of the cardiac cycle. Therefore, causing hypotensionand bradycardia
Relevant AnatomyThe Cervical Plexus..The anterior rami of the upper four cervical nerves unite bya series of loops to form the cervical plexus, whosefunction is the supply of the skin and muscles of the neckand the innervation of the diaphragm.Formation of the plexusThe loops are three in number,C1–2, C2–3 and C3–4,with a further loop (C4–5) oftenpresent to connect the cervicalplexus with the brachial plexus.They lie on the scalenus mediusand legato scapulae muscles underthe cover of the sternocleidomastoidmuscle.
BranchesThe branches of the cervical plexus can be divided into fourgroups.1 Communicating branches, which pass to the hypoglossalnerve, to the vagus and to the cervical sympathetic chain.2 Superficial branches, which supply cutaneous fibres to theneck.3 Deep branches, to the neck muscles.4 The phrenic nerve.Relevant Anatomy...
Relevant Anatomy...The superficial cervical plexusInnervates the skin of the anterolateral neck throughanterior primary rami of C2 through C4.Individual nerves emerge as four distinct nerves from theposterior border of the sternocleidomastoid muscle.The lesser occipital nerve usually is a direct branch fromthe main stem of the second cervical nerve. The largerremaining part of this stem then unites with a part of thethird cervical nerve to form a trunk that arises as the greaterauricular and the transverse cervical nerves.
Superficial Cervical Plexus BanchesAscending BranchesOccipitalis majorAuricularis magnusSuperficialis colliPhrenicSuprasternalDescendingBranchesSupraclavicularSupra-acromialRelevant Anatomy...Another part of the third cervical nerve runs downward to unitewith a major part of the fourth to form a supraclaviculartrunk, which then divides into the three groups of supraclavicularnerves.The supraclavicular nerves (C3, 4),on careful palpation, can be rolledover the subcutaneous anteriorborder of the clavicle.
Relevant Anatomy...The deep cervical plexusThis supplies the anterior vertebral muscles, i.e. the recticapitis, longus capitis and longus cervicis, as well as givingcontributions to scalenus medius (main innervation from rootsof branchial plexus).In addition, branches pass to levator scapulae (C3, 4) and totwo muscles whose principal innervation is from the spinalaccessory nerve: sternocleidomastoid (C2, 3) and trapezius(C3, 4).The fourth cervical nerve may send a branch downward tojoin the fifth cervical nerve and participate in the formation ofthe brachial plexus.
The superficial cervical plexus block.Distribution Of Anaesthesia..Skin of anterolateral neck.Position Of the Patient..The patient is in the supine orsemi-sitting position with thehead facing away from the sideto be blocked.Equipments required- Sterile towels and 4"x4" gauze packs- 20 mL syringe(s) with local anesthetic- Sterile gloves and marking pen- 1½ cm-long, 22-gauge, short bevel needle
The superficial cervical plexus block...Anatomic landmarksA line extending from the mastoid to C6 is drawn.The site of needle insertion is marked at the midpoint of the lineconnecting the mastoid process with Chassaignacs tubercle of C6transverse process.This is the location of thebranches of the superficialcervical plexus as theyemerge behind the posteriorborder of thesternocleidomastoid muscle.
The superficial cervical plexus block...After skin cleansing with an antiseptic solution, a skin wheel israised at the site of needle insertion using a 25-gauge needle.The needle is inserted perpendicularly just behind the posteriorborder of sternocleidomastoid. The needle depth be subcutenousand superficial to the deep cervical fascia.After negative blood aspiration, 5 mL of anaesthetic is injected.Two additional injections are made as the needle is directedsuperiorly and inferiorly at 30-45o.The most caudal injection usually blocks the supraclavicularnerves, while the most cephalic blocks greater auricular.This injection technique should be adequate to achieve blockadeof all four major branches of the superficial cervical plexus.
The superficial cervical plexus block...The goal of the injection is to infiltrate the local anestheticsubcutaneously and behind the sternocleido-mastoid muscle.Attention should be paid to avoid deep needle insertion.Paresthesia is occasionally elicited during needle insertion.However, paresthesia is nonspecific and should not be routinelysought.
