The document discusses regional anesthesia techniques including central nerve blocks like spinal, epidural, and caudal anesthesia as well as peripheral nerve blocks. It provides detailed anatomy of the spinal column and spinal cord. It describes the techniques for performing spinal and epidural anesthesia including patient positioning, skin preparation, needle placement, and assessment of the block. Factors affecting the spread and level of the block are also discussed.
This document provides information on spinal anatomy and spinal anesthesia. It describes the basic spinal anatomy including the vertebrae, spinal cord, meninges, and spinal nerves. It then discusses spinal anesthesia, including the indications, contraindications, procedure, advantages, disadvantages, mechanism of action, uptake and elimination of spinal anesthetics. It also covers factors that determine the distribution of spinal anesthetics such as characteristics of the local anesthetic solution, patient characteristics, injection technique, and characteristics of spinal fluid.
1. The dura mater, arachnoid mater, and pia mater coverings of the spinal cord are penetrated by the needle during a lumbar puncture.
2. The vertebral column and meninges (dura mater, arachnoid mater, and pia mater) provide support and protection to the spinal cord.
3. A lumbar puncture is performed by inserting a needle between the vertebrae in the lower back to collect cerebrospinal fluid from the subarachnoid space for analysis.
Pathophysiologic aspects, clinical manifestation a nd management ofSushant Yadav
The examiner passively abducts the patient's shoulder to 90 degrees, flexes the elbow to 90 degrees, and positions the forearm in neutral. The examiner then applies a gentle, sustained posteroanterior glide to the wrist while maintaining the shoulder and elbow positions.
- A positive test reproduces symptoms in the median nerve distribution.
- This test is useful for evaluating cervical radiculopathy involving C6 nerve root as it innervates the median nerve. A positive test suggests nerve root compression.
- The test is considered positive if symptoms are reproduced or increased with the maneuver.
- It has a sensitivity of 80-90% and specificity of 70-80% for cervical radiculo
This document discusses the anatomy relevant to central neuraxial blockade. It describes the structure of the vertebral column, spinal cord, meninges, epidural space, and related landmarks. Key points include the composition of vertebrae, curves of the spinal column, contents and layers of the meninges, boundaries of the epidural space, and surface landmarks used to identify vertebral levels for epidural injection. Safety considerations for pediatric patients are also mentioned, such as differences in spinal cord termination points and effects of sympathetic blockade.
1) There are 33 vertebrae in the spine, but due to fusion only 26 are functional. The vertebrae are divided into 7 cervical, 12 thoracic, and 5 lumbar vertebrae.
2) Degenerative disc disease is the most common cause of lower back pain. It involves the gradual drying out and loss of the intervertebral disc's ability to function as a shock absorber. This transfer of stress can lead to further degeneration of surrounding structures like facet joints.
3) Stages of disc degeneration include disc bulge, annular tears, and disc herniation which can be protruded, extruded, or sequestrated as it progresses. Identification of the specific
This document discusses the anatomy relevant to central neuraxial blockade. It describes the structure of the vertebral column, spinal cord, meninges, epidural space, and related landmarks. Key points include the levels the spinal cord ends in infants versus adults, differences in pediatric anatomy and physiology that impact central blockade, and how surface landmarks can help identify vertebral levels for safe epidural injection.
The document discusses the anatomy and functions of the nervous system and brain. It describes the central nervous system as consisting of the brain and spinal cord. The brain is protected by three membranes (meninges) and contains four ventricles that produce cerebrospinal fluid. The cerebrum is the largest part of the brain and is divided into four lobes with different functional areas. Other parts include the brain stem and cerebellum. The document provides detailed information on the structure and roles of the various parts of the nervous system.
This document provides information on spinal anatomy and spinal anesthesia. It describes the basic spinal anatomy including the vertebrae, spinal cord, meninges, and spinal nerves. It then discusses spinal anesthesia, including the indications, contraindications, procedure, advantages, disadvantages, mechanism of action, uptake and elimination of spinal anesthetics. It also covers factors that determine the distribution of spinal anesthetics such as characteristics of the local anesthetic solution, patient characteristics, injection technique, and characteristics of spinal fluid.
1. The dura mater, arachnoid mater, and pia mater coverings of the spinal cord are penetrated by the needle during a lumbar puncture.
2. The vertebral column and meninges (dura mater, arachnoid mater, and pia mater) provide support and protection to the spinal cord.
3. A lumbar puncture is performed by inserting a needle between the vertebrae in the lower back to collect cerebrospinal fluid from the subarachnoid space for analysis.
Pathophysiologic aspects, clinical manifestation a nd management ofSushant Yadav
The examiner passively abducts the patient's shoulder to 90 degrees, flexes the elbow to 90 degrees, and positions the forearm in neutral. The examiner then applies a gentle, sustained posteroanterior glide to the wrist while maintaining the shoulder and elbow positions.
- A positive test reproduces symptoms in the median nerve distribution.
- This test is useful for evaluating cervical radiculopathy involving C6 nerve root as it innervates the median nerve. A positive test suggests nerve root compression.
- The test is considered positive if symptoms are reproduced or increased with the maneuver.
- It has a sensitivity of 80-90% and specificity of 70-80% for cervical radiculo
This document discusses the anatomy relevant to central neuraxial blockade. It describes the structure of the vertebral column, spinal cord, meninges, epidural space, and related landmarks. Key points include the composition of vertebrae, curves of the spinal column, contents and layers of the meninges, boundaries of the epidural space, and surface landmarks used to identify vertebral levels for epidural injection. Safety considerations for pediatric patients are also mentioned, such as differences in spinal cord termination points and effects of sympathetic blockade.
1) There are 33 vertebrae in the spine, but due to fusion only 26 are functional. The vertebrae are divided into 7 cervical, 12 thoracic, and 5 lumbar vertebrae.
2) Degenerative disc disease is the most common cause of lower back pain. It involves the gradual drying out and loss of the intervertebral disc's ability to function as a shock absorber. This transfer of stress can lead to further degeneration of surrounding structures like facet joints.
3) Stages of disc degeneration include disc bulge, annular tears, and disc herniation which can be protruded, extruded, or sequestrated as it progresses. Identification of the specific
This document discusses the anatomy relevant to central neuraxial blockade. It describes the structure of the vertebral column, spinal cord, meninges, epidural space, and related landmarks. Key points include the levels the spinal cord ends in infants versus adults, differences in pediatric anatomy and physiology that impact central blockade, and how surface landmarks can help identify vertebral levels for safe epidural injection.
The document discusses the anatomy and functions of the nervous system and brain. It describes the central nervous system as consisting of the brain and spinal cord. The brain is protected by three membranes (meninges) and contains four ventricles that produce cerebrospinal fluid. The cerebrum is the largest part of the brain and is divided into four lobes with different functional areas. Other parts include the brain stem and cerebellum. The document provides detailed information on the structure and roles of the various parts of the nervous system.
The document provides an overview of the anatomy of the vertebral column. It discusses the 33 vertebrae that make up the spine, their typical features, and variations in different regions. It describes the protective, supportive, and weight-bearing functions of the vertebral column. Key structures like the intervertebral discs, spinal cord, meninges, nerve roots, and blood supply are summarized. Considerations for regional anesthesia techniques and anatomical variations are also covered at a high level.
