general vs spinal vs regional

1. GeneralGeneral
v/sv/s
Spinal – EpiduralSpinal – Epidural
v/sv/s
Regional /Regional /
LocalLocal
Dr. Prakash Ambardekar
Senior Anaesthesiologist
Dept of Anesthesia

2.  Estimated population with diabetesEstimated population with diabetes
mellitus in this country is about 32 million.mellitus in this country is about 32 million.
 15-20 % have foot problems15-20 % have foot problems
 30% have P. V. D.30% have P. V. D.
 Frequent CAUSE for hospitalisationFrequent CAUSE for hospitalisation
 One of the expensive complication ofOne of the expensive complication of
D.M.D.M.

3. Diabetes Mellitus is not a simple endocrine
disorder
PATHOLOGICAL PROCESS AFFECTING PHYSIOLOGICAL PROCESS
IN TURN AFFECTING VARIOUS END-ORGANS
1] Cardio-vascular system - Angina pectoris,
- silent small to massive Myocardial
Infarcts,
- varying degrees of cardiomyopathies,
- varying types of Conduction blocks etc
- may be accompanied with Hypertension.
- coronary heart disease four times more
common in male and five times more
common in women D M population
Significance - Detailed Pre-Op Evaluation
- Intense Peri-operative Monitoring

4. 2] Reno-vascular system - Nephropathies leading
to Chronic renal failure
- Pt. on DIALYSIS
Significance - Identify pts. With IMPENDING
RENAL FAILURE
- Correction of Electrolyte
Imbalance
- Correction Of Anaemia
3] Central nervous system - Secondary to Age Related
- Septicaemia
- Electrolyte Imbalance
4] Autonomic nervous system - Autonomic Imbalance
Significance - Varying degrees of
Hypotension
- Arrhythmias

5. 5] Immunological system - suppression
- prone to infections
6] Septicaemia - following infection affecting various
systems
7] Fluid & Electrolyte status - Hyponatraemia
- Hypokalaemia
- Hyperkalaemia
- Altered pH
8] Pulmonary system - altered ventilation and perfusion
- obesity
- A R D S

6. 9] G. I. system - slows gastric emptying
- altered tone of G-O sphincter
- aspiration
10] Skeleto-muscular system
- stiff joint syndrome
- prayer’s sign
- fusion of upper cervical
vertebrae with limited neck -
movement and “Palm test “
- obesity
- short neck.
Thus, in Diabetes, the selection of Anesthesia
becomes a tricky and highly skillful job.

7. Special Problems
1] Aseptic technique is critical for all procedures in patients with
DM to decrease the incidence of postoperative infection.
2] Surgical removal of infected tissue (ie amputation of
gangrenous limb, incision of abscess, etc) results in dramatic
reductions in Insulin requirement (and the danger of hypo-
glycaemia) postoperatively.
3] Prabha Adhikari, Abraham Abey [2004] - It is well known that D M
pts are at a greater risk of peri-operative mortality and morbidity
after a major surgery especially with the presence of coexisting
diseases.
4]4] David Rothenberg [2006] - Mortality rates in diabetic patientsMortality rates in diabetic patients
have been estimated to be up to 5 times greater than inhave been estimated to be up to 5 times greater than in
nondiabetic patients, often related to the end-organ damagenondiabetic patients, often related to the end-organ damage
caused by the disease.

8. 5] Fortunately, intensive glycemic control has been shown5] Fortunately, intensive glycemic control has been shown
to have a profound effect on reducing the incidence ofto have a profound effect on reducing the incidence of
many of these complications in a variety of surgicalmany of these complications in a variety of surgical
populations.populations.
6] O H G like sulfonylureas should be stopped pre-6] O H G like sulfonylureas should be stopped pre-
operatively asoperatively as
-can cause hypoglycemia-can cause hypoglycemia
-being associated with interfering with ischemic-being associated with interfering with ischemic
myocardial preconditioning and may increase risk of peri-myocardial preconditioning and may increase risk of peri-
operative myocardial ischemia and infarction.operative myocardial ischemia and infarction.
7] Patients taking metformin should be advised to7] Patients taking metformin should be advised to
discontinue this drug because of the risk of developingdiscontinue this drug because of the risk of developing
lactic acidosis.lactic acidosis.
8]8] Hyperglycaemia at the time of cerebral ischaemic insults
is associated with a poor outcome.