The deep cervical plexus blockA deep cervical plexus block is essentially a paravertebral blockof the C2, C3, and C4 spinal nerves as they emerge from theforamina of the respective vertebrae.Blockade of the deep cervical plexus also results in the blockadeof the superficial cervical plexus.A deep cervical block is often accidentally accomplished when alarger volume of local anesthetic is used in the interscalenebrachial plexus block. The most common clinical use for this block includes a carotidendarterectomy and removal of cervical lymph nodes.
The deep cervical plexus block...Distribution Of Anaesthesia..The cutaneous innervation of both the deep andsuperficial cervical plexus blocks includes skin of theanterolateral neck and the ante- andretro-auricular areas.Positioning..The patient is in the supine or semi-sitting positionwith the head facing away from the side to be blocked.Materials required..• Sterile towels and 4"x4" gauze packs• 20-mL syringe with local anesthetic• Sterile gloves and marking pen• 1½" 25-gauge needle for skin infiltration• 1½ cm-long, 22-gauge, short bevel needle
The deep cervical plexus block...Anatomic LandmarksThe following three landmarks for a deep cervical plexus block areidentified and marked:1. Mastoid process2. Chassaignacs tubercle of C63. Posterior border of thesternocleidomastoid muscleThe anatomic landmarks for this block can be accentuated by askingthe patient to:- Lift the head up (tenses the sternocleidomastoid muscles)- Reach the knee with the hand on the ipsilateral side
The deep cervical plexus block...-A line is drawn connecting the mastoid process (MP) toChassaignacs tubercle of C6 transverse process.- Once this line is drawn, the insertion sites over the C2, C3, and C4are labeled some 2-cm, 4-cm, and 6-cm caudal from the mastoidprocess, respectively.-After cleaning the skin with an antiseptic solution, local anesthetic isinfiltrated subcutaneously alongside the line estimating the positionof the transverse processes
The deep cervical plexus block...-A needle connected to the syringe with local anesthetic is insertedbetween the palpating fingers and advanced at an angle perpendicularto the skin plane.The needle should never be oriented cephalad.A slight caudal orientation of the needle is thesingle best method to prevent the inadvertentinsertion of the needle toward the cervicalspinal cord.-The needle is advanced slowly until thetransverse process is contacted. At this point,the needle is withdrawn 1-2 mm, firmlystabilized, and 4 mL of local anesthetic is injected,after a negative aspiration test for blood. The needle is then removedand the entire procedure is repeated at the consecutive levels
The deep cervical plexus block...- Goal is contact with the posterior tubercle of the transverse process.The spinal nerves at the individual levels are located just in front ofthe transverse process.Failure to contact the transverse process on the first needle pass- Withdraw the needle to the skin, redirect it 15o inferiorly, and repeatthe procedure.- Withdraw the needle to the skin, reinsert the needle 1cm caudal, andrepeat the above procedure.
The cervical plexus blocks...- The onset time for these blocks is 10-15 minutes. The first sign ofthe blockade is the decreased sensation in the area of the distributionof the respective components of the cervical plexus.- It should be noted that due to the complex arrangement of theneuronal coverage of the various layers in the neck area as well as thecross-coverage from the contralateral side, the anesthesia achievedwith cervical plexus block is rarely complete.- While this should not be discouraging from the use of cervicalplexus block, its use does require an understanding surgeon who iswilling to supplement the block with the local anesthetic asnecessary.- Carotid surgery also requires blockade of the glossopharyngealnerve branches. This is easily accomplished intraoperatively byinjecting the local anesthetic inside the carotid artery sheath
The cervical plexus blocks...- Although the placement of deep cervical block may be associatedwith moderate patient discomfort, excessive sedation should beavoided.- During neck surgery the airway management may be difficult dueto the shared access to the head and neck with the surgeon.--Surgeries like carotid endarterectomy require that the patient befully conscious, oriented and cooperative during the entire surgicalprocedure.- A subcutaneous midline injection of the local anesthetic extendingfrom the thyroid cartilage distally to the suprasternal notch will blockthe branches crossing from the opposite side. This injection can beconsidered as a "field" block.