This document discusses cervical disc prolapse. It begins by describing the anatomy of the spine and intervertebral discs. It then discusses the causes, symptoms, and treatments of cervical disc prolapse. Conservative treatments include rest, medications, and traction. Surgical treatments include posterior or anterior approaches to remove the herniated disc material. Anterior cervical discectomy with fusion or disc arthroplasty are described as surgical options.
Spinal anaesthesia involves injecting local anaesthetic into the subarachnoid space to block spinal nerves. It was first introduced in the late 1800s. The spinal cord and nerves are surrounded by meninges including the dura, arachnoid and pia mater. Cerebrospinal fluid flows in the subarachnoid space. Spinal anaesthesia is performed using a small needle inserted between vertebrae to access this space and inject anaesthetic. The level and extent of nerve blockade depends on factors like drug used, dose, patient positioning and anatomy. It provides anaesthesia for surgeries below the level of injection while sparing consciousness above.
This document discusses the anatomy of the vertebral column and spinal canal. It describes the individual vertebrae, curves of the vertebral column, structures within the vertebral canal including the meningeal spaces, abnormalities, blood supply, the intervertebral disc, and changes that occur with aging. Key points include there being 33 vertebrae grouped into cervical, thoracic, lumbar, sacral and coccygeal sections, and the presence of primary and secondary curves forming the cervical, thoracic, lumbar and pelvic curves. The vertebral canal contains the spinal cord and meninges, and is protected anteriorly and posteriorly. The intervertebral disc acts as a shock absorber and its structure and function changes
The craniovertebral junction (CVJ) refers to the occiput, atlas, axis, and supporting ligaments. It forms a transition zone between the mobile cranium and rigid spinal column, enclosing the cervicomedullary junction. The key components of the CVJ include the occipital bone, atlas, axis, occipitoatlantal and atlantoaxial joints, and stabilizing ligaments like the transverse atlantal ligament and alar ligaments. Radiological imaging like plain radiographs, CT, and MRI are useful for evaluating the bony and soft tissue anatomy of the CVJ and detecting any abnormalities.
The document provides an overview of the anatomy of the eye. It describes the main structures of the eyeball including the coats, chambers, segments and dimensions. It then discusses specific structures like the conjunctiva, eyelids, blood supply and nerves. In summary:
1) The eyeball has three coats - fibrous, vascular and nervous - that protect and supply the inner contents. It is divided into anterior and posterior segments separated by the crystalline lens.
2) The conjunctiva lines the eyelids and coats the eyeball. It contains glands that secrete tears.
3) The eyelids are mobile curtains that protect the eyes and help spread tears. They meet at the medial and lateral
The document summarizes the biomechanics of the vertebral column. It describes the typical structure and regions of the vertebral column. It then discusses the typical vertebrae structure, intervertebral discs, articulations, ligaments, curves of the spine, and kinetics and kinematics including forces like compression, bending, torsion and shear. It also provides details on the specific structure and features of the cervical spine regions.
This document provides information about myelography, a radiographic examination of the spinal cord. It involves injecting contrast medium to detect spinal cord pathology. The spinal cord extends from the brain down the back and is protected by three meningeal layers. Cerebrospinal fluid surrounds and cushions the spinal cord. A myelogram is performed by puncturing the subarachnoid space and injecting contrast medium before taking radiographic images. Risks include reaction to the contrast medium, increased intracranial pressure, or aggravating existing conditions like arachnoiditis. Patients must stop certain medications beforehand and remain on bed rest afterwards.
The document discusses various peripheral nerve blocks including:
- Cervical plexus block which targets nerves arising from C1-C4 including the lesser occipital nerve, greater auricular nerve, and supraclavicular nerve.
- Superficial and deep cervical plexus blocks are used for neck surgeries and procedures. The superficial block targets cutaneous branches while the deep block targets the paravertebral region from C2-C4.
- Stellate ganglion block provides sympathetic blockade for chronic pain syndromes and is performed at the C6 level, targeting the stellate ganglion. Complications include Horner's syndrome and injury to nearby structures.
The document summarizes the anatomy of the orbit including its walls, contents, fasciae, nerves, vessels, and related structures. Key points include:
1. The medial orbital wall is the thinnest and contains the frontal process of maxilla, lacrimal bone, orbital plate of ethmoid, and body of sphenoid.
2. The lateral orbital wall is the strongest and contains the orbital surface of the zygomatic bone and greater wing of sphenoid.
3. The orbit contains the eyeball, extraocular muscles, nerves like the optic and oculomotor, vessels like the ophthalmic artery, and lacrimal gland.
4. The periorbit
The vestibular system detects motion and orientation of the head. It consists of five sensory end organs - three semicircular canals and two otolith organs. The semicircular canals detect rotational movement and contain cristae that sense angular acceleration. The utricle and saccule are the otolith organs and detect linear acceleration and gravity. They contain hair cells covered by an otolith membrane with embedded crystals that provide inertia against endolymph fluid. Together, the vestibular system works with vision and proprioception to maintain balance and spatial orientation.
The document discusses the anatomy of the scapula and surrounding structures. It provides details on:
1. The bones, surfaces, borders, angles, and processes of the scapula.
2. The muscles that originate and insert on the scapula, including the deltoid, supraspinatus, infraspinatus, teres minor, subscapularis, and teres major muscles.
3. The joints around the scapula, including the sternoclavicular, acromioclavicular, scapulothoracic, and glenohumeral joints.
4. The arterial anastomoses around the scapula that
Cervical disc prolapse occurs when a cervical disc herniates and compresses the nerve root. The cervical spine has 7 vertebrae and 6 intervertebral discs that act as shock absorbers and allow motion. A disc is composed of an inner nucleus pulposus surrounded by the outer annulus fibrosus. Common sites of prolapse are C5-C6 and C6-C7. Clinical features include neck pain radiating to the arm. Imaging like MRI or CT is used to confirm prolapse. Treatment involves rest, medications, traction and surgery like anterior cervical discectomy if non-operative measures fail.
The document provides an overview of the nervous system, including its three main parts: central nervous system (CNS), peripheral nervous system (PNS), and autonomic nervous system (ANS). It describes the structure and components of the CNS, PNS, and ANS. It also discusses key structures within the CNS like the brain, spinal cord, spinal meninges, and vertebral canal.
The document provides an overview of the nervous system, including the central nervous system (CNS), peripheral nervous system (PNS), and autonomic nervous system (ANS). It describes the major components and features of each system, including:
- The CNS contains the brain and spinal cord. The brain is divided into the forebrain, midbrain, and hindbrain. The spinal cord contains 31 pairs of spinal nerves.
- The PNS connects the CNS to the limbs and organs. It contains cranial and spinal nerves.
- The ANS regulates involuntary functions and is divided into the sympathetic and parasympathetic systems. It contains ganglia and both afferent and efferent fibers
2015.01.22 Central Neuraxial Blockade.pptxluna439975
Central neuroaxial blockade involves placing local anesthetics around the central nervous system, including spinal, epidural, and caudal blocks.
The history of these techniques began in 1898 when Bier performed the first subarachnoid blockade on himself using cocaine, resulting in a postdural puncture headache. Since then, techniques have evolved with improvements in anesthesia and catheter technology.
The anatomy involves the vertebral column, spinal cord, three protective membranes (dura, arachnoid, and pia mater), and the subarachnoid and epidural spaces containing cerebrospinal fluid. Local anesthetics act by blocking sodium channels in nerves to prevent conduction.
