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GeneralGeneral
v/sv/s
Spinal – EpiduralSpinal – Epidural
v/sv/s
Regional /Regional /
LocalLocal
Dr. Prakash Ambardekar
Sen...
 Estimated population with diabetesEstimated population with diabetes
mellitus in this country is about 32 million.mellit...
Diabetes Mellitus is not a simple endocrine
disorder
PATHOLOGICAL PROCESS AFFECTING PHYSIOLOGICAL PROCESS
IN TURN AFFECTIN...
2] Reno-vascular system - Nephropathies leading
to Chronic renal failure
- Pt. on DIALYSIS
Significance - Identify pts. Wi...
5] Immunological system - suppression
- prone to infections
6] Septicaemia - following infection affecting various
systems...
9] G. I. system - slows gastric emptying
- altered tone of G-O sphincter
- aspiration
10] Skeleto-muscular system
- stiff ...
Special Problems
1] Aseptic technique is critical for all procedures in patients with
DM to decrease the incidence of post...
5] Fortunately, intensive glycemic control has been shown5] Fortunately, intensive glycemic control has been shown
to have...
RISK FACTORS DURING ANAESTHESIA
1] MALE / FEMALE – CARDIAC AFFECTION FOR CHD
2] CARDIAC AUTONOMIC NEUROPATHY
3] RENAL INVO...
CHOICE OF ANAESTHESIACHOICE OF ANAESTHESIA
SELECTION :SELECTION :
1] General Anaesthesia1] General Anaesthesia
2] Regional...
General Anaesthesia : Indications
1] Any Pt. on VENTILATOR
2] Any Pt. Hypersensitive to L. A. Agent
3] REFUSAL from Pt.
4]...
General Anesthesia: [besides usual precautions]
a] Risk of Aspiration and PONV
b] Difficult intubations
c] Resistant hypot...
Spinal & Epidural Anaesthesia
a] Prevention and management of hypotension
b] Cannot be repeated frequently
[ except in con...
Why regional anaesthesia ?
1] Ideal for day-care patients
2] Safety in high risk patients
3] No intra-op regurgitation & a...
Why regional anaesthesia ? Continued….
6] Minimal effects on vital parameters
7] Safer in emergency situations
8] Can be r...
STRESS RELIEFSTRESS RELIEF
Patients, coming to O. T., despite Good CounselingPatients, coming to O. T., despite Good Couns...
Limitations
1] Surgical time limit is between
1-3 hrs.
2] Patient’s co-operation is must
3] Failure or partially acted blo...
StatisticsStatistics
Total No. of PATIENTS - 1757Total No. of PATIENTS - 1757
No. RECEIVED Leg Blocks - 1400 [ 79.68% ]No....
Pre-block preparation
Besides usual instructions….
Application of elastocrepe bandage
2-3 days prior to surgery
Advantages...
Pre-block preparation
Counseling the patient regarding the
procedure and the expectation from
the patient (compliance and ...
Lower leg block or modified ankle block
Deep peroneal nerve – can be
blocked by injecting
subcutaneously
3-5 mm along the ...
Lower leg block or modified ankle block
Post. Tibial nerve –
Blocked by injecting
3-5 ml 2% xylocaine
at the junction of p...
Sural nerve
Inject 2% xylocaine
between the tendoachilles
and the calcaneaum on
the lateral aspect
Lower leg block or modi...
Ring block –
0.5 % xylocaine around the
leg to block cutaneous nerves
Lower leg block or modified ankle block
Calcaneal nerve block
2 Finger breadths
proximal to the
medial malleolus
Inject along the
direction of the nerve
Lower leg...
Mid leg block
Anterior Tibial nerve
Inject 2- 4 ml 2% xylocaine
subcutaneously 5-7 mm
along the lateral border of
the shin
Mid leg block
Posterior Tibial Nerve
Spinal needle no 23 G is inserted from the lateral side
of the leg over the ant. bord...
Mid leg block
Sural nerve
Inject 2 – 3 ml 2% xylocaine
along a line extended proximally
tangential to the lateral border
o...
Ring block
0.5 % xylocaine around the
leg to block cutaneous
nerves
Mid leg block
High leg block
Anterior Tibial nerve
Inject 3-4 ml 2% xylocaine
5-10 mm deep lateral to the
upper end of shin
High leg block
Posterior Tibial nerve
2-4cm below the neck of the fibula
Lateral approach –
Spinal needle no 23 G is passe...
Lateral Popliteal Nerve
2- 4 ml 2% xylocaine
injected around the
neck of fibula
High leg block
Ring block
0.5 % xylocaine around the
leg to block cutaneous
nerves
High leg block
If patient has a pain-free leg,
then one may give sciatic nerve
block in the lower third of thigh alongwith
lat. Popliteal...
CONCLUSIONCONCLUSION
1] EVALUATE THE PATIENT1] EVALUATE THE PATIENT IN TOTO.IN TOTO.
2] COUNSEL THE PATIENT & THE RELATIVE...
Practice regularly
Your patience
The surgeons’ patience
The patients’ patience!
Steps to success with local blocks
Patient...
In Diabetic FootIn Diabetic Foot
Blocks are the way toBlocks are the way to
the goal !!the goal !!
1362564357 general vs spinal vs regional
1362564357 general vs spinal vs regional
1362564357 general vs spinal vs regional
1362564357 general vs spinal vs regional
1362564357 general vs spinal vs regional
1362564357 general vs spinal vs regional
1362564357 general vs spinal vs regional
1362564357 general vs spinal vs regional
1362564357 general vs spinal vs regional
1362564357 general vs spinal vs regional
1362564357 general vs spinal vs regional
1362564357 general vs spinal vs regional
1362564357 general vs spinal vs regional
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1362564357 general vs spinal vs regional

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general vs spinal vs regional

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1362564357 general vs spinal vs regional

  1. 1. GeneralGeneral v/sv/s Spinal – EpiduralSpinal – Epidural v/sv/s Regional /Regional / LocalLocal Dr. Prakash Ambardekar Senior Anaesthesiologist Dept of Anesthesia
  2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 20. Pre-block preparation Counseling the patient regarding the procedure and the expectation from the patient (compliance and accurate replies regarding paresthesia)
  21. 21. 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
  22. 22. 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.
  23. 23. Sural nerve Inject 2% xylocaine between the tendoachilles and the calcaneaum on the lateral aspect Lower leg block or modified ankle block
  24. 24. Ring block – 0.5 % xylocaine around the leg to block cutaneous nerves Lower leg block or modified ankle block
  25. 25. 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
  26. 26. Mid leg block Anterior Tibial nerve Inject 2- 4 ml 2% xylocaine subcutaneously 5-7 mm along the lateral border of the shin
  27. 27. 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
  28. 28. 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
  29. 29. Ring block 0.5 % xylocaine around the leg to block cutaneous nerves Mid leg block
  30. 30. High leg block Anterior Tibial nerve Inject 3-4 ml 2% xylocaine 5-10 mm deep lateral to the upper end of shin
  31. 31. 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.
  32. 32. Lateral Popliteal Nerve 2- 4 ml 2% xylocaine injected around the neck of fibula High leg block
  33. 33. Ring block 0.5 % xylocaine around the leg to block cutaneous nerves High leg block
  34. 34. 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 -
  35. 35. 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.
  36. 36. 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!!
  37. 37. In Diabetic FootIn Diabetic Foot Blocks are the way toBlocks are the way to the goal !!the goal !!

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