Local AnalgesicsOnset (min) Anesthesia (hrs) Analgesia (hrs)2% Lidocaine(+HCO3; +epinephrene)10-15 2-3 3-60.5% Ropivacaine 10-20 3-4 4-100.25% Bupivacaine(+ epinephrene)10-20 3-4 4-10- A superficial cervical plexus block requires 10-15 mL of localanesthetic (3-5 mL per each redirection/ injection). Most patientsbenefit from the use of a long-acting local anesthetic.- A deep cervical plexus block requires 3-5 mL of local anestheticper level to ensure reliable blockade. Except perhaps with patientswith significant respiratory disease (blockade of the phrenic nerve),most patients benefit from the use of a long-acting local anesthetic
InfectionLow riskA strict aseptic technique is usedHematomaAvoid multiple needle insertions, particularly in anticoagulated patientsKeep a 5 minute steady pressure on the site when the carotid artery is inadvertenlypuncturedPhrenic Nerve BlockadePhrenic nerve blockade (diaphragmatic paresis) invariably occurs with a deep cervicalplexus blockA deep cervical plexus block should be carefully considered in patients with significantrespiratory diseaseBilateral deep cervical block in such patients may be considered contraindicatedBlockade of the phrenic nerve does not occur after superficial cervical plexus blockLocal anesthetic toxicityCentral nervous system toxicity is the most serious consequence of the cervical plexusblock. This complication occurs because of the rich vascularity of the neck, includingvertebral and carotid artery vessels; it is usually caused by an inadvertent intravscularinjection of local anesthetic rather then absorbtionCareful and frequent aspiration should be performed during the injectionNerve injuryLocal anesthetic should never be injected against resistance or when the patient complainsof severe pain on injectionSpinal anesthesiaThis complication may occur with injection of a larger volume of local anesthetic insidethe dural sleeve that accompanies the nerves of the cervical plexusIt should be noted that a negative aspiration test for CSF does not rule out the possibilityof intrathecal spread of local anestheticAvoidance of high volume and pressure during injection are the best measures to avoidthis complication
Cervical Epidural Anaesthesia-Epidural anesthesia has been traditionally limited to proceduresinvolving the lower limbs, pelvis, perineum, and lower abdomen.-As clinicians have become more experienced with itsapplication, epidural anesthesia with or without sedation has beenused as the sole anesthetic or in combination with general anesthesiafor a larger variety of cases.- Dogliotti in 1933 was the first to describe cervical epiduralanesthesia. #- Bonica et al described a series of cases in which cervical epiduralanesthesia was used for surgery of the upper extremities.###Dogliotti AM: A new method of block anesthesia, regimental procedural anesthesia. Amer J Surg (1933); 20 : 107## Bonica JJ, Backup PH, Anderson CE, Hadfield D, Crepps WR, Monk BF: Peridural block: Analysis of 3, 637 casesand a review. Anaesthesiology (1957) 18:719
Cervical Epidural Anaesthesia...-Ciocatto discussed the technique of continuous epidural block forthe control of severe pain due to metastatic carcinoma of thecervical spine or disc extrusion.#-Michalek reported the use of cervical epidural anesthesia at the C6–7 level for a total parathyroidectomy with parathyroid glandimplantation into the forearm. He concluded that combinedprocedures involving the neck and upper limbs could be safelyconducted under cervical epidural blockade. ##-Several studies have described the use of high thoracic epiduralanesthesia for off-pump coronary revascularization and even forminimally invasive aortic valve replacement.#Ciocatto E: The management of pain, Int. Anesth. Clin. (1964); 2:3##Anesth Analg. 2004 Dec;99(6):1833-6, table of contents.
Cervical Epidural Anaesthesia...- In patients in whom general anesthesia could lead to prolongedventilatory care, such as those with diffuse interstitial lungdisease, thoracic epidural anesthesia as the sole anesthetic has beendescribed as a successful alternative.- Although it is intriguing to realize that epidural blockade can beperformed for procedures that in the past were limited to generalanesthesia, the decision about whether to use this form of neuraxialblockade should be determined by the needs of the patient.- Physiologically, blocks above T5 have a far greater effect onpatient hemodynamics than blocks at T10 or lower. However, ifthe benefits of epidural blockade outweigh the risks to thepatient, and the sensory blockade needed for the particular procedurecan be obtained, then it is indicated.
