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Issue Editor : Dr. Ganesh Ghongate
Executive Editor : Dr. J. Ravindranath
Assistant Editor : Dr. R. Sengupta
Editorial BoardDr. Nitin AbhyankarDr. Shrirang PanditDr. Vijay Natarajan
Dr. Jaydeep Date Dr. Dattatraya DhavaleDr. Mahesh Thombare
Dr. Bharat DikshitDr. P. K. Sharma
Board of TrusteesShri. Mukundas M. Lohia PresidentShri. Hasmukhlal A. Shah Vice PresidentShri. Devichand K. Jain Mg. TrusteeShri. Rajkumar H. Chordia Jt.Mg. TrusteeShri. Rasiklal M. Dhariwal TrusteeShri. Chandmal M. Parmar TrusteeShri. Dahyabhai M. Shah TrusteeDr. Chensukhlal J. Munot TrusteeShri. Amichand K. Sanghvi TrusteeShri. Hemraj D. Katariya TrusteeShri. Kiritbhai R. Shah TrusteeShri. Champaklal V. Suratwala TrusteeShri. Mukunddas M. Kasat TrusteeShri. Bhabutmal P. Jain TrusteeShri. Purushottam M. Lohia TrusteeShri. Prakash R. Dhariwal TrusteeShri. Harinarayan J. Rathi TrusteeShri. Nainesh M. Nandu Trustee
* Views expressed by authors are their own and not necessarily those of the editorial board.
* For Private circulation only.* Copyright reserved.* Registration with Register of News Papers of India
No. - MAHBIL/2000/1809
Publisher, Printer & Editor : Mr. Devichand K. Jain, Managing TrusteeOwner of Bulletin : Rajasthani & Gujarati Charitable Foundation
through Poona Hospital & Research Centre, Pune 411 030.
Place of Publication : 27, Sadashiv Peth, Pune - 30.Name of Printing Press : Typographica Press Services 2181, Sadashiv Peth, Tilak Road, Pune 30.
Contents Page
Editorial 2
Regional Anaesthesia 3Dr. Ganesh Ghongate
Neuraxial Anaesthesia - Anatomy & 5Mechanism of ActionDr. Ganesh Ghongate
Spinal Anaesthesia 8Dr. Ganesh Ghongate
Hospital Update 11
Epidural Anaesthesia 15Dr. Janhavi Thatte
Caudal Anaesthesia 18Dr. Rajendra Gosavi
Complications of Neuraxial Blocks 20Dr. Ganesh Ghongate
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Vol. 15, Issue No. 3 July-September 2014
PHRCBULLETIN
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Dear Readers,
Greetings from PHRC.
It gives me immense pleasure to present our PHRC bulletin dedicated to regional anaesthesia. Anaesthesia & surgery have progressed together as complimentary faculties.
Progressively complicated & prolonged surgeries demanded improved anaesthetic techniques and progress towards safer anaesthesia encouraged advancements in the surgical field.
Over the years the morbidity associated with general anaesthesia became apparent & the emphasis shifted towards regional techniques which require more skill but are safer & associated with fewer complications, once they are mastered.
Today most of the surgical procedures are carried out under central neuraxial blockade i.e. spinal and epidural anaesthesia.
The practical considerations explained in the articles definitely increase success rate and reduce complications. In this issue we give you an idea of regional anaesthesia and its technical considerations.
This issue also includes a Marathi article giving a brief idea regarding anaesthesia and its applications. It will definitely help to clear concepts regarding anaesthesia for any kind of surgery and ensure good outcome.
Thank you.
With regards,
Dr. Ganesh D. Ghongate Consultant Anaesthesiologist Poona Hospital & Research Centre
EDIToRIAL
5*Consultant Anaesthesiologist, E-mail : [email protected] , Cell : 9823219497.
Regional AnaesthesiaDr. Ganesh Ghongate*
Regional anaesthesia and analgesia has the potential to provide excellent operating conditions and prolonged post – operative pain relief at a low cost & with fewer side effect.
Regional anaesthesia can be used alone or in combination with general Anaesthesia.
Regional anaesthesia offers better and longer pain relief with fewer side effects than the drugs used for general Anaesthesia. As a result, it is increasingly popular for ambulatory anaesthesia and has contributed to the percentage of day – care patients increasing from less than 10% to around 65%.
v Relative indications of regional anaesthesia• To avoid some of the known dangers of general
Anaesthesia such as impossible intubation and severe respiratory failure, and where relaxation problems are expected.
• Patients who specifically request for regional Anaesthesia.
• To provide high quality of pain relief.• As a part of post – operative multimodal
rehabilitation programme to enable early return of function.
v Fundamental of regional anaesthesia is blocking the nerve conduction of the supplying area by injecting local anaesthetic solution in the perineural area. The most commonly used local anaesthetics are lignocaine and bupivacaine.
v Practical considerations :-
Regional anaesthesia and analgesia is used less frequently than it might be because of -
• Time taken to establish the block.• Inexperience of the anaesthetist and the fear of
failure.• Fear of neurological complications.• Unpopularity of having awake patients during
operations.• Concern that a single injection block may wear
off in a few hours.
v Few of these problems can be overcome by using new techniques like• Use of peripheral nerve stimulator.• Use of ultrasound for exact placement of drug.• Use of perineural catheters for continuous
analgesia for longer time.
v Different techniques of regional anaesthesia are. H Topical Anaesthesia:- Topical Anaesthesia can be applied. • On gauze swabs • As liquid in spray • As a cream, gel or ointment • As an aerosol • By direct instillations (e.g. Conjunctiva,
Nose and trachea) • Sites of topical analgesia are conjunctival
sac, external ear, nasal cavities, upper air passages, perineal area and vagina.
H Infiltration analgesia :- A weal of local anaesthetic is raised in the
skin. Lignocaine 1-2% with adrenaline is ideal for this procedure.
It is used mainly for skin incision and suturing of skin.
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H Neuraxial anaesthesia :- It is a type of regional anaesthesia & includes
spinal, epidural and caudal anaesthesia. This is a better option for lower abdominal, lower limb surgeries and genitourinary surgeries.
Some studies suggest post–operative morbidity & mortality is reduced when neuro – axial blockade is used alone or along with general Anaesthesia.
H Peripheral nerve blocks :- It includes injection of local anaesthetics into
perineural sheath of peripheral nerves. The use or peripheral nerve blocks is
increasing as primary and sole anaesthetic technique to facilitate painless surgeries. Patient satisfaction is improved and less cognitive impairment and side effects are seen compared to general anaesthesia.
Types of blocks -
I. Upper Extremity • Brachial plexus block –
a) Interscalene b) Supra clavicular (Subclavian) c) Infra clavicular d) Axillary • Bier’s • Peripheral nerve block of Arm
II. Lower extremity • Lumbar plexus (Psoas block) • Femoral Nerve block • Sciatic Nerve block • Ankle block
III. Trunk • Superficial cervical plexus block • Inter costal block • Paravertebral Nerve block • Inguinal Nerve block • Penile block
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poona hospital & research centre.
department of anaesthesia.