The document discusses the anatomy and clinical presentations of the third cranial nerve (oculomotor nerve). It begins by describing the origin and course of the nerve, including its nuclei in the midbrain and pathways through the brainstem and cavernous sinus. It then discusses the individual branches and functions of the nerve in innervating the extraocular muscles and parasympathetic fibers to the eye. The summary concludes by noting that damage to the third cranial nerve can cause a total third nerve palsy presenting with ptosis, external eye movement limitations, pupil dilation and loss of accommodation.
This document discusses the prenatal development of the cranial base. It begins with an introduction and overview of cranial base anatomy. It then describes the three major phases of skull base development: appearance of the mesenchymal anlage, chondrification, and ossification. Specific details are provided on the development of individual bones that make up the cranial base, including the ethmoid, sphenoid, and occipital bones. The document also discusses how variations in cranial base morphology can influence adjacent craniofacial structures and relationships.
The document discusses acid-base balance and disorders. It defines acids and bases, and explains how the body maintains acid-base balance through buffers, respiratory regulation, and renal regulation. It describes the four major acid-base disorders: respiratory acidosis, respiratory alkalosis, metabolic acidosis, and metabolic alkalosis. For each disorder it provides the primary cause, effects on bicarbonate and pH levels, and examples of compensatory mechanisms and potential treatments.
This document provides information on intraosseous vascular access. It discusses indications for IO insertion including cardiac arrest, deteriorating patient, trauma, and inability to obtain IV access. It reviews safe insertion of the EZ-IO needle including equipment, sites, and steps. Potential risks and complications are outlined. Drugs and fluids that can be administered via IO are noted. Practical tips are provided such as pushing fluids due to resistance. Patient safety tips emphasize obtaining definitive venous access when possible and removing the IO.
The document provides an overview of the anatomy of the vertebral column. It discusses the 33 vertebrae that make up the spine, their typical features, and variations in different regions. It describes the protective, supportive, and weight-bearing functions of the vertebral column. Key structures like the intervertebral discs, spinal cord, meninges, nerve roots, and blood supply are summarized. Considerations for regional anesthesia techniques and anatomical variations are also covered at a high level.
This document discusses cervical disc prolapse. It begins by describing the anatomy of the spine and intervertebral discs. It then discusses the causes, symptoms, and treatments of cervical disc prolapse. Conservative treatments include rest, medications, and traction. Surgical treatments include posterior or anterior approaches to remove the herniated disc material. Anterior cervical discectomy with fusion or disc arthroplasty are described as surgical options.
Spinal anaesthesia involves injecting local anaesthetic into the subarachnoid space to block spinal nerves. It was first introduced in the late 1800s. The spinal cord and nerves are surrounded by meninges including the dura, arachnoid and pia mater. Cerebrospinal fluid flows in the subarachnoid space. Spinal anaesthesia is performed using a small needle inserted between vertebrae to access this space and inject anaesthetic. The level and extent of nerve blockade depends on factors like drug used, dose, patient positioning and anatomy. It provides anaesthesia for surgeries below the level of injection while sparing consciousness above.
This document discusses the anatomy of the vertebral column and spinal canal. It describes the individual vertebrae, curves of the vertebral column, structures within the vertebral canal including the meningeal spaces, abnormalities, blood supply, the intervertebral disc, and changes that occur with aging. Key points include there being 33 vertebrae grouped into cervical, thoracic, lumbar, sacral and coccygeal sections, and the presence of primary and secondary curves forming the cervical, thoracic, lumbar and pelvic curves. The vertebral canal contains the spinal cord and meninges, and is protected anteriorly and posteriorly. The intervertebral disc acts as a shock absorber and its structure and function changes
The craniovertebral junction (CVJ) refers to the occiput, atlas, axis, and supporting ligaments. It forms a transition zone between the mobile cranium and rigid spinal column, enclosing the cervicomedullary junction. The key components of the CVJ include the occipital bone, atlas, axis, occipitoatlantal and atlantoaxial joints, and stabilizing ligaments like the transverse atlantal ligament and alar ligaments. Radiological imaging like plain radiographs, CT, and MRI are useful for evaluating the bony and soft tissue anatomy of the CVJ and detecting any abnormalities.
The document provides an overview of the anatomy of the eye. It describes the main structures of the eyeball including the coats, chambers, segments and dimensions. It then discusses specific structures like the conjunctiva, eyelids, blood supply and nerves. In summary:
1) The eyeball has three coats - fibrous, vascular and nervous - that protect and supply the inner contents. It is divided into anterior and posterior segments separated by the crystalline lens.
2) The conjunctiva lines the eyelids and coats the eyeball. It contains glands that secrete tears.
3) The eyelids are mobile curtains that protect the eyes and help spread tears. They meet at the medial and lateral
The document summarizes the biomechanics of the vertebral column. It describes the typical structure and regions of the vertebral column. It then discusses the typical vertebrae structure, intervertebral discs, articulations, ligaments, curves of the spine, and kinetics and kinematics including forces like compression, bending, torsion and shear. It also provides details on the specific structure and features of the cervical spine regions.
This document provides information about myelography, a radiographic examination of the spinal cord. It involves injecting contrast medium to detect spinal cord pathology. The spinal cord extends from the brain down the back and is protected by three meningeal layers. Cerebrospinal fluid surrounds and cushions the spinal cord. A myelogram is performed by puncturing the subarachnoid space and injecting contrast medium before taking radiographic images. Risks include reaction to the contrast medium, increased intracranial pressure, or aggravating existing conditions like arachnoiditis. Patients must stop certain medications beforehand and remain on bed rest afterwards.
The document discusses various peripheral nerve blocks including:
- Cervical plexus block which targets nerves arising from C1-C4 including the lesser occipital nerve, greater auricular nerve, and supraclavicular nerve.
- Superficial and deep cervical plexus blocks are used for neck surgeries and procedures. The superficial block targets cutaneous branches while the deep block targets the paravertebral region from C2-C4.
- Stellate ganglion block provides sympathetic blockade for chronic pain syndromes and is performed at the C6 level, targeting the stellate ganglion. Complications include Horner's syndrome and injury to nearby structures.
The document summarizes the anatomy of the orbit including its walls, contents, fasciae, nerves, vessels, and related structures. Key points include:
1. The medial orbital wall is the thinnest and contains the frontal process of maxilla, lacrimal bone, orbital plate of ethmoid, and body of sphenoid.
2. The lateral orbital wall is the strongest and contains the orbital surface of the zygomatic bone and greater wing of sphenoid.
3. The orbit contains the eyeball, extraocular muscles, nerves like the optic and oculomotor, vessels like the ophthalmic artery, and lacrimal gland.
4. The periorbit
The vestibular system detects motion and orientation of the head. It consists of five sensory end organs - three semicircular canals and two otolith organs. The semicircular canals detect rotational movement and contain cristae that sense angular acceleration. The utricle and saccule are the otolith organs and detect linear acceleration and gravity. They contain hair cells covered by an otolith membrane with embedded crystals that provide inertia against endolymph fluid. Together, the vestibular system works with vision and proprioception to maintain balance and spatial orientation.
The document discusses the anatomy of the scapula and surrounding structures. It provides details on:
1. The bones, surfaces, borders, angles, and processes of the scapula.
2. The muscles that originate and insert on the scapula, including the deltoid, supraspinatus, infraspinatus, teres minor, subscapularis, and teres major muscles.
3. The joints around the scapula, including the sternoclavicular, acromioclavicular, scapulothoracic, and glenohumeral joints.
