new technique for pain management ,described by dr forero ,it can replace epidural anesthesia,paravertebral anesthesia and other regional blocks.it can be used for both acute and chronic painful conditions
new technique for pain management ,described by dr forero ,it can replace epidural anesthesia,paravertebral anesthesia and other regional blocks.it can be used for both acute and chronic painful conditions
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
In critical care medicine the invasive life saving techniques are often employed and when all goes well such interventions will be withdrawn to all for normal physiology to resume. Identifying this point for safe withdrawal for the resumption of normal respiratory function is of utmost importance.
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
In critical care medicine the invasive life saving techniques are often employed and when all goes well such interventions will be withdrawn to all for normal physiology to resume. Identifying this point for safe withdrawal for the resumption of normal respiratory function is of utmost importance.
Anaesthesia challenges in neonatal emergencies-1.pptxsouravdash24
Neonatal emergencies present unique challenges in anesthesia, requiring specialized knowledge and skills to ensure safe and effective care for these vulnerable patients. This presentation delves into the intricacies of providing anesthesia to neonates in emergency situations, discussing physiological differences, equipment considerations, medication dosages, and monitoring techniques tailored to this population. Explore essential strategies and best practices for managing airway, ventilation, and hemodynamic stability in neonatal emergencies, aiming to optimize outcomes and mitigate risks. Whether you're a seasoned anesthesiologist or a healthcare professional seeking insight into neonatal anesthesia, this presentation offers valuable insights into navigating the complexities of neonatal emergencies with confidence and expertise.
Anesthesia consideration in intestinal obstruction is gastric aspiration, rapid sequence induction, electrolyte and acid base disorder, hydration, AKI and hemodynamic status.
Hypothyroidism and hyperthyroidism have significant clinical effects. Both should be optimized. Anesthesia providers should be able to diagnose and manage.
Blood pressure optimization is important in pheochromocytoma patients before going to surgery. It is important for the anesthesia providers to diagnose, optimize and manage those patients..
Anesthetic management in Diabetic mellitusTenzin yoezer
Diabetic is a systemic disease. Preoperative assessment includes blood sugar control, involvement of systems, and types of medication. Intraoperative and postoperative management is also vital.
Describes coronary blood supply anatomy, myocardial oxygen demand and supply, and basic anesthesia consideration (history taking, special investigation, and optimization)
Scalp block is simple and easy to perform. It has the advantages of minimizing cardiovascular effects and decreasing intraoperative analgesia requirements.
New GCS, the GCS-P was adopted in 2018 by the same person who proposed GCS. It gives better prognosticate outcomes compared to GCS.
Guillain Barre’ syndrome(GBS) and Anesthesia considerationTenzin yoezer
Patients with GBS need special care when coming to the surgery. They have a high risk of aspiration, airway compromise, autonomic instability, altered response to NMBs. It is the duty of the anesthesia providers to recognize those problems and minimize the complications.
It is a rare but potentially catastrophic event that is associated with high mortality. The reported incidence of ICA varies considerably across studies.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
2. Roleofneuraxial
anesthesia in
anesthetic
practice
Studies have shown – reduces postop morbidity when used alone
or in combination with GA
Less convincing studies – it is associated reduced periop
mortality
Reduces the incidence of venous thrombosis, PE, cardiac
complication, bleeding and transfusion, vascular graft occlusion,
pneumonia, respiratory depression in the Upper abdominal and
thoracic surgery
Allows earlier return of bowel function
Propose mechanism: avoidance of large dose of anesthetics and
opioids, reduces hypercoagulable state, increases tissue blood
flow, improving oxygenation from decreased splinting, enhances
persistalsis, suppressing neuroendocrine stress hormone
7. Blood supply of spinal cord
Supplied by 2 arteries:
a) Single spinal artery – arises from vertebral artery
Supplies anterior 2/3
b) Paired posterior spinal arteries – supplies posterior 1/3
Receives additional supply from intercostal artery from
thoracic and lumbar
0ne important radicular artery arising from aorta– artery of
Adamkiewz/ arteria radicularis magna
Typically unilateral and nearly arises from left side
Provides major supply to anterior spinal cord
Injury to this artery – anterior spinal artery syndrome
8. Mechanism of action
• Principal action is at nerve root
• Blockade of posterior nerve root – somatic and visceral sensation
• Anterior nerve root blockade – motor and autonomic outflow
Somatic blockade
• Interrupts afferent transmission and abolishes efferent impulses
• Smaller and myelinated fibers – easily blocked
• Differential blockade – size and character of fiber, conc. of L A
• Judged by temperature sensitivity 2 segment cephalic whereas
sensation block(pain ,light touch) is usually several more cephalic
than motor blockade
9. Autonomic
blockade
Sympathetic outflow – thoracolumbar
Exist from T1 – L2
Small and myelinated B fiber
Parasympathetic outflow – craniosacral
Neuraxial doesn't’t block vagus nerve
Physiological response to neuraxial blockade is result
of decreased sympathetic tone or unopposed
parasympathetic tone, or both.