HOD • DR. RAJENDRA GOSAVI
• DR. D. V. KUSHTE • DR. S. C. MUTHA
• DR. (MS.) S. S. LOKARE • DR. (MS.) R. THOMAS
• DR. S. S. NILEGAONKAR • DR. A. D. GAIKWAD
•DR. (MS.) A. S. LIMAYE • DR. V. B. MAHAJAN
• DR. (MS.) J. M. THATTE • DR. S. A. MAHADIK
• DR. (MS.) C. S. PATKAR • DR. G. D. GHONGATE
7*Consultant Anaesthesiologist, E-mail : [email protected] , Cell : 9823219497.
Neuraxial Anaesthesia - Anatomy & Mechanism of ActionDr. Ganesh Ghongate *
Central neuraxial blockade includes spinal, epidural and caudal anaesthesia. We must know the anatomy and mechanism of action of neuraxial Anaesthesia for better results and fewer complications.
ANAToMY -THE VERTEBRAL COLUMNThe spine is composed of vertebral bones and fibrocartilaginous intervertebral discs. There are 7 cervical, 12 thoracic and 5 lumbar vertebrae. The sacrum is a fusion of 5 sacral vertebrae and there are small rudimentary coccygeal vertebrae. The spine as a whole provides structural support for the body and protection for the spinal cord and nerves and allows a degree of mobility in several spatial planes. At each vertebral level, paired spinal nerves exit the central nervous system.
Vertebrae differ in size and shape at various levels. The first cervical vertebra, the Atlas lacks a body & has unique articulation with base of the skull & second vertebra. The second vertebra also called
Axis, consequently has atypical articulating surfaces. All 12 thoracic vertebrae articulate with their corresponding ribs. Lumbar vertebrae have larger anterior cylindrical vertebral bodies. A hollow ring is defined anteriorly by the vertebral body, laterally by the pedicles and transverse processes & posteriorly by the laminae & spinous processes. The laminae extend between transverse processes & spinous processes & the pedicles extend between vertebral bodies and transverse processes. When stacked vertically, the hollow ring becomes the spinal canal in which the spinal cord and its coverings sit.
The individual vertebral bodies are connected by the intervertebral discs. The pedicles are notched superiorly and inferiorly, these notches forming the intervertebral foramina, from which spinal nerves exit. Sacral vertebrae normally fuse into
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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.
The spinal column normally forms a double C, being convex anteriorly in the cervical and lumbar regions. Ventrally the vertebral bodies & intervertebral discs are connected & supported by the anterior and posterior longitudinal ligaments. Dorsally, ligamentum flavum, interspinous ligament, and supraspinous ligament provide additional stability. Using midline approach, a needle passes
through these three dorsal ligaments and through an oval space between the bony lamina and spinous process of adjacent vertebrae.
THE SPINAL CoRDThe spinal canal contains the spinal cord and its coverings (the meninges), fatty tissue, and a venous plexus. The meninges are composed of three layers; the pia mater, the arachnoid mater, and the dura mater; all are continuous with their cranial counterparts. The pia mater is closely adherent to the spinal cord; whereas the arachnoid mater is usually closely adherent to the thicker and denser dura mater.
Cerebrospinal fluid (CSF) is contained between the pia and arachnoid maters in the subarachnoid space. The spinal subdural space is poorly demarcated potential space that exists between the dura and arachnoid membranes. The epidural space is better defined potential space within the spinal canal that is bounded by the dura and the ligamentum flavum.
The spinal cord normally extends from the foramen magnum to the level of L1 in adults. In children the spinal cord ends at L3 and moves to L1 as they grow older. 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 spinal nerves arise above their respective vertebrae, but starting at T1 they exit below their vertebrae. As a result there are eight cervical nerve roots and only seven cervical vertebrae. The cervical and upper thoracic nerve roots exit nearly at the same level. But because the spinal cord ends at the L1, lower nerve roots course some distance before exiting intervertebteral foramina. These lower spinal nerves form the cauda equina (horse’s tail). Therefore performing a lumbar puncture below L1in adult (L3 in child) avoids potential trauma to cord; as these nerve roots are pushed away rather
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than pierced by an advancing needle.
The dural sac and the subarachnoid and subdural spaces usually extend upto S2 in adults and often to S3 in children. Because of this fact and smaller body size, caudal anaesthesia carries a greater risk of subarachnoid injection in children than in adults.
BLooD SUPPLY -The blood supply to the spinal cord and the nerve roots is derived from a single anterior spinal artery and paired posterior arteries. The anterior spinal artery supplies the anterior two thirds of the cord, where as the posterior spinal arteries supply the posterior one third. The anterior and posterior spinal arteries receive additional blood flow from the intercostal arteries in the thorax and the lumbar arteries in the abdomen. One of these radicular arteries is typically large, the Artery of Adamkiewics, or Arteria radicularis magna, arising from the aorta. It is usually unilateral and nearly always arises on the left side, providing blood supply to the anterior, lower two-third of the spinal cord. Injury to this artery can result in tha anterior spinal artery syndrome.
Mechanism of actionThe principle site of action for neuraxial blockade is the nerve root. Local anaesthetic is injected into CSF (spinal anaesthesia) or the epidural space (epidural and caudal Anaesthesia) and bathes the nerve roots in the subarachnoid space or epidural space, respectively. Direct injection of local anaesthetic into CSF for spinal Anaesthesia allows a relatively small dose and volume of local anaesthetic to achieve dense sensory and motor blockade. In contrast, the same local anaesthetic concentration is achieved at nerve roots only with much higher volumes of local anaesthetic with epidural and caudal Anaesthesia. Blockade of neural transmission (conduction) in the posterior
nerve root fibres interrupts somatic and visceral sensations, whereas blockade of anterior nerve root fibers prevents efferent motor and autonomic outflow.
SoMATIC BLoCKADE By interrupting the transmission of painful stimuli and abolishing skeletal muscle tone, neuraxial blocks can provide excellent operating conditions. Sensory blockade interrupts both somatic and visceral painful stimuli, whereas motor blockade produces skeletal muscle relaxation. Smaller and myelinated fibers are more easily blocked than larger and unmyelinated ones. This and the fact that the concentration of local anaesthetic decreases with increasing distance from level of injection, explain the phenomenon of differential blockade.
Differential blockade typically results in sympathetic blockade (judged by temperature sensitivity) that may be two segments higher than the sensory block (pain, light touch), which in turn is usually two segments higher than the motor blockade.
AUToNoMIC BLoCKADE Interruption of efferent autonomic transmission at the spinal nerve roots can produce sympathetic and parasympathetic blockade. Sympathetic outflow from the spinal cord may be described as thoracolumbar, whereas parasympathetic outflow is craniosacral. Sympathetic preganglionic nerve fibers (small, myelinated B fibers) exit the spinal cord with the spinal nerves from T1 to the L2 level. In contrast, parasympathetic preganglionic nerve fibers exit the spinal cord with cranial and sacral nerves.
Neuraxial anaesthesia does not block the vagus nerve. The physiological responses of neuraxial blockade therefore result from decreased sympathetic tone and/or unopposed parasympathetic tone.
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Spinal anaesthesia involves the use of local anaesthetics injected into the intrathecal space to produce a reversible loss of sensation and motor function.