4. The arterial anastomoses around the scapula that
Cervical disc prolapse occurs when a cervical disc herniates and compresses the nerve root. The cervical spine has 7 vertebrae and 6 intervertebral discs that act as shock absorbers and allow motion. A disc is composed of an inner nucleus pulposus surrounded by the outer annulus fibrosus. Common sites of prolapse are C5-C6 and C6-C7. Clinical features include neck pain radiating to the arm. Imaging like MRI or CT is used to confirm prolapse. Treatment involves rest, medications, traction and surgery like anterior cervical discectomy if non-operative measures fail.
The document provides an overview of the nervous system, including its three main parts: central nervous system (CNS), peripheral nervous system (PNS), and autonomic nervous system (ANS). It describes the structure and components of the CNS, PNS, and ANS. It also discusses key structures within the CNS like the brain, spinal cord, spinal meninges, and vertebral canal.
The document provides an overview of the nervous system, including the central nervous system (CNS), peripheral nervous system (PNS), and autonomic nervous system (ANS). It describes the major components and features of each system, including:
- The CNS contains the brain and spinal cord. The brain is divided into the forebrain, midbrain, and hindbrain. The spinal cord contains 31 pairs of spinal nerves.
- The PNS connects the CNS to the limbs and organs. It contains cranial and spinal nerves.
- The ANS regulates involuntary functions and is divided into the sympathetic and parasympathetic systems. It contains ganglia and both afferent and efferent fibers
2015.01.22 Central Neuraxial Blockade.pptxluna439975
Central neuroaxial blockade involves placing local anesthetics around the central nervous system, including spinal, epidural, and caudal blocks.
The history of these techniques began in 1898 when Bier performed the first subarachnoid blockade on himself using cocaine, resulting in a postdural puncture headache. Since then, techniques have evolved with improvements in anesthesia and catheter technology.
The anatomy involves the vertebral column, spinal cord, three protective membranes (dura, arachnoid, and pia mater), and the subarachnoid and epidural spaces containing cerebrospinal fluid. Local anesthetics act by blocking sodium channels in nerves to prevent conduction.
The document discusses the anatomy and clinical presentations of the third cranial nerve (oculomotor nerve). It begins by describing the origin and course of the nerve, including its nuclei in the midbrain and pathways through the brainstem and cavernous sinus. It then discusses the individual branches and functions of the nerve in innervating the extraocular muscles and parasympathetic fibers to the eye. The summary concludes by noting that damage to the third cranial nerve can cause a total third nerve palsy presenting with ptosis, external eye movement limitations, pupil dilation and loss of accommodation.
This document discusses the prenatal development of the cranial base. It begins with an introduction and overview of cranial base anatomy. It then describes the three major phases of skull base development: appearance of the mesenchymal anlage, chondrification, and ossification. Specific details are provided on the development of individual bones that make up the cranial base, including the ethmoid, sphenoid, and occipital bones. The document also discusses how variations in cranial base morphology can influence adjacent craniofacial structures and relationships.
The document discusses acid-base balance and disorders. It defines acids and bases, and explains how the body maintains acid-base balance through buffers, respiratory regulation, and renal regulation. It describes the four major acid-base disorders: respiratory acidosis, respiratory alkalosis, metabolic acidosis, and metabolic alkalosis. For each disorder it provides the primary cause, effects on bicarbonate and pH levels, and examples of compensatory mechanisms and potential treatments.
This document provides information on intraosseous vascular access. It discusses indications for IO insertion including cardiac arrest, deteriorating patient, trauma, and inability to obtain IV access. It reviews safe insertion of the EZ-IO needle including equipment, sites, and steps. Potential risks and complications are outlined. Drugs and fluids that can be administered via IO are noted. Practical tips are provided such as pushing fluids due to resistance. Patient safety tips emphasize obtaining definitive venous access when possible and removing the IO.
This document discusses the cardiovascular, respiratory, renal, hepatic, and other physiologic effects of pneumoperitoneum during laparoscopic surgery. Pneumoperitoneum, or insufflation of carbon dioxide gas into the abdominal cavity, can cause hemodynamic changes such as decreased venous return and cardiac output. It can also decrease lung volumes and impair respiratory function. These effects are more pronounced in elderly or debilitated patients undergoing laparoscopic surgery. The document emphasizes the importance of intraoperative monitoring and management strategies to optimize patient hemodynamics and ventilation during pneumoperitoneum, especially in high-risk patients.
Physiologic changes during pregnancy.pptxTadesseFenta1
Physiological changes during pregnancy alter the body's response to anesthesia. These changes begin early in pregnancy and progress significantly. By term, there are reductions in MAC values (up to 40%), sensitivity to local anesthetics (up to 30%), and FRC (up to 20%). Pregnant women also experience increased oxygen consumption (20-50%), minute ventilation (40-50%), cardiac output (up to 50%), blood volume (45%), and risk of aspiration. Anesthesia requires accounting for these changes through techniques like left uterine displacement, preoxygenation, and rapid sequence induction.
This document discusses medical ethics and key concepts. It defines ethics as a system of moral principles that affect decision making. Medical ethics applies these principles to medicine and considers patients' rights and welfare. The four basic principles of medical ethics are respect for autonomy, non-maleficence, beneficence, and justice. Effective communication is important for maintaining ethics and professionalism in healthcare. Anesthesiologists must thoughtfully communicate with patients throughout the perioperative process to respect patient autonomy and fulfill their professional duties.
Anesthetic Management of Abdominal Surgery.pptxTadesseFenta1
This document outlines an anesthesia course for abdominal and genitourinary surgery. The course aims to enable anesthetists to safely manage anesthesia for patients undergoing abdominal, gastrointestinal, hepatobiliary, anal, and genitourinary surgeries. It covers preoperative evaluation, risks associated with abdominal surgery, anesthetic techniques for different procedures, postoperative complications, and management of patients with hepatic or cardiovascular disease. The course assessments include assignments, quizzes, and a final written exam.
Anesthesia for Genitourinary Surgery.pptxTadesseFenta1
This document provides information about anesthesia for genitourinary surgeries and procedures. It discusses considerations for cystoscopy, transurethral resection of the prostate (TURP), lithotripsy, and the lithotomy position. Regional or general anesthesia is typically used depending on the procedure and patient factors. Complications of TURP can include hemorrhage, TURP syndrome from fluid absorption, bladder perforation, hypothermia, septicemia, and disseminated intravascular coagulation. Careful monitoring is important to detect issues like fluid overload and hyponatremia.
This document outlines an EMT training course on advanced airway management and the use of the pharyngeal esophageal airway device (PEAD), also known as the Combitube. The agenda covers respiratory anatomy and physiology, respiratory volumes and management, assessing respiratory problems, respiratory/cardiac arrest management, basic airway techniques, suctioning, and the use of dual-lumen airway devices like the Combitube. Objectives are provided for each lesson, which include demonstrating techniques like Combitube insertion and ensuring correct placement. Practical skills testing with a physician is also mentioned.