10. Cardiovascular
manifestation
Variable BP drop and decrease in HR
Determined by level of block
More cephalic – more extensive sympathetic block
Vasomotor tone is primarily determined by sympathetic fibers
from T5- L1
Blocking those fibers – vasodilation of venous capacitance vessels
and pooling of blood in lower extremities and viscera.
Effect of arterial vasodilation may be minimized by compensatory
vasoconstriction above the block
High spinal – blocks compensatory vasoconstriction and blocks
cardiac sympathetic accelerator fibers (T1 – T4)
Unopposed vagal tone – sudden cardiac arrest
11. Mxof
hypotension
andbradycardia
Left uterine displacement in preganant woman
Head-down position – autotransfusion
IVF bolus 5-10 mL/kg
Phenyephrine – direct alpha adrenergic,
Vasoconstriction, increase SVR, reflexively increase
bradycardia
Ephedrine – direct and indirect beta adrenergic effect
Increase heart contractility and HR,vasocontriction
Epinephrine – 2-5 mcg bolus
vasopressor
12. Pulmonary
manifestation
Minimal physiological alteration – diaphragm is innervated by C3-
C5
Even with high thoracic – Vt is unchanged.
Small decrease in vital capacity – loss of abdominal muscles
But have to outweigh the advantages in severe chronic lung disease
– reply on intercostal and abdominal muscles
In high spinal – impairs intercostal and abdominal muscles
- impairs effective cough and clearing of secretion
Surgery above umbilical – instead of SA, thoracic epidural with
diluted LA and opioids may be helpful
Epidural analgesia – improves pulmonary outcome by reducing
incidence of pneumonia and respiratory failure, improves
oxygenation, decreases duration of ventilatory support
13. GI
manifestation
Neuraxial block-induced sympathectomy allows vagal
dominance
Leads to active peristalsis
Therefore improves operative condition during
intestinal surgery when used adjunct to GA
Post op epidural analgesia – earlier return of GI
function
** reduced hepatic blood flow due to decrease MAP
14. Urinarytract
manifestation
Little effect on kidney function – RBF is maintained
with autoregulation
Urinary retention – blockade of both sympathetic and
parasympathetic outflow of lumbosacral
Thus need urinary catheter/ minimal use of fluid
15. Metabolicand
endocrine
Surgical trauma and activation of somatic and visceral afferent
nerve – activation of systemic neuroendocrine stress response
Releases adrenocorticotropic hormones, cortisol, epinephrine,
norepinephrine, vasopressin, RAS
With neuraxial blockade:
Partial suppression – major invasive abdominal/thoracic
surgery
Total blockade – lower extremities surgery
16. Clinical
considerationto
SA&EA
ABSOLUTE CI
CONTROVERSIAL
Lack of consent
Infection at the site of injection
Coagulopathy/bleeding diathesis
Severe hypovolemia
Increase ICP
RELATIVE CI
Sepsis
Uncooperative
Preexisting neurology deficit
Demyelinating lesion
Stenotic valvular heart lesions
LVO obstruction(hypertrophic obstructive cardiomyopathy)
Severe spinal deformity
• Prior back surgery
• Complicated surgery
• Prolong operation
• Major blood loss
• Maneuvers that
compromise respiration
17. Neuraxial blockade in the setting of Anti-cogulant and antiplatelet
agent
American society if reginal and Pain medicine issue guideline