It is a skillfull procedure. It requires less dose of drug as it is directly placed in CSF, which bathes nerve roots and produces immediate effect.
Indications : • Lower Abdominal Surgery • Obstetric Surgery • Orthopedic Surgery of Lower Limbs • Genitourinary / Perineal Surgery
Contraindications :« Absolute. 1) Patient refusal 2) Coagulopathy or bleeding Diathesis. 3) Increased Intracranial pressure 4) Infection at the site of Injection.
« Relative. • Unco-operative Patient • Severe Hypovolemia • Sepsis • Severe/Aortic stenosis & Mitral Stenosis.
« Technical Considerations : Spinal Anaesthesia should be performed only
in a facility in which all the equipment and drugs needed for resuscitation & intubation are immediately available.
• Consent should be checked. • Patient should be explained about the procedure
to be done.
*Consultant Anaesthesiologist, E-mail : [email protected] , Cell : 9823219497.
Spinal AnaesthesiaDr. Ganesh Ghongate *
• Minimum monitoring required includes – o Pulse oxymetry o Blood pressure o ECG
« Surface Anatomy :Spinous processes are generally palpable over spine and help define the midline. A line drawn between the highest points of both iliac crests (Tuffier’s Line) usually crosses either the body of L4 or L4-L5 interspace. Counting spinous processes up and down from the reference point, identifies other spinal levels.
« Patient Positioning : It can be done in three PositionsA. Sitting Position : The anatomic midline is
often easier to appreciate when patient is sitting than it is in lateral decubitus position. Flexion of spine (arching the back “Like a Mad Cat”) maximizes the “target” area between adjacent spinous processes and brings the spine closer to skin surface.
B. Lateral Decubitus : Patient lies on his side with knees flexed and pulled high against the abdomen or chest assuming a ‘Fetal Position’. An assistant can help the patient assume and hold this position.
C. Prone Position: The position may be used for anorectal procedure utilizing a hypobaric anaesthetic solution.
• The advantage is that the block is performed in the same position as for operative procedure so no need to move the patient.
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• The disadvantage is that CSF will not freely flow through the needle so that correct subarachnoid needle tip placement will need to be confirmed by CSF aspiration.
« Anatomic Approach : Anatomic landmarks for the desired block are
first identified. A sterile field is established with betadine solution. A skin weal is raised at the level of the chosen interspace with local anaesthetic using a small (26 gauze) needle.
A. Mid-line Approach : The spine is palpated and patient’s body position is examined to ensure that plane of back is perpendicular to that of floor.
After preparing and anaesthetizing the skin, the spinal needle is introduced in midline. After the needle courses deeper, it will enter the supraspinous & interspinous ligaments, felt as an increase in tissue density. Then the needle penetrates the ligament flavum, an obvious increase in resistance is usually encountered. The needle enters the epidural space. The needle is advanced further through the epidural space and penetrates the arachnoid membrance as signaled by free flowing CSF.
B. Para-median Approach: The paramedian technique may be selected if SAB block is difficult, particularly in patients who can not position properly (eg, severe arthritis, Kyphoscoliosis or prior lumbar spine surgery).
C. Assessing level of blockade: with knowledge of sensory dermatomes, the sensory level achieved by a block can be assessed by a blunted needle (pinprick) where as the level of sympathetic block is assessed by measuring skin temperature sensation.
« Spinal Needles : Spinal needles are comm- ercially available in an array of sizes (16-30 gauge), length and level and designs.
Broadly they can be divided into either of sharp (cutting) – tipped or blunt tipped needles.
« The Quincke needle is a cutting needle with end injection port.
Spinal needle placed in the subarachnoid space
« The Whitacre and pencil point needles have rounded points and side injection ports.
« The Sprotte is a side injection needle with a long side port.
The introduction of blunt tip (pencil point) needles has markedly decreased the incidence of post dural puncture headache.
In general the smaller the gauge of needle, the lower the incidence of headache.
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« Factors affecting the level of spinal anaesthesia.
- Most important factors. • Baricity of anaesthetic solution. • Position of patient during injection
- Immediately after injection. • Drug doasage • Site of injection.
- Other factors. Age. Cerebrospinal fluid. Curvature of the spine. Drug volume. Intra-abdominal pressure. Needle direction. Patient height. Pregnancy.
Above table lists factors that affect level of blockade following spinal anaesthesia.
In general higher the dosage or site of injection the higher the level of anaesthesia obtained.
A hyperbaric solution of local anaesthetic is denser (heavier) than CSF & tends to move down with
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gravity. Hypobaric solution is lighter than CSF and moves up.
Thus with head down position a hyperbaric anaesthetic solution spreads cephalad and hypobaric solution moves caudad.
CSF volume inversely co-relates with the level of anaesthesia. Increased intra abdominal pressure or condition that cause engorgement of the epidural veins, thus decreasing CSF volume, are associated with higher blocks.
« Spinal Anaesthesia agents : Most commonly used agents are local
anaesthetics. Hyperbaric buprivacaine (sensorcaine) &
lignocaine are commonly used. Addition of adrenaline can prolong its duration
of action. Other agents than can be used after analgesia
are – - Ketamine - Fentanyl - Morphine - neostigmine
« Complications : will be discussed in next article.
• A particularly sour-tempered nurse was harassing Rajeev during his week-long stay in hospital.
An old aunt came to visit him and remarked in all her wisdom, ‘I always told you, an apple a day keeps the doctor away.’
Rajeev promptly replied, ‘And what does it take to get rid of the nurse?’
vvv
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Hospital UpdateCONGRATULATIONS –• Dr. Suhas Mondhe & Dr. Govind Vaijwade for successfully passing DNB General Medicine
Examination.• Head of Department of Cardiology Dr. Suhas Hardas performed a complex Coronary Angioplasty
that was Live Telecast via satellite to Orlando C3 conference, Florida. This was viewed by about 2000cardiologists across the world. The procedure carried out by Dr. Hardas and his team was very wellappreciated by the cardiology fraternity. This is the first time that our local talents were showcasedinternationally.
l CAMPS -• Blood Donation Camps :
A total of 5 Blood Donation Camps were arranged during the months June & July 2014. People gavevery encouraging response to these Camps. A total of 430 people donated blood during thesecamps.The 28th Blood Donation Camp was held in memory of Late Shri Rakesh D. Jain in Poona Hospital& Research Centre on 15th July 2014 to mark the occasion of his 8th Death Anniversary. ShriGaneshji Bidkar, Leader of B.J.P., PMC, inaugurated the camp. More than 140 people donatedblood. Several Trustees of the hospital were also present on the occasion.
• Free Vertigo Detection & Treatment Camps : Two camps were arranged on 22nd June 2014 & 20th
July 2014 for individuals suffering from frequent attacks of vertigo, each lasting for just a fewseconds. A total of 81 people participated & benefited. The Consultation, VNG test & Repositioningwere done free of cost in these camps.
PATIENTS FASHION SHOW –A Unique fashion show by 50 Bariatric Surgery (weight-loss surgery) patients was held in PoonaHospital & Research Centre, Auditorium on 01st June 2014. Dr Jayashree Todkar, Bariatric Surgeonarranged this event to mark 10 years of performing such complicated surgeries. The patients were in theage-group of 16 to 68 and enthusiastically participated in the fashion show.