This document provides an overview of respiratory physiology, including:
- The structures and functions of the respiratory system
- The mechanics of breathing involving the lungs, chest wall, diaphragm and pleura
- The respiratory center in the brainstem that controls breathing
- Gas exchange that occurs between the alveoli and blood in the lungs
- Factors that impact ventilation and perfusion matching in the lungs
- Definitions of various lung volumes and capacities measured in respiratory physiology
This document discusses thoracic anesthesia and includes outlines of topics, objectives, and details on preoperative evaluation, preparation, intraoperative monitoring, physiology of the lateral decubitus position under different conditions, and management of one-lung ventilation. Specifically, it covers assessing the surgical patient, optimizing medical conditions preoperatively, important intraoperative monitors, how induction of anesthesia and opening the chest impact ventilation and perfusion in the lateral position, and goals of managing one-lung ventilation.
Anesthesia for Patients with Renal Disease.pptxTadesseFenta1
The document discusses anesthesia considerations for patients with renal disease undergoing various genitourinary surgeries. It covers the effects of anesthetic agents on renal function, as well as positioning techniques and their physiologic impacts. Guidelines are provided for preoperative evaluation, induction, maintenance, fluid management, and specific procedures like TURP to safely anesthetize patients with renal impairment.
The document discusses common renal pathologies and their management in the perioperative period. It covers acute renal failure (ARF), chronic renal failure (CRF), diabetic nephropathy, nephrotic syndrome, glomerulonephritis, and pyelonephritis. ARF is classified as prerenal, intrinsic, or postrenal based on etiology. CRF results in fluid and electrolyte abnormalities, cardiac and pulmonary issues, and anemia. Diabetic nephropathy is caused by hypertension and hyperglycemia damaging the kidneys over time. Treatment focuses on controlling blood sugar and hypertension.
This document discusses the pathophysiology and management of burn patients. It covers:
1) Major burns cause massive tissue destruction and inflammatory response, leading to burn shock from fluid shifts and systemic effects if >20% TBSA.
2) Burns trigger a hypermetabolic response for weeks, with increased cardiac work and protein catabolism impairing healing.
3) Resuscitation follows the Parkland formula to replace fluid losses. Fluid management aims to maintain urine output and prevent organ dysfunction.
The document discusses airway anatomy and equipment for airway management. It reviews the anatomy of the upper airway from the nose to the bronchi and describes key differences in pediatric anatomy. Common airway equipment is outlined including laryngoscopes, endotracheal tubes, face masks, and laryngeal mask airways. Effective face mask ventilation techniques are also summarized.
The operating room poses hazards including physical (back injury, fire), chemical (anesthetic gases, cleaning agents), and biological (infectious materials, needle sticks) risks. Regulations and guidelines aim to minimize these dangers. Grounding systems prevent electric shocks to patients, while fire risks are reduced by separating fuels, heat sources, and oxygen. Catastrophic events like anaphylaxis and malignant hyperthermia require immediate interventions - anaphylaxis treatment includes epinephrine, while malignant hyperthermia involves dantrolene, cooling, and oxygen administration. The resuscitation trolley must contain appropriate drugs to manage emergencies.
The document provides information on instrument processing, including the steps involved in decontamination, cleaning, sterilization, and high-level disinfection. It describes the learning objectives, introduces key terms, and discusses various chemical disinfectants and their appropriate uses. Specific processes and best practices are outlined for decontamination using chlorine solutions, cleaning instruments, sterilization using various methods like steam, dry heat and chemicals, and high-level disinfection through boiling, steaming or chemicals. Factors that impact effectiveness and proper techniques, concentrations, exposure times are emphasized throughout.
The document provides guidelines for infection prevention and control in operating theatres. It discusses principles like considering all people potentially infectious, hand hygiene, use of personal protective equipment (PPE) like gloves, gowns and masks. It describes different types of PPE and when they should be used. Surgical scrubs and maintaining asepsis are also outlined, including inspecting hands for cuts, removing jewelry, adjusting masks and scrubs lasting 5 minutes with specific techniques. Strict personal hygiene is necessary for operating room workers to prevent transmission of infections.
The document outlines the organization and personnel roles in the operating room (OR). It discusses the physical areas of the OR including design, equipment, and traffic flow. It describes the roles of the sterile team including the surgeon, assistants, and scrub nurse who maintain the sterile field. The roles of the unsterile team including the anesthesia provider and circulating nurse who prepare supplies and equipment are also outlined. Specific responsibilities for each role in pre-operative, intra-operative, and post-operative periods are provided. Item counts are performed before and after procedures for patient and personnel safety.
Perioperative Pain Management by abe 2018.pptTadesseFenta1
The document discusses acute and chronic pain management. It covers definitions of pain, physiology of pain including pathways and modulation, assessment of pain, classification of pain as acute or chronic and nociceptive or neuropathic. It also discusses importance of treating acute perioperative pain to reduce complications and enhance recovery while balancing risks of adverse effects from overtreatment of pain. Management of both acute and chronic pain is an important objective of the course.
This document discusses fluid management and replacement during anesthesia. It describes how the body's fluid is divided into compartments and how dehydration can occur from fasting or fluid loss. It provides a formula to calculate a patient's fasting fluid deficit based on weight and time fasting. It also explains how to calculate fluid maintenance needs, insensible fluid loss, and additional fluids needed based on the level of surgical trauma. The goal is to replace all fluid losses to maintain adequate intravascular volume and prevent complications during and after surgery.
it describes the bony anatomy including the femoral head , acetabulum, labrum . also discusses the capsule , ligaments . muscle that act on the hip joint and the range of motion are outlined. factors affecting hip joint stability and weight transmission through the joint are summarized.
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...Dr. Vinod Kumar Kanvaria
Exploiting Artificial Intelligence for Empowering Researchers and Faculty,
International FDP on Fundamentals of Research in Social Sciences
at Integral University, Lucknow, 06.06.2024
By Dr. Vinod Kumar Kanvaria
Strategies for Effective Upskilling is a presentation by Chinwendu Peace in a Your Skill Boost Masterclass organisation by the Excellence Foundation for South Sudan on 08th and 09th June 2024 from 1 PM to 3 PM on each day.
How to Manage Your Lost Opportunities in Odoo 17 CRMCeline George
Odoo 17 CRM allows us to track why we lose sales opportunities with "Lost Reasons." This helps analyze our sales process and identify areas for improvement. Here's how to configure lost reasons in Odoo 17 CRM
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
How to Build a Module in Odoo 17 Using the Scaffold MethodCeline George
Odoo provides an option for creating a module by using a single line command. By using this command the user can make a whole structure of a module. It is very easy for a beginner to make a module. There is no need to make each file manually. This slide will show how to create a module using the scaffold method.
A review of the growth of the Israel Genealogy Research Association Database Collection for the last 12 months. Our collection is now passed the 3 million mark and still growing. See which archives have contributed the most. See the different types of records we have, and which years have had records added. You can also see what we have for the future.
3. Cont…
• Vertebrae differ in shape and size at the various levels.
• The first cervical vertebra, the atlas, lacks a body and has
unique articulations with the base of the skull and the second
vertebra.
• The second vertebra,called the axis, consequently has atypical
articulating surfaces.
6/14/2023 Prepared By FB 3
4. Cont…
• All 12 thoracic vertebrae articulate with their corresponding
rib.
• Lumbar vertebrae have a large anterior cylindrical vertebral
body.
• A hollow ring is defined anteriorly by the vertebral body,
laterally by the pedicles and transverse processes, and
posteriorly by the lamina and spinous processes.
6/14/2023 Prepared By FB 4
5. Cont…
• The laminae extend between the transverse processes and
the spinous processes
• The pedicle extends between the vertebral body and the
transverse processes.
• When stacked vertically, the hollow rings become the spinal
canal in which the spinal cord and its coverings sit.