Incidence of epidural haematoma – 1:150,000
18. Oralantiplatelet
drugs
Ticlopidine – 14 days
Clopidogrel – 7days
Prasugrel – 7-10 days
Ticagrelor – 5 days
Abiciximab – 48 hr
Eptifibatide – 8 h
Metabolite of clopidogrel and prasugrel inhits P2Y12
receptors – inhibits platelet aggregation
21. Patient position
Sitting – “angry cat back”
Lateral decubitus –
fetal position
Buie’s(Jacknife) position
22. Factors
influencinglevel
ofspinalblock
MOST IMPORTANT FACTORS
Baricty of anesthetic solution
Position of the patient
During injection
Immediately after injection
Drug dose: large dose more cephalic
Site of injection
OTHER FACTORS
Age
CSF
Curvature of the spine
Drug volume
Intra-abdominal pressure
Needle direction: cephalic vs lateral/caudad
Patient height
pregnancy
23. Position of the spine
• With normal spine anatomy: apex of
thoracolumbar curvature is T4
• In supine position hyperbaic solution
produce block below T4
• “Glass spine effect”
24. Specific gravity of CSF = 1.003 to 1.008 at 37oC
Hyperbaracity = adding glucose
Hypobaricity = adding steril water/fentanyl
Lumbar CSF inversely correlates with dermatomes
spread
Increase abdominal pressure – decrease CSF– greater
dermatomal spread
Eg: epidural vein engorgement, pregnancy, ascites,
large abdominal tumor, obesity
Age related low volume CSF
Kyphoscolosis – low volume CSF
27. Epidural
anesthesia
Performed at lumbar, thoracic, cervical, sacral(caudual
block)
Content of epidural space:
Nerve root - travel in the space laterally
Fatty connective tissue
Lymphatics
Venous (Batsons) plexus
Septa/connective tissue bands – reason for unilateral
block
28. Angulation of epidural needle
Note that acute angle (30 -50oC
is required for thoracic whereas only
slightly cephalid orientation is required
for cervical and lumbar
29. Epidural
activation
Volume and conc. in epidural is larger- high chance of
toxicity if given intrathecally or intravascular if full
dose given
To safegaurd – test dose / increamental dose
Classic test dose: 3 mL of 1.5% lidocaine with 1:200,00
epiephrine(0.005 mg/mL)
Intravacular injection: tachycardia, increasing size of T
wave
31. Dosage – 0.5 -1 mg/kg of 0.125% to .25% bupi/ ropi with
or without epinephrin
***Armitage formula: 0.25% 0f bupi
0.5 mL/kg for lumbosacral
1 mL/kg for thoraco-lumbar
1.25 mL/kg for mid thoraci
Opiods, morphine can be included
Anorectal surgery:
15-20mL of 1.5% to 2% lidocaine with or without epi
May add 50-100mcg Fentanyl
**Avoid caudal block in Pionidal cyst- risk of infection
32. Factorsaffecting
levelof block
Is not predictable as SA
Generally in Aduly 1-2 mL of LA per segment block is
accepted
Eg: to achieve T4 sensory level from L4/5 would
injection require 12-24 mL
For segmental or analgesic block, less volume is
required
33. Factorsaffecting
levelof block
1) Age – dose requirement decreases with age (probably
due to age related decrease in the size of compliance of
epidural space)
2) Height – shorter require 1mL/segment, taller
2mL/segment
3) Gravity
4) Additive to LA –
Opioids affects quality of block than duration
Epinephrine 5mcg/mL prolongs duration by decreasing
vascular absorption and reduces peak systemic blood
volume
34. Epidural agents
• Following initial 1-2mL/segment, repeated dose