9. RISK FACTORS DURING ANAESTHESIA
1] MALE / FEMALE – CARDIAC AFFECTION FOR CHD
2] CARDIAC AUTONOMIC NEUROPATHY
3] RENAL INVOLVEMENT
4] GLYCEMIC CONTROL
5] ASSOCIATED MEDICAL DISEASES
6] SMOKING, OBESITY etc.

10. CHOICE OF ANAESTHESIACHOICE OF ANAESTHESIA
SELECTION :SELECTION :
1] General Anaesthesia1] General Anaesthesia
2] Regional Analgesia -2] Regional Analgesia - SpinalSpinal
- Epidural - one shot- Epidural - one shot
- continous- continous
- Nerve blocks in Thigh- Nerve blocks in Thigh
- sciatic- sciatic
- femoral- femoral
- Nerve blocks in Leg- Nerve blocks in Leg
- Ant. Tibial- Ant. Tibial
- Post. Tibial- Post. Tibial
- Lat. Popliteal- Lat. Popliteal
- Sural- Sural
- Field block- Field block

11. General Anaesthesia : Indications
1] Any Pt. on VENTILATOR
2] Any Pt. Hypersensitive to L. A. Agent
3] REFUSAL from Pt.
4] FAILURE of Regional Anaesthesia

12. General Anesthesia: [besides usual precautions]
a] Risk of Aspiration and PONV
b] Difficult intubations
c] Resistant hypotension which may last for longer time
d] Management of ischaemic changes and arrhythmias
e] Management of blood sugar

13. Spinal & Epidural Anaesthesia
a] Prevention and management of hypotension
b] Cannot be repeated frequently
[ except in continuous epidural analgesia ]
especially for small but painful procedures.

14. Why regional anaesthesia ?
1] Ideal for day-care patients
2] Safety in high risk patients
3] No intra-op regurgitation & aspiration
4] No PONV
5] Minimal alteration in drug schedule
-specially in diabetics

15. Why regional anaesthesia ? Continued….
6] Minimal effects on vital parameters
7] Safer in emergency situations
8] Can be repeated frequently
9] Conscious & arousable patient
at the end of the surgery
10] Reduction in morbidity & mortality

16. STRESS RELIEFSTRESS RELIEF
Patients, coming to O. T., despite Good CounselingPatients, coming to O. T., despite Good Counseling
May be pretty APPREHENSIVE.May be pretty APPREHENSIVE.
This can be managed byThis can be managed by
1] REASSURANCE - Verbal1] REASSURANCE - Verbal
2] REASSURANCE – Tactile2] REASSURANCE – Tactile
3] SEDATION – mild to moderate3] SEDATION – mild to moderate
4] REASSURANCE – under Light Sedation.4] REASSURANCE – under Light Sedation.

17. Limitations
1] Surgical time limit is between
1-3 hrs.
2] Patient’s co-operation is must
3] Failure or partially acted block

18. StatisticsStatistics
Total No. of PATIENTS - 1757Total No. of PATIENTS - 1757
No. RECEIVED Leg Blocks - 1400 [ 79.68% ]No. RECEIVED Leg Blocks - 1400 [ 79.68% ]
- Low Leg Block - 1109 [ 79.21% ]- Low Leg Block - 1109 [ 79.21% ]
- Mid Leg Block - 210 [ 15.00% ]- Mid Leg Block - 210 [ 15.00% ]
- High Leg Block - 84 [ 6.00% ]- High Leg Block - 84 [ 6.00% ]
Failure of the Block - 41 [ 2.93% ]Failure of the Block - 41 [ 2.93% ]
{ All were given TIVA or GA }{ All were given TIVA or GA }
No. did NOT RECEIVE Blocks - 357 [ 20.31%]No. did NOT RECEIVE Blocks - 357 [ 20.31%]
- Spinal - 123 [ 7.00%]- Spinal - 123 [ 7.00%]
- Epidural{one shot/cont.} - 122 [ 6.94%]- Epidural{one shot/cont.} - 122 [ 6.94%]
- General Anaesthesia - 112 [ 6.37%]- General Anaesthesia - 112 [ 6.37%]