CME’S, SEMINAR’S & TRAINING PROGRAMMES –• Abbott Healthcare Ltd., organized a Lecture on ‘Cardiology’ on 16th May 2014.• Indian Society of Anaesthesiologists, arranged a Lecture on ‘Hypothermia’ on 23rd May 2014.• Food & Drug Association, Pune, arranged a Meeting on 31st May 2014.• Dr Jayashree Todkar organized a Patient Get-together on 1st June 2014.• IPCA Pharmaceuticals organized a CME on ‘Current Trends in Cardiology’ for Jain Doctors
Association on 29th June 2014.
• Department of Medicine, Poona Hospital & Research centre organized the following CMEs� ‘Diabetes Mellitus’, ‘Liver Disease’ & ‘Heart Disease’ on 10th June 2014.� ‘Anemia & Pregnancy’, ‘Hypertension & Pregnancy’ & ‘Arrhythmias in Pregnancy’ on 08th
July 2014.
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DEPARTMENT MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
MORNING 10 A.M. TO 12.30 P.M.
MEDICINE DR. N. M. BEKE Dr. V. GUNDECHA DR. A. BAHULIKAR DR. V. G. SHAH DR. M. TULPULE DR. K. P. RUNWAL DR. A. TAMBOLKAR
SURGERY DR. R. S. DUMBRE DR. D. JAIN DR. A. PORWAL DR. A. FERNANDES DR. B. DIKSHIT DR. S. SHAH DR. A. FERNANDES
GYNAE & OBSTETRICS DR. (MS) S ANPAT DR. (MS) S. KAKATKAR DR. A. SHAH DR (MS) N. DESAI DR. (MS) G. BARVE DR. (MS) N. DESAI ----
PAEDIATRICS DR. P. V. ALATE ---- DR. L. RAWAL DR. P. V. ALATE ---- DR. L. RAWAL ----
ORTHOPAEDICS DR. R. KOTHARI DR. A. DESAI DR. R. ARORA DR. R. KOTHARI DR. A. DESAI DR. N. NAHAR ----
E.N.T. (10.30a.m.-1.30p.m.) DR. A. M. ATHANIKAR DR. (MS) V. SHIRVEKAR DR. (MS) V. JOSHI DR. A. M. ATHANIKAR DR. S. PABALKAR DR. (MS) V. JOSHI ----
OPTHALMOLOGY DR. (MS) V. RAWAL DR. P. GORANE Dr. (MS) S. PURANIK DR. R. BHANGE DR. (MS) V. RAWAL Dr. (MS) S. PURANIK ----
PSYCHIATRY DR. V. G. WATVE DR. D. M. DHAWALE DR. S. CHAUGULE DR. V. G. WATVE DR. D. M. DHAWALE DR. S. CHAUGULE DR. M. DIXIT / DR. H. KULKARNI
DERMATOLOGY DR. H. S. CHOPADE DR. S. TOLAT DR. H. S. CHOPADE ---- DR. H. S. CHOPADE ---- ----
CHEST DISEASES DR. N. ABHYANKAR ---- DR. N. ABHYANKAR DR. AJIT KULKARNI DR. N. ABHYANKAR DR. (MS) V. KHADKE DR. J. JAIN
ONCOLOGY DR. S. M. KARANDIKAR DR. S. M. KARANDIKAR ---- ---- DR. S. M. KARANDIKAR ---- ----
ONCOSURGERY ---- ---- DR. S. MOHITE DR. S. MOHITE ---- DR. S. MOHITE ----
11.30 A.M. TO 12.30 P.M.
CARDIOLOGY DR. M. ASAWA DR. S. SATHE DR. S. HARDAS DR. H. GUJAR / DR. I. ZANWAR DR. P. SHAH DR. C. CHAVAN ----
CARDIAC SURGERY DR. V. NATARAJAN DR. M. BAFANA DR. V. NATARAJAN DR. R. JAGTAP * DR. V. NATARAJAN DR. R. JAGTAP * * By Appointment Only
DR. V. NATARAJAN
NEUROLOGY DR. N. BHANDARI DR. S. KOTHARI DR. (MS) A. BINIWALE DR. P. K. SHARMA DR. S. KOTHARI DR. P. K. SHARMA ----
NEURO-SURGERY DR. P. BAFNA DR. S. PATKAR DR. N. LONDHE DR. S. PATKAR DR. P. BAFNA DR. S. PATKAR ----
NEPHROLOGY DR. N. C. AMBEKAR DR. S. V. UKIDVE (10-12 p.m.) DR. N. C. AMBEKAR DR. S. V. UKIDVE (10 - 12 p.m.) DR. N. C. AMBEKAR DR. S. V. UKIDVE (10-12 p.m.)
URO-SURGERY DR. S. BHAVE ---- DR. J. DATE DR. S. BHAVE DR. J. DATE ---- ----
PLASTIC SURGERY DR. R. GANDHI DR. S. PANDIT DR. R. GANDHI DR. S. PANDIT DR. S. PANDIT DR. R. GANDHI ----
GASTROENTEROLOGY (MED.) DR. V. THORAT DR. N. DUBALE DR. V. THORAT ---- DR. S. JAIN DR. N. DUBALE ----
GASTROENTEROLOGY (SURG) ---- DR. R. TANDULWADKAR ---- DR. R. TANDULWADKAR DR. M. THOMBARE ---- ----
ENDOCRINOLOGY DR. M. MAGDUM ---- ---- ---- DR. M. MAGDUM ---- ----
HAND SURGERY DR. A. WAHEGAONKAR DR. A. GHOSH ---- DR. A. WAHEGAONKAR DR. A. GHOSH ---- ----
AFTERNOON 1 P.M. TO 3.30 P.M.
MEDICINE DR. C. G. SHETTY DR. (MS) A. SHAHADE DR. (MS) G. DAMLE DR. S.V. NAGARKAR DR. A. CHOPDAWALA DR. A. CHOPDAWALA ----
SURGERY DR. P. PRADHAN DR. B. DIKSHIT ---- DR. A. FERNANDES ---- ---- ----
GYNAE & OBSTETRICS ---- DR. (MS) M. CHIPLONKAR ---- ---- ---- DR. (MS) M. CHIPLONKAR ----
VASCULAR SURGERY ---- ---- DR. D. R. KAMERKAR ---- ---- ---- ----
OPHTHALMOLOGY Dr. (MS) S. PURANIK Dr. (MS) S. PURANIK Dr. (MS) S. PURANIK Dr. (MS) S. PURANIK Dr. (MS) S. PURANIK DR. (MS) V. RAWAL ----
CARDIOLOGY---- ---- ---- ---- ---- ---- ----
NEUROLOGY DR. D. SASTE (2 to 4 p.m.) ---- DR. N. BHANDARI ---- ---- ---- ----
SURGERY3.00 p.m. to 5 p.m. DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR ----
ORTHOPAEDICS 3.00 - 5.00 p.m. DR. S. SONAWANE DR. H. PATKAR DR. S. SONAWANE DR. H. PATKAR DR. S. SONAWANE DR. H. PATKAR ----
ONCOLOGY 2.00 p.m. - 3.00 p.m. ---- ---- DR. A. RANADE / DR. A. BHATT ---- DR. A. RANADE / DR. A. BHATT ---- ----
SPECIALITY CLINICS
HERNIA CLINIC 12.30 p.m. - 1.30 p.m. ---- ---- ---- DR. M. P. DESARDA ---- ---- ----
DIABETOLOGY 8.30 a.m - 9.30 a.m. DR. (MS.) G. DAMLE DR. B. B. HARSHE ---- ---- DR. B. B. HARSHE ----
HEMATOLOGY 9.00 a.m.-11.00 a.m. ---- ---- ---- DR. V. RAMANAN ---- ---- ----
PROCTOLOGY12.00 p.m. to 2.00 p.m. ---- ---- ---- ---- ---- DR. ASHWIN PORWAL ----
(10.00 a.m. to 12.30 p.m.)