on fixed interval until desired dose is achieved
• Once some regression in sensory level has
occurred – 1/3 or ½ of initial activation dose is
reinjected at incremental dose
• Previously chlorprocaine with bisulfite was
associated with neurotoxicity, with EDTA severe
backache(?local hypocalcemia)
• Surgical anesthesia – 0.5% Bupivacaine
• 0.75% Bupi no longer used in obstetric – cardiac
arrest after accidental IV injection
• 0.0625% Bupi fro Labour analgesia
• Ropivacaine produces less motor block than at
Bupi at similar conc maintaining satisfactory
sensory block
35. LApH
adjustment
LA solution is acidic for cheamically stable and
bacteriostatic
Addition of epinephrine makes more acidic than palin
Weak bases – primarily exist as ionic form
Onset of action is slow with low pH
Need incharged ion to cross lipid membrane
Addition of NaHCO2 (1mEq/10mL) speeds onset
With Bupivacaine above pH 6.8, NaHCO2 precipitates
and thus not added
36. Failedepidural
block
1) False epidural space –
Soft ligament
Entry into paraspinous muscle
Intrathecal
Subdural
Intravenous
2) Unilateral block – withdraw 1-2 cm
Reinject and turn pt to unblocked side
3) Segmental sparing – due to septation
Additional LA and turning to unblocked side
4) Sacral sparing – large nerve root of L5, S1, S2 and delay
onset
Elevate the bed and reinject the LA
5) Visceral pain during traction despite good block –visceral
fibers that travel with vagus nerve isresponsible
38. Commonly employed to peadiatric surgery with GA in
surgeries below diaphragm –mainly to avoid toxic
effect from GA
In adult used in anorectal surgery
Needle/catheter penetrates sacrococcygeal ligament
Dural sac extends till S1 in adult and S3 in infants (
high chance of intrathecal injection)
39. Complicationof
neuraxialblock
Large survey shows low incidence of serious
compliction
ASA closed claim project data over 20yr(1980 – 1999):
Regional anesthesia accounts for 18% liability
Temporary/nondisabling -13%
Permanent nerve injury – 10%
Permanenant brain damage – 8%
Other permanent injuries – 4%
Majority of claim involved lumbar epidural (42%),
spinal anesthesia (34%).
Occurs mostly in obstetric patients
40. A)Complication
associated with
excessresponses
toappropriately
placed drug
1) High neural blockade
can occur both in SA and EA
Casues:
Excessive dose
Failure to reduce standard doses in selected pts ( elderly,
pregnant, obese, short stature)
Unusual sensitivity/ speed of LA
Clinical features:
Dyspnea,numbness or weakness of UL, nausea,
hypotension
Mx:
Reassurance to pt
O2
Treatment of bradycardia and hypotension
41. 2)Highspinal
3)Totalspinal
SA ascending into cervical levels cases severe
hypotension, bradycardia, and respiratory insufficiency
Unconsciousness, apnea, and hypotension resulting
from high level of anesthesia are referred to as “HIGH
SPINAL”, or when it extends to cranial nerves –
”TOTAL SPINAL”
Apnea is result of severe sustained hypotension and
medullary hypoperfusion
Mx of high/total spinal:
Supporting ventilation
Supplementing oxygen
Supporting circulation- fluids, vasopressors, fluid
Intubation if necessary/ indicated
42. 4)Cardiacarrest
duringSA
High incidence -1:1500
Many cases were preceded by bradycardia.