19. Pre-block preparation
Besides usual instructions….
Application of elastocrepe bandage
2-3 days prior to surgery
Advantages :-
• limb becomes soft & supple
• reduced oedema , improved limb
circulation
• pH of tissue fluid alters
Success rate improves

20. Pre-block preparation
Counseling the patient regarding the
procedure and the expectation from
the patient (compliance and accurate
replies regarding paresthesia)

30. Lower leg block or modified ankle block
Deep peroneal nerve – can be
blocked by injecting
subcutaneously
3-5 mm along the lat border
of the shin with 2 ml 2%
xylocaine with 24 g 1.5 inch
needle

31. Lower leg block or modified ankle block
Post. Tibial nerve –
Blocked by injecting
3-5 ml 2% xylocaine
at the junction of proximal 1/3rd
with distal 2/3rd of medial
malleolus to calcaneum, where
normally pulsations of post.
Tibial artery is felt.

32. Sural nerve
Inject 2% xylocaine
between the tendoachilles
and the calcaneaum on
the lateral aspect
Lower leg block or modified ankle block

33. Ring block –
0.5 % xylocaine around the
leg to block cutaneous nerves
Lower leg block or modified ankle block

34. Calcaneal nerve block
2 Finger breadths
proximal to the
medial malleolus
Inject along the
direction of the nerve
Lower leg block or modified ankle block

37. Mid leg block
Anterior Tibial nerve
Inject 2- 4 ml 2% xylocaine
subcutaneously 5-7 mm
along the lateral border of
the shin

38. Mid leg block
Posterior Tibial Nerve
Spinal needle no 23 G is inserted from the lateral side
of the leg over the ant. border of fibula going medially
downwards just to slip the interosseous border of tibia ,
advance 1-2 mm & deposit 8-10 ml 2% xylocaine

39. Mid leg block
Sural nerve
Inject 2 – 3 ml 2% xylocaine
along a line extended proximally
tangential to the lateral border
of the tendo achilles

40. Ring block
0.5 % xylocaine around the
leg to block cutaneous
nerves
Mid leg block

43. High leg block
Anterior Tibial nerve
Inject 3-4 ml 2% xylocaine
5-10 mm deep lateral to the
upper end of shin

44. High leg block
Posterior Tibial nerve
2-4cm below the neck of the fibula
Lateral approach –
Spinal needle no 23 G is passed
from the lateral side of the leg over
the ant. border of fibula going
medially downwards just to slip the
interosseous border of tibia,
advance 1-2 mm & deposit 8-10 ml
2% xylocaine.

45. Lateral Popliteal Nerve
2- 4 ml 2% xylocaine
injected around the
neck of fibula
High leg block

46. Ring block
0.5 % xylocaine around the
leg to block cutaneous
nerves
High leg block

47. If patient has a pain-free leg,
then one may give sciatic nerve
block in the lower third of thigh alongwith
lat. Popliteal nerve block and ring block.
A) Posterior approach
B) Lateral approach
High leg block
An alternate technique -

48. CONCLUSIONCONCLUSION
1] EVALUATE THE PATIENT1] EVALUATE THE PATIENT IN TOTO.IN TOTO.
2] COUNSEL THE PATIENT & THE RELATIVES2] COUNSEL THE PATIENT & THE RELATIVES
3] PRACTICE WHAT YOU BELIEVE IS SAFE - -3] PRACTICE WHAT YOU BELIEVE IS SAFE - -
SAFE FOR YOU, YOUR PATIENT, YOUR TEAM.SAFE FOR YOU, YOUR PATIENT, YOUR TEAM.
4] ONCE YOU GET FAMILIAR WITH BLOCKS, YOU4] ONCE YOU GET FAMILIAR WITH BLOCKS, YOU
WILL FIND WIDER INDICATIONS AND GREATERWILL FIND WIDER INDICATIONS AND GREATER
SATISFACTION.SATISFACTION.

49. Practice regularly
Your patience
The surgeons’ patience
The patients’ patience!
Steps to success with local blocks
Patients’ comfort
The surgeons comfort
Your comfort
AND SAFETY!!

50. In Diabetic FootIn Diabetic Foot
Blocks are the way toBlocks are the way to
the goal !!the goal !!