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DEPARTMENT MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
MORNING 10 A.M. TO 12.30 P.M.
MEDICINE DR. N. M. BEKE Dr. V. GUNDECHA DR. A. BAHULIKAR DR. V. G. SHAH DR. M. TULPULE DR. K. P. RUNWAL DR. A. TAMBOLKAR
SURGERY DR. R. S. DUMBRE DR. D. JAIN DR. A. PORWAL DR. A. FERNANDES DR. B. DIKSHIT DR. S. SHAH DR. A. FERNANDES
GYNAE & OBSTETRICS DR. (MS) S ANPAT DR. (MS) S. KAKATKAR DR. A. SHAH DR (MS) N. DESAI DR. (MS) G. BARVE DR. (MS) N. DESAI ----
PAEDIATRICS DR. P. V. ALATE ---- DR. L. RAWAL DR. P. V. ALATE ---- DR. L. RAWAL ----
ORTHOPAEDICS DR. R. KOTHARI DR. A. DESAI DR. R. ARORA DR. R. KOTHARI DR. A. DESAI DR. N. NAHAR ----
E.N.T. (10.30a.m.-1.30p.m.) DR. A. M. ATHANIKAR DR. (MS) V. SHIRVEKAR DR. (MS) V. JOSHI DR. A. M. ATHANIKAR DR. S. PABALKAR DR. (MS) V. JOSHI ----
OPTHALMOLOGY DR. (MS) V. RAWAL DR. P. GORANE Dr. (MS) S. PURANIK DR. R. BHANGE DR. (MS) V. RAWAL Dr. (MS) S. PURANIK ----
PSYCHIATRY DR. V. G. WATVE DR. D. M. DHAWALE DR. S. CHAUGULE DR. V. G. WATVE DR. D. M. DHAWALE DR. S. CHAUGULE DR. M. DIXIT / DR. H. KULKARNI
DERMATOLOGY DR. H. S. CHOPADE DR. S. TOLAT DR. H. S. CHOPADE ---- DR. H. S. CHOPADE ---- ----
CHEST DISEASES DR. N. ABHYANKAR ---- DR. N. ABHYANKAR DR. AJIT KULKARNI DR. N. ABHYANKAR DR. (MS) V. KHADKE DR. J. JAIN
ONCOLOGY DR. S. M. KARANDIKAR DR. S. M. KARANDIKAR ---- ---- DR. S. M. KARANDIKAR ---- ----
ONCOSURGERY ---- ---- DR. S. MOHITE DR. S. MOHITE ---- DR. S. MOHITE ----
11.30 A.M. TO 12.30 P.M.
CARDIOLOGY DR. M. ASAWA DR. S. SATHE DR. S. HARDAS DR. H. GUJAR / DR. I. ZANWAR DR. P. SHAH DR. C. CHAVAN ----
CARDIAC SURGERY DR. V. NATARAJAN DR. M. BAFANA DR. V. NATARAJAN DR. R. JAGTAP * DR. V. NATARAJAN DR. R. JAGTAP * * By Appointment Only
DR. V. NATARAJAN
NEUROLOGY DR. N. BHANDARI DR. S. KOTHARI DR. (MS) A. BINIWALE DR. P. K. SHARMA DR. S. KOTHARI DR. P. K. SHARMA ----
NEURO-SURGERY DR. P. BAFNA DR. S. PATKAR DR. N. LONDHE DR. S. PATKAR DR. P. BAFNA DR. S. PATKAR ----
NEPHROLOGY DR. N. C. AMBEKAR DR. S. V. UKIDVE (10-12 p.m.) DR. N. C. AMBEKAR DR. S. V. UKIDVE (10 - 12 p.m.) DR. N. C. AMBEKAR DR. S. V. UKIDVE (10-12 p.m.)
URO-SURGERY DR. S. BHAVE ---- DR. J. DATE DR. S. BHAVE DR. J. DATE ---- ----
PLASTIC SURGERY DR. R. GANDHI DR. S. PANDIT DR. R. GANDHI DR. S. PANDIT DR. S. PANDIT DR. R. GANDHI ----
GASTROENTEROLOGY (MED.) DR. V. THORAT DR. N. DUBALE DR. V. THORAT ---- DR. S. JAIN DR. N. DUBALE ----
GASTROENTEROLOGY (SURG) ---- DR. R. TANDULWADKAR ---- DR. R. TANDULWADKAR DR. M. THOMBARE ---- ----
ENDOCRINOLOGY DR. M. MAGDUM ---- ---- ---- DR. M. MAGDUM ---- ----
HAND SURGERY DR. A. WAHEGAONKAR DR. A. GHOSH ---- DR. A. WAHEGAONKAR DR. A. GHOSH ---- ----
AFTERNOON 1 P.M. TO 3.30 P.M.
MEDICINE DR. C. G. SHETTY DR. (MS) A. SHAHADE DR. (MS) G. DAMLE DR. S.V. NAGARKAR DR. A. CHOPDAWALA DR. A. CHOPDAWALA ----
SURGERY DR. P. PRADHAN DR. B. DIKSHIT ---- DR. A. FERNANDES ---- ---- ----
GYNAE & OBSTETRICS ---- DR. (MS) M. CHIPLONKAR ---- ---- ---- DR. (MS) M. CHIPLONKAR ----
VASCULAR SURGERY ---- ---- DR. D. R. KAMERKAR ---- ---- ---- ----
OPHTHALMOLOGY Dr. (MS) S. PURANIK Dr. (MS) S. PURANIK Dr. (MS) S. PURANIK Dr. (MS) S. PURANIK Dr. (MS) S. PURANIK DR. (MS) V. RAWAL ----
CARDIOLOGY---- ---- ---- ---- ---- ---- ----
NEUROLOGY DR. D. SASTE (2 to 4 p.m.) ---- DR. N. BHANDARI ---- ---- ---- ----
SURGERY3.00 p.m. to 5 p.m. DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR DR. (MS) S. KELKAR ----
ORTHOPAEDICS 3.00 - 5.00 p.m. DR. S. SONAWANE DR. H. PATKAR DR. S. SONAWANE DR. H. PATKAR DR. S. SONAWANE DR. H. PATKAR ----
ONCOLOGY 2.00 p.m. - 3.00 p.m. ---- ---- DR. A. RANADE / DR. A. BHATT ---- DR. A. RANADE / DR. A. BHATT ---- ----
SPECIALITY CLINICS
HERNIA CLINIC 12.30 p.m. - 1.30 p.m. ---- ---- ---- DR. M. P. DESARDA ---- ---- ----
DIABETOLOGY 8.30 a.m - 9.30 a.m. DR. (MS.) G. DAMLE DR. B. B. HARSHE ---- ---- DR. B. B. HARSHE ----
HEMATOLOGY 9.00 a.m.-11.00 a.m. ---- ---- ---- DR. V. RAMANAN ---- ---- ----
PROCTOLOGY12.00 p.m. to 2.00 p.m. ---- ---- ---- ---- ---- DR. ASHWIN PORWAL ----
(10.00 a.m. to 12.30 p.m.)