Many cases in young and healthy pts
Prevention:
Correction of hypovolemia
Prompt treatment of hypovolemia and bradycardia
43. 5)Urinary
retention
Blockade of S2-4 roots – decrease urinary bladder tone
and inhibits voiding reflex
Other complications:
6) Anterior spinal artery syndrome
7) Horner syndrome
44. B)Complication
associated with
needle or
catheter insertion
1) Inadequate anesthesia or analgesia
Inversely proportional to experience
Movement of needle during injection
Incomplete entry of needle opening into the space
Injection of LA solution into nerve root sleeve
45. 2)Intravascular
injection
CNS – tinnitus, metallic test, circumoral
numbness,seizure, unconscious
CVS – hypotension, arrhythmias, depressed contractility
Common in epidural and caudual since SA uses small dose
Prevention:
Aspirating before injection
Test dose
Incremental dose
Mx- ACLS
20% Lipid emulsion (1.5 mL/kg bolus, 0.25 mL/kg/min or
15 mL/kg/h)
Rank of LA potency is same rank in producing seizure and
cardiac toxicty
Levobupivacaine, Ropivacaine, Bupivacaine, Tetracaine
>lidocaine, mepivacaine >chloroprocaine
46. 3)Totalspinal
anesthesia
Accidental injection into intrathecal during epidural and
caudal
4) Subdural injection
Can happen during several attempts for EA
Onset is 15- 30 minutes ( compared to rapid onset in
intrathecal) and is patchy block
Can manifest as high spinal block
5) Back ache
Due to tissue trauma while inserting needle
Bruising and local inflammatory response with or without
reflex muscle spasm
Usually mild and self limiting
May last for few weeks – subsides by PCM, NSAIDs
Have to consider epidural haematoma or abscess
*** majority of the population has chronic backache
47. 6)Neurologicalinjury
a)nerverootdamage
b)Spinalcordinjury
c)caudaequinal
syndrome
More perplexing /distressing
Must rule out epidural hematoma and abscess
Nerve Root or Cord(if above L1 in adult and L3 in
children) may be injured
Most resolve spontaneously but, some are permanent
If sustained paresthesia during procedure – immediately
withdraw needle.
Stop injection immediately if there is pain
7) Dural puncture/leak
PDPH
Diplopia
Tinnitus
48. 8)
Epidural/spinal
hematoma
Needle or Cather trauma to epidural vein
Incidence of Spinal hematoma – 1: 150,000
For epidural hematoma – 1: 220,000
Onset is sudden ( compared to epidural abscess)
Red flag symptoms:
Sharp back ache and leg pain with motor weakness or
sphincter dysfunction, or both
If suspected: urgent CT/ MRI
Neurological consultation
Outcome – good neurological outcome in prompt
surgical decompression
Prevention: avoid neuraxail with coagulopathy,
significant thrombocytopenia, platelet dysfunction,
those on fibrinolytic or thrombolytic therapy
49. 9)Meningitis
and
arachnoiditis
Due to contamination of the equipment, solution or
organism tracked in from the skin
Indwelling catheter may colonize with skin organism
Strict aseptic technique- esp in obstetric where family
members want to see the procedure
Family members should also wear mask and gown
50. 10) Epidural
abscess
Spinal epidural abscess is rare but potentially
devastating complication
Incidence varies from 1:6500 to 1:500,000 epidural
Most commonly seen in epidural catheter
There are 4 classic stages of EA:
1st stage – back pain that is intensified by percussion
over the spine
2nd stage – nerve root or radicular pain
3rd stage – motor and sensory deficit or sphincter
dysfunction
4th stage – paraplegia or paralysis
51. Prognosis correlates with degree if neurological dysfunction at the time of diagnosis
Clue – fever and back pain after epidural anesthesia
Once suspected, remove epidural catheter and tip send for culture
Injection site – examined for signs of infection: pus if present for culture
Blood culture
If highly suspicious start antibiotic that covers staphylococcus ( aureus and
epidermis)
MRI/CT spine to rule out
Urgent consultation with neurosurgical and infectious specialist
Surgery – in addition to pus drainage, laminectomy
Prevention:
Minimizing catheter manipulation and maintaining closed system
Using micropore(0.22um) bacterial filter
Removing after defined time( some clinician remove after 4 days)
52. 11)Shearingof
anepidural
catheter
Risk of shearing and breaking of epidural catheter if
withdrawn through needle
If catheter breaks off within space – observe the
patient
If superficial – remove surgically
53. C) Complication
associatedwith
drugtoxicity
1) LAST
Excessive absorption of LA from epidural or caudal
Rare if appropriate dose is administered
2) Transient neurological symptoms(TNS)
Also referred as transient radicular irradiation
Characterized by back pain radiating to leg without sensory or motor
deficit, occurring after resolution of SA and resolving within few days
Commonly associated with hyperbaric lidocaine (12%), tetracaine(2%),
Bupivacaine(1%), mepivacaine, prilocaine, procaine, subarachnoid
ropivacaine
Pathogenesis – conc dependent neurotoxicity of LA
Incidence is greatest among outpatient, particularly male pt
undergoing surgery in lithotomy position.
Less incidence among other than lithotomy position
3) Cauda equina syndrome