• The individual vertebral bodies are connected by the
intervertebral disks.
6/14/2023 Prepared By FB 5
6. Cont…
• Four small synovial joints at each vertebra, two articulating
with the vertebra above it and two with the vertebra below
adjacent to the transverse processes.
• The pedicles are notched superiorly and inferiorly, these
notches forming the intervertebral foramina from which the
spinal nerves exit.
• Sacral vertebrae normally fuse into one large bone, the
sacrum, but each one retains discrete anterior and posterior
intervertebral foramina.
• The laminae of S5 and all or part of S4 normally do not fuse,
leaving a caudal opening to the spinal canal,the sacral hiatus.
6/14/2023 Prepared By FB 6
7. Cont…
• The spinal column normally forms a double C, being convex
anteriorly in the cervical and lumbar regions.
• Ligamentous elements provide structural support, and,
together with supporting muscles, help to maintain the
unique shape.
• Ventrally, the vertebral bodies and intervertebral disks are
connected and supported by the anterior and posterior
longitudinal ligaments.
6/14/2023 Prepared By FB 7
8. Cont…
• Dorsally, the ligamentum flavum, interspinous ligament, and
supraspinous ligament provide additional stability.
• Using the midline approach, a needle passes through these
three dorsal ligaments and through an oval space between
the bony lamina and spinous processes of adjacent vertebra.
6/14/2023 Prepared By FB 8
9. Cont…
• The anterior and posterior nerve roots at each spinal level join
one another and exit the intervertebral foramina, forming
spinal nerves from C1 to S5.
• At the cervical level, the nerves arise above their respective
vertebrae,but starting at T1, exit below their vertebrae.
• As a result, there are eight cervical nerve roots, but only
seven cervical vertebrae.
6/14/2023 Prepared By FB 9
10. Cont…
• The cervical and upper thoracic nerve roots emerge from the
spinal cord and exit the vertebral foramina nearly at the same
level.
• But, because the spinal cord normally ends at L1, lower nerve
roots course some distance before exiting the intervertebral
foramina.These lower spinal nerves form the cauda equina
(“horse’s tail”.
6/14/2023 Prepared By FB 10
11. Cont…
• Therefore, performing a lumbar (subarachnoid) puncture
below L1 in an adult (L3 in a child) usually avoids potential
needle trauma to the cord; damage to the cauda equina is
unlikely, as these nerve roots fl oat in the dural sac below L1
and tend to be pushed away (rather than pierced) by an
advancing needle.
• An extension of the pia mater, the filum terminale, penetrates
the dura and attaches the terminal end of the spinal cord
(conus medullaris) to the periosteum of the coccyx
6/14/2023 Prepared By FB 11
12. Cont…
• The blood supply to the spinal cord and nerve roots is derived
from a single anterior spinal artery and paired posterior spinal
arteries.
• The anterior spinal artery is formed from the vertebral artery
at the base of the skull and courses down along the anterior
surface of the cord.
• The anterior spinal artery supplies the anterior two-thirds of
the cord, whereas the two posterior spinal arteries supply the
posterior one-third.
• The posterior spinal
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13. Spinal Cord
– Adult
• Begins: Foramen Magnum
• Ends: L1
– Newborn
• Begins: Foramen Magnum
• Ends: L3
– Terminal End: Conus Medullaris
– Cauda Equina: Nerve group of lower dural sac
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15. Cont…
Epidural Space
• Space that surrounds the spinal meninges
Ligamentum Flavum
– Binds epidural space posteriorly
• Widest at Level L2
• Narrowest at Level C5
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16. Spinal Meninges
Dura Mater
◦ Outer most layer
◦ Fibrous
Arachnoid
◦ Middle layer
◦ Non-vascular
Pia
◦ Inner most layer
◦ Highly vascular
Sub Arachnoid Space
◦ Lies between the
arachnoid and pia
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18. Spinal Technique
• Midline Approach
– Skin
– Subcutaneous tissue
– Supraspinous ligament
– Interspinous ligament
– Ligamentum flavum
– Epidural space
– Dura mater
– Arachnoid mater
• Paramedian or Lateral Approach
• Same as midline excluding supraspinous & interspinous
ligaments, 2 cm lateral to the inferior aspect of the superior
spinous process of the desired level.
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19. Cont…
Anatomy.
The skin
Subcutaneous fat
The supraspinous ligament
The interspinous ligament
The ligamentum flavum
The epidural space
The dural sac.
The subarachnoid space
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21. Spinal Anesthesia
• Indications & Advantages
– Full stomach
– Anatomic distortions of upper airway
– TURP surgery
– Obstetrical surgery (T4 Level)
– Decreased post-operative pain
– Continuous infusion
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22. Spinal Anesthesia
• Contraindications
– Absolute:
• Refusal
• Infection
• Coagulopathy
• Severe hypovolemia
• Increased intracranial pressure
• Severe aortic or mitral stenosis
– Relative:
• Use your best judgment
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23. Spinal Anesthetic Agents
Only preservative-freelocal anesthetic solutions are used.
Addition of vasoconstrictors (α-adrenergic agonists,
epinephrine (0.1–0.2 mg)) and opioids enhance the quality
and/or prolong the duration of spinal anesthesia.
Vasoconstrictors seem to delay the uptake of local anesthetics
from CSF and may have weak spinal analgesic properties.
Opioids and clonidine can likewise be added to spinal
anesthetics to improve both the quality and duration of the
subarachnoid block.
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24. Cont…
• Hyperbaric bupivacaine and tetracaine are two of the most
commonly used agents for spinal anesthesia.Both are
relatively slow in onset (5–10 min) and have a prolonged
duration (90–120 min).
• Although both agents produce similar sensory levels,spinal
tetracaine more consistently produces motor blockade than
does the equivalent dose of bupivacaine.
• Addition of epinephrine to spinal bupivacaine prolongs its
duration only modestly.
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25. Cont…
• Lidocaine and procaine have a relatively rapid onset (3–5 min)
and short duration of action (60–90 min).
• Their duration is only modestly prolonged by vasoconstrictors.
• Although lidocaine spinal anesthesia has been used
worldwide, some experts no longer use this agent because of
the phenomenon of transient neurological symptoms and
cauda equina syndrome (CES)
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26. Pre-operative Visit.
Patients should be told about their anaesthetic during the
pre-operative visit.
It is important to explain that although spinal anaesthesia
abolishes pain, they may be aware of some sensation in
the relevant area, but it will not be uncomfortable and is
quite normal.
They must be reassured that, if they feel pain they will be
given a general anaesthetic.
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27. Premedication
- not always necessary, but if a patient is apprehensive,
a benzodiazepine such as 5-10 mg of diazepam may be
given orally 1 hour before the operation.
Other sedative or narcotic agents may also be used.
Anticholinergics such as atropine or scopolamine
(hyoscine) are unnecessary
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28. Preparation for Lumbar Puncture
1 . spinal needle.
2 . Introducer
3 . 5ml syringe for the spinal anaesthetic solution.
4 . 2 ml syringe for local anaesthetic to be used for skin
infiltration.
5 . selection of needles for drawing up the local
anaesthetic solutions and for infiltrating the skin.
6 . gallipot with a suitable antiseptic for cleaning the skin,
eg chlorhexidine, iodine, or methyl alcohol.
7 . Sterile gauze swabs for skin cleansing.