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Rajasthani & Gujarati Charitable Foundation’s
POONA HOSPITAL & RESEARCH CENTRE
27, Sadashiv Peth, Pune 411 030.Tel. : 24331706, 66096000, Fax : 24338477
DEPARTMENT oF DENTAL SURGERYTimings Monday Tuesday Wednesday Thursday Friday Saturday
09.30 to Dr. Paresh Dr. Anjali Dr. Shashikant Dr. Charudatta --- Dr. Surendra11.30 a.m. Gandhi Gandhi Bamb Naik Rathi
12.30 to Dr. Mukund Dr. Paresh Dr. Mukund Dr. Paresh Dr. Mukund Dr. Charudatta02.30 p.m. Kothawade Gandhi Kothawale Gandhi Kothawade Naik
03.30 to Dr. Shashikant Dr. Surendra --- Dr. Shashikant Dr. Surendra Dr. Anjali5.30 p.m. Bamb Rathi Bamb Rathi Gandhi
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CASHLESS FACILITIES
TPAs : The following TPAs (Third Party Administrators) have a tie up with Poona Hospitalfor their members to avail of the treatment facilities provided by the hospital.* Medi Assist India Pvt. Ltd. * Genins India Ltd.* Medicare TPA Services (I) Ltd. * Park Mediclaim.* MD India Health Care Services Pvt. Ltd. * Raksha TPA Services.* Paramount Healthcare Services Ltd. * Dedicated Health Care Services.* Health India (Bhaichand Amoluk Ins.)
INSURANCE CoMPANIES : Poona Hospital also provides cashless facilities topolicy holders of the following Insurance Companies* ICICI Prudential, * MAX BUPA Health Insurance* Bajaj Allianz Gen. Insurance Co. Ltd. * Cholamandalam MS Gen. Ins.* Future Generali Total Insurance Solutions * Religare Insurance Co. Ltd.* Star Health & Allied Insurance Co. Ltd. * Apollo Munich* IFFco Tokio General Insurance * Reliance General Insurance* ICICI Lombard General Insurance (I Health Care),
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Epidural Anaesthesia involves the use of local anaesthetics injected into the epidural space to produce a reversible loss of sensation and motor function. Epidural anaesthesia requires larger amounts of local anaesthetic than a spinal anaesthetic. Close attention to the total dose is required to avoid toxicity.
Epidural anaesthesia is versatile and can be administered by a single injection or through a catheter. The use of a catheter allows the Anaesthesia provider to add local anaesthetics as surgery progresses, extending duration beyond the original dose.
Epidural anaesthesia can be combined with a general anaesthetic or used as the sole anaesthetic. In addition, the epidural catheter can be used for postoperative analgesia.
Epidural Anaesthesia provides excellent operating conditions for surgical procedures below the umbilicus. Procedures include: cesarean section procedures on the uterus, perineum hernia repairs genitourinary procedures lower extremity orthopedic procedures
In addition, it is an excellent option for the elderly patient who may not tolerate a general anaesthetic. It is important not to use an epidural anaesthetic in patients who are hypovolemic or severely dehydrated. Patients receiving an epidural anaesthetic should be preloaded with 5-1 liter of crystalloid solution, such as Ringer's lactate, immediately prior to the block.
*Consultant Anaesthesiologist, E-mail : [email protected] , Cell : 9822052885.
Epidural AnaesthesiaDr. Janhavi Thatte *
Epidural anaesthesia has a higher rate of failure for surgical procedures in the perineal area. Lower lumbar and sacral nerve roots are large and there is an increase in the amount of epidural fat which can affect local anaesthetic penetration and subsequent blockade. This phenomenon is known sacral nerve sparing.
Advantages of Epidural Anaesthesia Several advantages of neuraxial blockade were listed in the Introduction to Neuraxial Blockade section of this manual. Additional advantages specific to epidural Anaesthesia include: • Easy to perform (though it takes a bit more
skill than spinal Anaesthesia) • Reliable form of Anaesthesia • Provides excellent operating conditions • The ability to administer additional local
anaesthetics increasing duration • The ability to use the epidural catheter for
postoperative analgesia • Return of gastrointestinal function generally
occurs faster than with general Anaesthesia • No interference with airway.• Fewer pulmonary complications compared to
general Anaesthesia
Decreased incidence of deep vein thrombosis and pulmonary emboli formation compared to general anaesthesia
Disadvantages of Epidural Anaesthesia There are several disadvantages of epidural Anaesthesia including: • Risk of block failure. The rate of failure is
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slightly higher than with a spinal anaesthetic. Always be prepared to induce general Anaesthesia if block failure occurs.
• Onset is slower than with spinal Anaesthesia.
Factors Affecting Level of Blockade Factors that affect the level of epidural Anaesthesia are fewer and less predictable than for spinal Anaesthesia and include the following: 1. Volume of local anaesthetic 2. Age 3. Height of patient4. Gravity 5. Intra-abdominal pressure
Volume :The rule of thumb for the dose of an epidural injection is 1-2 ml of local anaesthetic per dermatome. The dose may be variable from patient to patient and type of surgery. A segmental block for epidural analgesia would require a smaller dose. The volume of local anaesthetic plays a crucial role in the block level.
AgeAs patients age advances less local anaesthetic is required to achieve the same level of blockade as compared to their younger counterpart. This is largely due to changes in the size and compliance of the epidural space.
Height Height plays a role in epidural block level. The shorter the patient, the less anaesthetic required to achieve the same level of anaesthesia as a tall patient.
Gravity Positioning the patient after injection of local anaesthetic into the epidural space impacts its spread and level, but not to the degree that it does with spinal anaesthesia.
Intra Abdominal pressureMore the intra abdominal pressure, less dose of anaesthetic is required. It is very important to reduce the dose in conditions like obesity, pregnancy and ascites.
Positioning and preparationPatients are typically positioned in lateral decubitus or sitting.
1. Lateral decubitus : The patient’s back should be at the edge of the bed, while keeping the shoulders and hips perpendicular to the bed to prevent rotation of spine.
The knees are drawn upward toward the chest, with forward neck flexion, and active protrusion of the lower back.
2. Sitting : May help identify midline, particularly in obese patients
The anticipated injection site is prepared with appropriate antiseptic solution and draped in sterile fashion.
Identification of surface anatomy
The most prominent spinous process at the cervical level is C7.