Cervical Epidural Anaesthesia...- The epidural space is smaller than the subarachnoid space, extendsfrom the base of the skull to the sacral hiatus, and surrounds the duramater anteriorly, laterally, and posteriorly. The epidural space isbound posteriorly by the ligamentum flavum and laterally by thepedicles and the intervertebral foramina. It is a space filled with thefat, areolar tissue, lymphatics, veins, and nerve roots that traverseit, but no free fluid. The volume of fat is greater in obese individualsand less in the elderly.1. Anterior epidural space,2. Posterior epidural space,3. Ligamentum flavum,4. Blood vessels in the epidural space,5. Pedicles, 6. Nerve roots,7. Transverse process,8. Vertebral body, 9. Spinal cord
Cervical Epidural Anaesthesia...-The interlaminal space at C6 and C7 is slit-like but easily accesiblewhen the neck is flexed.The ligamenta flavum in the cervical spine is thinner than at otherlevels, the epidural space is more concentric with the laminae anddura with a distance varying from 3-4 mm at the mid-sagittal point.This interval can be increased to about 5-6 mm with forward neckflexion.-Epidural puncture in the cervical region is therefore technicallysimpler than THORACIC ENTRY because of the prominence of the6th and 7th spinous processes and the amount of widening thatoccurs in the interlaminal spaces with flexion as opposed to theinterlaminal spaces in the thoracic region where there is practicallyno increase in size with anteroposterior movement.
Cervical Epidural Anaesthesia...-Because of the increased negative pressure in the thoracicregion, cephalad movement of any injected fluid will be impeded bythe natural tendency for it to move towards the area of greaternegativity. Placing the patient in a steep Trendelenburg position willfacilitate cephalad movement of the local anesthetic.-The subatmospheric pressure in the cervical epidural space isexaggerated by forward flexion, particularly when the patient issitting.-Either a median or a paramedian approach may be used. Advantagesof the paramedian approach over the midline approach are-much greater ease with which it is possible to insert an epiduralcatheter, and-the lowered risk of accidental dural puncture.
Cervical Epidural Anaesthesia...Choice of Anesthetic AgentThe choice of anesthetic will depend on the duration required. Incervical regions, duration of epidural anesthesia is approximately 15% shorter than expected from an equivalent dose in the lumbarregion.The volume of local anesthetic required to block all the cervical andupper 4-5 dermatomes is 8-12 ml. An initial dose of 8 ml isrecommended. If this is inadequate, then an additional 12 ml shouldbe administered after waiting 30 minutes.The concentration of local anesthetic will depend on whether a fullmotor block, sensory analgesia or sympathetic block is required.
Cervical Epidural Anaesthesia...Complications-Because of the size of needle, accidental dural puncture will almostinvariably result in a severe spinal headache.- Accidental puncture of an epidural vein will be revealed by a testdose containing 1:200,000 (5 mcg/ml) of adrenaline.- Neural injury from either catheter or needle is possible.- Epidural hematoma, although extremely rare, is always a possibilityand while it is known to occur spontaneously.-Epidural abscess may be associated with an in-dwelling epiduralcatheter but can occur after installation of steroid.-Although frequently anticipated, diaphragmatic paralysis is rarelyseen with cervical epidural anesthesia.It does seem however that the phrenic nerves are more resistant thanother segmental nerves to the Cm of local anesthetic agents.
Cervical Epidural Anaesthesia...Physiological effects block Above T4The cardiovascular effects of a block above T4 are the result of ahigh sympathetic block. The cardiac sympathetic fibers arise from T1to T4, and when blocked, profound hypotension and bradycardia canoccur.In addition to the cardiac effects, a high level of sympatheticblockade causes:Increased central venous pressure without an increase in strokevolumeVasoconstriction in the head, neck, and upper limbsSplanchnic nerve blockade with blockade of medullary secretionof catecholaminesBlockade of vasoconstrictive effect on the capacitance vessels ofthe lower limbs
Cervical Epidural Anaesthesia...-When a sympathetic block occurs at such a high level, thecardiovascular system may be left without its mechanisms forresponding to low cardiac output states. This can be detrimental to apatient with limited cardiac reserve because profound hypotensionwith bradycardia and decreased contractility can result.The anesthesiologist must be prepared to take over the control of thecirculatory system until the block subsides and the patient stabilizes.- Rarely, respiratory arrest during high epidural blockade has beenreported. The reported causes of rare instances of respiratory arrest isfrom the sympathetic block, leading to decreased cardiac output withsubsequent reduced blood flow to the brain.