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29. Cont…
8 . sticking plaster to cover the puncture site.
The local anaesthetic to be injected intrathecally should be
in a single use ampoule.
Never use local anaesthetic from a multi-dose vial for
intrathecal injection.
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30. Pre-loading.
The volume of fluid given will vary with the age of the
patient and the extent of the proposed block. A young, fit
man having a hernia repair may only need 500 mls.
Older patients are not able to compensate as efficiently
as the young for spinal-induced vasodilation and
hypotension and may need 1000mls for a similar
procedure. If a high block is planned, at least a 1000mls
should be given to all patients. Caesarean section
patients need at least 1500 mls.
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31. Cont…
The fluid should preferably be normal
saline or Hartmann's solution.
-Colloids like hetasrach, dextran, can be
used.
-5% dextrose is readily metabolised and so
is not effective in maintaining the blood
pressure.
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34. Assessing the Block.
The patient is unable to lift his legs from the bed, the
block is at least up to the mid-lumbar region.
It is unnecessary to test sensation with a sharp needle
Test for a loss of temperature sensation using a swab
soaked in either ether or alcohol.
The patient can be gently pinched with artery forceps or
fingers on blocked and unblocked segments
Surgeons and patients should be reminded that when a
block is successful, a patient may still be aware of touch
but will not feel pain.
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35. Factors Affecting Spread Of Local Anesthetic:
• 1- Baricity; (heavy-Isobaric)
• 2-Position
• 3-Volume injected
• 4-Level of Injection
• 5-Concentration Of local anesth
• 6- Speed Of injection
• 7-Abdomial pressure (asites-pregnancy-
tumours) .
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36. • In the horizontal supine
position ,hyperbaric local
anesthetic solutions injected at
the height of the lumbar
lordosis (circle) flow down the
lumbar lordosis to pool in the
sacrum and in the thoracic
kyphosis.
• Pooling in the thoracic
kyphosis is thought to explain
the fact that hyperbaric
solutions produce blocks with
an average height of T4-6.
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37. Problems With Spinal Block
• 1-NO block at all…………………… .. ..
• 2-Block is one sided………… … ……. …
• 3-Block is not high enough…… … ….
• 4-Block is too high…………………………..
• 5-Nausea &Vomiting…………… . ….. ......
• 6-Shivering………………………… ….. .
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38. Epidural anesthesia
• produces a reversible loss of sensation and motor function
much like a spinal with the exception that local anesthetic is
placed within the epidural space.
• Larger doses of local anesthetic are required to produce
anesthesia when compared to a spinal anesthetic.
• Doses must be monitored to avoid toxicity.
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39. Cont…
• An epidural catheter allows the versatility to extend the
duration of anesthesia beyond the original dose by the
administration of additional local anesthetic.
• Epidural catheters may be left in place for postoperative
analgesia.
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40. Advantages
• Easy to perform (though it takes a bit more practice than
spinal anesthesia)
• Reliable form of anesthesia
• Provides excellent operating conditions
• The ability to administer additional local anesthetics
increasing duration
• The ability to use the epidural catheter for postoperative
analgesia
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41. Cont…
• Return of gastrointestinal function generally occurs faster
than with general anesthesia
• Patent airway
• Fewer pulmonary complications compared to general
anesthesia
• Decreased incidence of deep vein thrombosis and pulmonary
emboli formation compared to general anesthesia
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42. Disadvantages
• Risk of block failure
• Onset is slower
• Risk of complications
• Risk for infection
• Continuous epidural catheters should not be used on the
ward if the patient’s vital signs are NOT closely monitored.
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43. Factors Affecting Height of Epidural
Blockade
• Volume of local anesthetic- 1-2 ml of local anesthetic per
dermatome
• Age- A 20 year old vs 80 year old
• Height of the patient-The shorter the patient the less local
anesthetic required.
• Gravity
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44. Epidural Needles
• The standard epidural needle is typically 17–18 gauge,3 or 3.5
inches long, and has a blunt bevel with a gentle curve of 15–
30° at the tip.
• The Tuohy needle is most commonly used.
• The blunt, curved tip theoretically helps to push away the
dura aft er passing through the ligamentum flavum instead of
penetrating it.
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45. Epidural Catheters
• Placing a catheter into the epidural space allows for
continuous infusion or intermittent bolus techniques.
• In addition to extending the duration of the block, it may
allow a lower total dose of anesthetic to be used.
• Typically, a 19- or 20-gauge catheter is introduced through a
17- or 18-gauge epidural needle.
• The catheter is advanced 2–6 cm into the epidural space.
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46. Epidural Anesthesia
Test Dose: 1.5% Lido with Epi 1:200,000
◦ Tachycardia (increase >30bpm over resting HR)
◦ High blood pressure
◦ Light headedness
◦ Metallic taste in mouth
◦ Ring in ears
◦ Facial numbness
◦ Note: if beta blocked will only see increase in BP not HR
Bolus Dose: Preferred Local of Choice
◦ 10 milliliters for labor pain
◦ 20-30 milliliters for C-section
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47. Epidural Anesthesia
• Distances from Skin to Epidural Space
– Average adult: 4-6cm
– Obese adult: up to 8cm
– Thin adult: 3cm
• Assessment of Sensory Blockade
– Alcohol swab
• Most sensitive initial indicator to assess loss of
temperature
– Pin prick
• Most accurate assessment of overall sensory block
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48. Caudal Anesthesia
• It is used to provide peri and post operative analgesia
in adults and children.
• It may be the sole anaesthetic for some procedures,
or it may be combined with general anaesthesia.
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49. Caudal…..
• Caudal epidural anesthesia is a common regional
technique in pediatric patients.
• It may also be used for anorectal surgery in adults.
• The caudal space is the sacral portion of the epidural
space.
• Caudal anesthesia involves needle and/or catheter
penetration of the sacrococcygeal ligament covering
the sacral hiatus that is created by the unfused S4
and S5 laminae.
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50. Caudal…..
• The hiatus may be felt as a groove or notch above
the coccyx and between two bony prominences, the
sacral cornua.
• Its anatomy is more easily appreciated in infants and
children.
• The posterior superior iliac spines and the sacral
hiatus defi ne an equilateral triangle.
• Calcification of the sacrococcygeal ligament may
make caudal anesthesia difficult or impossible in
older adults.
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51. Caudal…..
• Within the sacral canal, the dural sac extends
to the first sacral vertebra in adults and to
about the third sacral vertebra in infants,
making inadvertent intrathecal injection more
common in infants.
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52. Cont….
• In children, caudal anesthesia is typically combined with general
anesthesia for intraoperative supplementation and
postoperative analgesia.
• It is commonly used for procedures below the diaphragm,
including urogenital, rectal, inguinal, and lower extremity
surgery.
• Pediatric caudal blocks are most commonly performed after the
induction of general anesthesia.
• The patient is placed in the lateral or prone position with one or
both hips flexed, and the sacral hiatus is palpated.
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53. • After sterile skin preparation, a needle or intravenous
catheter (18–23 gauge) is advanced at a 45° angle cephalad
until a pop is felt as the needle pierces the sacrococcygeal
ligament.
• The angle of the needle is then flattened and advanced.
• Aspiration for blood and CSF is performed, and, if negative,
injection can proceed.
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54. cont…
• A dosage of 0.5–1.0 mL/kg of 0.125–0.25% bupivacaine (or
ropivacaine), with or without epinephrine,can be used.