A line drawn between the tips of the scapula corresponds T7, while one drawn between the iliac crests (Tuffier’s line) corresponds L4.
Using index and middle finger side by side, palpate the spinous processes by sliding side to side and up and down the midline.
Median or midline approach• Commonly performed for lumbar epidurals• The target interspace is identified, and the
approach is similar to the midline spinal anaesthetic technique.
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• The epidural needle is inserted in the midline of the target interspace and carefully advanced through the interspinous ligament.
• Attach the low-friction syringe containing preservative-free saline and proceed with the loss-of-resistance technique.
• Alternative techniques may be used for identification of the epidural space such as loss of resistance to air or the “hanging drop” method, although an increased incidence of accidental dural puncture has been associated with the air technique.
Paramedian approach• May be used for any level but commonly
applied to thoracic epidurals.
Epidural Needle
The standard epidural needle is typically 17-18 gauge, 3 or 3.5 inches long. It has blunt bevel with a gentle curve of 15-30 degree at the tip. The Tuohy needle is used most commonly.
Epidural CatheterEpidural catheters are useful for intra-operative
epidural Anaesthesia and/or post-operative analgesia. Typically a 19 or 20 gauge catheter is introduced through a 17 or 18 gauge epidural needle.
Generally the epidural catheter is advanced 2-6 cm into epidural space. Epidural catheter has radio
opaque markings at tip and at each centimeter from tip.
Test doseEpidural catheter should be aspirated to rule out intrathecal or intravascular location prior to bolus injection.
Injection upto 3 mL of 1.5% lidocaine with 1:200,000 epinephrine may help detect subarachnoid injection (rapid onset of spinal Anaesthesia) or intravascular placement (increased HR by ∼30 bpm in <1 minute)
• A notoriously mischievous student in medical college was up to his usu-al tricks.
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This time, the professor was ready for him. He promptly replied, ‘I don’t know really,’ then added after a pause, ‘How old are you?’
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Caudal Block• Caudal extradural analgesia (CEA) has a wide
application in children. The technique is easier than with adults with a higher success rate of approximately 95%.
• In children, CEA can achieve a higher derma- tomal block than adults. Epidural fat is less dense and less tightly packed with the result that local anaesthetic can spread more easily.
• CEA is used for a range of surgical and orthopaedic procedures below the umbilicus.
PremedicationChildren are premedicated with drugs like anticholinergic i.e. Glycopyrolate 8 mcg./kg, sedative like ketamine 1 mg/kg in intra muscullary. A good intra venous line is secured prior to procedure.
Technique• Position the patient in the left lateral position
with the legs flexed at the hip. Aseptic technique is a prerequisite.
*H.O.D., Dept. of Anaesthesia, E-mail : [email protected] , Cell : 9822089488.
Caudal AnaesthesiaDr. Rajendra Gosavi *
• Identify the sacral hiatus as the apex of an equilateral triangle with the base formed by a line joining the posterior superior iliac spines.
• Alternatively with the hips flexed at 90° a line extended from the mid-line of the femur will intersect with the sacral hiatus. The natal cleft does not always correspond to bony midline structures.
• Define the boundaries of the sacral hiatus. This is again a triangle with the base formed by a line joining the sacral cornua and the apex representing the lower part of the fourth sacral vertebra. The sacral hiatus is covered by the sacrococcygeal membrane.
• Make a small nick in the skin with a needle to reduce the possibility of a dermoid. Direct a blunt, short-bevel (regional block) needle at 60° to the skin from the midpoint of the line joining the sacral cornua. Alternatively use a 22G or 20G cannula depending on the size of the child. A small ‘give’ indicates penetration of the sacrococcygeal membrane. Flatten the
21
cannula or needle slightly, then advance. If using a cannula, withdraw the stylet to just behind the cannula before advancing the cannula into the caudal space. Do not advance the needle or cannula any more than is necessary.
• Advancement of a cannula rather than needle may reduce the incidence of inadvertent dural or vascular puncture. Easy progression of the cannula is a good prognostic indicator of success.
• Test aspiration should be gentle; vessel walls can collapse producing a false negative result.
• Aspiration should then be repeated during injection of the local anaesthetic. A ‘whoosh’ test using air should be avoided because of the risk of air embolus.
• The commonest reason for a failed attempt is positioning the needle too caudally.
Dosage• The Armitage regime (using 0.25% Bupivacaine
or 0.2% Ropivacaine) Required block Volume (ml/kg) Lumbasacral 0.5 Thoracolumbar 1 Mid thoracic 1.25
• If the calculated volume is greater than 20 ml, use 0.19% bupivacaine (three parts local anaesthetic to one part saline).
• The duration of the block averages 4–8 h using this regime.
• Caudal blockade can be extended with: o clonidine 1 µg/kg o diamorphine 30 µg/kg o ketamine 0.5 mg/kg (preservative-free) o morphine 50 µg/kg (preservative-free).
• Adrenaline has been implicated in cases of spinal ischaemia and should be avoided. Clonidine produces postoperative sedation. Morphine and diamorphine increase the incidence of urinary retention and should be reserved for surgery in which catheterization is required.
Advantages/complications• Simple, safe, successful, with a wide range of
indications.• Motor block, paresthesia, urinary retention,
inadvertent dural puncture or intravascular injection can all occur.
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The complications of epidural, spinal or caudal Anaesthesia range from minor to life threatening.
Broadly the complications can be thought of as physiological excess effects those resulting from placement of needle (or catheter) & drug toxicity.
Complication of Neuraxial Anaesthesia
A. Adverse or exaggerated physiological responses
1. Urinary retention2. High Block 3. Total Spinal Anaesthesia4. Anterior Spinal Artery Syndrome5. Horner's Syndrome
B. Complications related to needle / catheter placement
1. Trauma • Backache • Postdural Puncture Headache
2. Neural Injury • Nerve Root Damage • Spinal Cord Damage • Cauda Equina Syndrome
3. Bleeding • Intraspinal / Epidural Hematoma
4. Misplacement • No effect / Inadequate Anaesthesia • Subdural Block • Inadvertent Subarachnoid Block • Inadvertent Intravascular Injection
Complications of Neuraxial BlocksDr. Ganesh Ghongate *
5. Infection • Meningitis • Epidural Abscess
6. Inflammation • Arachnoiditis
C. Drug Toxicity 1. Systemic Local Anaesthetic Toxicity 2. Transient Neurological Symptoms 3. Cauda Equina Syndrome
Individual complications of regional anaesthesia:
1. Post dural puncture headache :PDPH is one of the most common complications of neuraxial block. Any breach in the dura mater, which may follow a spinal anaesthetic, an epidural “wet tap”, diagnostic lumbar puncture, or migration of epidural catheter may result in PDPH.
The mechanism of PDPH is thought to be persistent leakage of cerebrospinal fluid (CSF) through the dural defect at a rate faster than that of CSF production. The transdural leak leads to decreased CSF volume and pressure. During upright position, gravity causes traction on highly innervated meninges and pain sensitive intracranial vessels, which refer pain to the frontal, occipital and neck and shoulder region via trigeminal, glossopharyngeal and vagus and upper cranial nerves respectively.