• Opioids may also be added (eg, 50–70 mcg/kg of morphine),
although they are not recommended for outpatients because
of the risk of delayed respiratory depression.
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55. Indications
• Anaesthesia and analgesia below the umbilicus
• Obstetric analgesia :For the 2nd stage or instrumental
deliveries.
• Care should be taken as the foetal head lies close to the site of
injection and there is real risk of injecting local anaesthetic
into the foetus.
• Chronic pain problems relating to lower limbs and lower
abdominal pains.
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56. Contraindications
• Infection near the site of the needle insertion.
• Coagulopathy or anti coagulation.
• Pilonidal cyst
• Congenital abnormalities of the lower spine or meninges,
because of the unclear or impalpable anatomy.
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57. • The caudal epidural space is
the lowest portion of the
epidural system and is
entered through the sacral
hiatus.
• The sacrum is a triangular
bone that consists of the five
fused sacral vertebrae (S1-
S5).
• It articulates with the fifth
lumber vertebra and the
coccyx.
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58. • The sacral hiatus is a defect in
the lower part of the posterior
wall of the sacrum formed by
the failure of the laminae of S5
and/or S4 to meet and fuse in
the midline.
• The sacral canal is a
continuation of the lumbar
spinal canal which terminates
at the sacral hiatus.
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59. Caudal Anesthesia
• Anatomy
– Sacrum
• Triangular bone
• 5 fused sacral vertebrae
• Needle Insertion
– Sacrococcygeal membrane
– No subcutaneous bulge or
crepitous at site of injection
after 2-3ml
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60. Technique
Prepared as for general anaesthesia:
1.NPO
2. Prepare all appropriate equipment for resuscitation
3. Follow aseptic technique
4. semi-prone position
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61. 5) The landmarks are palpated.
The sacral hiatus and the
posterior superior iliac
spines form an equilateral
triangle pointing inferiorly.
6)The sacral hiatus can be
located by first palpating
the coccyx, and then sliding
the palpating finger in a
cephalad direction until a
depression in the skin is felt.
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62. 7) Once the sacral hiatus is
identified the area above is
carefully cleaned with
antiseptic solution, and a 22
gauge cannula or needle is
directed at about 90 degree
to skin and inserted till a
"click" is felt as the sacro-
coccygeal ligament is
pierced.
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63. Cont…
Care should be taken not to insert the needle too far
as the dura lies at or below the S2 level in the child.
(8) The needle should be aspirated looking for either
CSF or blood.
The injection should never be more than 10 ml/30
seconds
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64. Caudal Anesthesia
• Post Operative Problems
– Pain at injection site is most common
– Slight risk of neurological complications
– Risk of infection
• Dosages
– commonly used drugs-Lignocaine 1% and
Bupivacaine 0.25%.
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65. Complications
a. IV or IO injection-: may lead to grand mal seizures and/or cardio-
respiratory arrest.
b. Dural puncture:-total spinal block will occur if the dose for a
caudal block is injected into the subarachnoid space
c. Perforation of the rectum
d. Sepsis.
e. Urinary retention.
f. Haematoma
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66. Axillary Block
• Position
– Head turned away
from arm being
blocked
– Abduct to 90º
– Forearm is flexed to
90º
– Palpate brachial artery
for pulse
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67. Axillary Block
• Advantages
– Provides anesthesia for forearm & wrist
– Fewer complications than a supraclavicular block
• Limitations
– Not for shoulder or upper arm surgery
– Musculocutaneous nerve lies outside of the
sheath and must be blocked separately
• Complications
– Intravascular injection
– Elevated bleeding time increases risk for
hematoma
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68. Axillary Block
• Dosing
– Lidocaine 1% 30-40ml
– Etidocaine 1% 30-40ml
– Bupivacaine 0.5% 30-40ml
• Note 40ml is most common dose
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69. Wrist Block
Radial nerve block
• To block the branches of the
radial nerve, make an injection
along the radial artery’s lateral
border 2 cm proximal to the
wrist .
• Then extend the injection
dorsally over the border of the
wrist
• Injection of 5 to 7 mL of local
anesthetic is usually sufficient.
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70. Ulnar nerve block
Ulnar artery pulsation as a
landmark for the ulnar nerve
block at the wrist; however,
the ulnar pulse is difficult to
appreciate in many patients.
A practical approach is to insert
the block needle just proximal
to the ulnar styloid process.
After aspiration to confirm that
the needle is not within the
ulnar artery,inject 3 to 5 mL of
local anesthetic.
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71. Median nerve block
Identify the tendons of the flexor
palmaris longus and flexor
carpi radialis by flexing the
wrist during palpation.
Insert the needle between the
tendons 2 cm proximal to the
wrist flexor crease,posteriorly
towards the deep fascia
Inject 3 to 5 mL of local
anesthetic while withdrawing
he needle.
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72. Ankle Block
• Blockade of 5 Nerves
– Tibial nerve
• Largest
• Heal & medial side sole of foot
– Superficial perineal nerve
• Branch of common perineal
• Dorsal (top) portion of foot
– Saphenous nerve
• Branch of femoral nerve
• Medial side of leg, ankle, & foot
– Sural nerve
• Branch of posterior tibial nerve
• Posterior lateral half of calf, lateral side of foot, & 5th toe
– Deep perineal nerve
• Continuation of common perineal nerve
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74. Ankle Block…
Tibial Nerve.
• located posterior to the posterior
tibial artery at the level of the
medial malleolus.
• Palpate the artery and insert the
needle passing posterior to the
artery.
• A nerve stimulator can be used
to help localize the nerve. The
needle will typically contact the
medial malleolus; after this
contact occurs, slightly withdraw
the needle.
• Inject 3 to 5 mL of local
anesthetic
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75. Ankle Block…
Deep Peroneal Nerve
This nerve runs lateral to the
dorsalis pedis artery at the
level of the foot.Palpate the
artery and insert the needle
lateral to the artery.
If bone is contacted, withdraw
the needle slightly before
injecting 2 to 4 mL of local
anesthetic
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76. Ankle Block…
Superficial Peroneal Nerve
Inject a subcutaneous wheal of
local anesthetic (5 mL) from
the anterior border of the
tibia to the lateral malleolus
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77. Saphenous Nerve
Inject a subcutaneous wheal
of local anesthetic (5 mL),
directing it posteriorly from
the tibial ridge to the
medial malleolus
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78. Ankle Block…
Sural Nerve
Insert the needle between the
Achilles tendon and the
lateral malleolus, and
subcutaneously infiltrate 5
mL of local anesthetic along
this course
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79. Regional Anesthesia in the Anticoagulated Patient
• Basic Labs:
– Platelet counts >50,000 (minimum), prefer >100,000
– Prothrombin time (PT) & Partial thrombin time (PTT)
– Thrombin time
– Hemoglobin & Hematocrit
– Bleeding time
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80. Regional Anesthesia in the Anticoagulated Patient
• Heparin:
– IV discontinue 4 hours prior to block
– SQ can block one hour prior to dose
– Do not D/C cath until 4 hours after heparin D/C’d & obtain
normal lab values
• LMWH:
– Stop 10 days prior to surgery
– Post op D/C cath 2 hours prior or 10 hours after first dose
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81. Regional Anesthesia in the Anticoagulated Patient
• NSAIDS:
– May be safe for regional block
– Ideal to stop 5 days prior to surgery
• ASA:
– Stop 7-10 days prior to surgery
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