The diagnosis is basically clinical. It usually presents 48-72 hrs after the procedure is typically bilateral, fronto–occipital extending up to neck & shoulders. Pain is described as dull or throbbing; usually
*Consultant Anaesthesiologist, E-mail : [email protected] , Cell : 9823219497.
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associated with nuchal stiffness & backache. The hallmark of PDPH is that it is postural in nature. It often subsides during supine position and may be associated with malaise, photophobia, nausea, vomiting and cranial nerve palsies.
The risk factors of PDPH are young age, female sex, pregnancy and prior history of PDPH. Use of smaller and non cutting (Whitacre) needles decreases the incidence of PDPH.
The treatment is conservative or invasive. The conservative measures include bed rest, hydration, analgesics, abdominal binders and caffeine. These measures will decrease downward traction, increase CSF production, constrict the intracranial vessels and provide symptomatic relief.
The invasive treatment is epidural blood patch, which is considered to be the most effective treatment.
2. Backache :Backache is a frequent complaint of neuraxial anaesthesia. Although incidence is high, neuraxial anaesthesia may not be the sole cause. The frequency of backache is approximately similar after spinal or general anaesthesia. Localised trauma to the intervertebral disk or excessive stretching of associated ligaments after loss of lumber lordosis due to relaxation of paraspinal muscles are supposed to be the causative factors. The pain is usually mild and self limiting although it may last for several weeks. Nonsteroidal anti-inflammatory agents and warm or cold compresses are sufficient for backache.
3. Transient Neurological symptoms :Transient neurological symptoms (TNS) were first reported in 1993 by Schneider et al who described the development of severe radicular back pain after resolution of an uneventful lidocaine spinal anaesthetic.
There was no sensory or motor deficit and no signs of bowel and bladder dysfunction. The symptoms resolved within one week. The aetiology of TNS is not well defined. However, up to 30% of
patients with TNS report severe pain. Zoric et al in their systemic review analysed that the use of lidocaine for spinal anaesthesia increased the risk of developing TNS. There was no evidence that this painful condition was associated with any neurologic pathology; the symptoms disappeared spontaneously by the fifth postoperative day. The risk of developing TNS after spinal anaesthesia with Lidocaine was significantly higher than when bupivacaine, prilocaine, or procaine was used. Study identified other risk factors for the development of TNS besides Lignocaine: outpatient status, obesity and lithotomy position.
4. Total spinal anaesthesia : Total spinal anaesthesia can happen when there is unintentional intrathecal administration of local anaesthetics during epidural or caudal anaesthesia. The onset is usually rapid.
Patient exhibits signs of cardiovascular collapse in the form of severe hypotension, bradycardia and respiratory insufficiency. Careful aspiration, use of test dose and incremental drug dosing can help avoid this complication.
If total spinal anaesthesia occurs, patients are put in Trendelenberg position so as to increase venous return, administered fluids along with inotropic support to raise blood pressure, They may need tracheal intubation to support ventilation. Fortunately need for sedation during intubation and mechanical ventilation is minimal.
5. Spinal or epidural hematoma :Epidural or spinal haematoma is a rare, but potentially disastrous complication of central neuraxial blocks.
The variables associated with increased incidence of spinal hematoma are; female gender, increased age, traumatic needle/catheter placement, indwelling epidural catheter placement, immediate preoperative, intra- operative and postoperative LMWH administration. Patient usually presents with sudden new onset sharp back and leg pain
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with numbness, weakness, and bladder and bowel dysfunction. When spinal hematoma is suspected, neurologic imaging (MRI and CT scan) and neurologic consultation should be immediately obtained.
Good neurological recovery is seen in patients who have undergone surgical decompression within 8-12 hours.
6. Epidural abscess :
Epidural abscess is a serious complication after neuraxial block. The incidence varies from 0.015% to 0.7% according to different studies.
Although epidural abscess is uncommon, early diagnosis and treatment is paramount. Symptoms of epidural abscess usually begin several days after neural block, sometimes after months, and include back pain, fever, malaise, signs of cord compression including sensory changes, flaccid paralysis followed by spastic paralysis, elevated blood leukocytes count, elevated cerebrospinal fluid protein and leukocytes.
Clinical signs, duration of symptoms and the rate of neurological deterioration show a high inter-individual variability, and the classic triad (spinal pain, fever and neurological deficit) is often not found, especially not at first presentation to a physician.
Associated risk factors are diabetes mellitus, chronic renal failure, epidural or systemic steroid injection, herpes zoster and chronic alcohol abuse.
The management of epidural abscess involves drainage of the abscess and eradication of the microorganism as the basic principles of therapy.
Surgical therapy is the treatment of choice in the overwhelming majority of cases. Rapid surgical intervention is not only needed to minimize neurological damage, but also for controlling sepsis. Duration of antimicrobial treatment is usually 4–6 weeks for epidural abscess.
7. Meningitis :Dural puncture may be a risk for infection of subarachnoid space. Exact mechanism by which bacteria reach the central nervous system may not be known but the infectious source may be exogenous (e.g., contaminated equipment or medication) or endogenous (a bacterial source in the patient seeding to the needle or catheter site).
Microorganisms can also be transmitted via a break in aseptic technique, and indwelling catheters may be colonized from a superficial site (skin) and subsequently serve as a wick for spread of infection from the skin to the epidural or intrathecal space.
The symptoms appear hours to days after anaesthesia, sometimes onset time may be up to one month. Initial clinical presentation is fever and headache, with backache with emesis, classical sign of meningism and lithargy. CSF is usually turbid with raised leukocytes, proteins and low glucose concentration. In great majority of cases the causative organism is alpha- haemolytic streptococcus. Lumbar puncture aids diagnosis.
Give appropriate antibiotics early, usually before the causative organism or its sensitivity is established.
8. Arachnoiditis :Arachnoiditis is a rare complication of neuraxial anaesthesia, may appear as transient nerve root irritation, cauda equina or conus medullaris syndromes.
Regarding regional anaesthesia in the neuraxis, arachnoiditis has resulted from epidural abscesses, traumatic punctures (blood), local anaesthetics, detergents, antiseptics or other substances unintentionally injected into the spinal canal.
Patient usually presents with pain in the lower back, dysesthesia and numbness not following the usual dermatome distribution.
9. Cardiac Arrest :The incidence of cardiac arrest during regional
25
anaesthesia varies in different studies and it ranges from 1.5-6.4/10000 cases. Theories regarding the mechanism by which neuraxial block contributes to cardiac arrest involve a circulatory aetiology. Initially sedation was speculated to have contributed to many of the cardiac arrests during spinal anaesthesia. Another likely cause could be decrease in preload associated with neuraxial block resulting in a shift in cardiac autonomic balance toward the parasympathetic system leading to bradycardia. At least three mechanisms have been proposed, including activation of the low-pressure baro- receptors in the right atrium, the receptors within the myocardial pacemaker cells, and mechanoreceptors in the left ventricle (stimulating a paradoxical Bezold-Jarisch response). In addition, a high sympathetic level may directly favour vagal tone; sedation, hypoxemia, hypercarbia, and chronic medications (such as [beta]-adrenergic antagonists) may contribute to the development and severity of bradycardia. Intravascular fluid administration, administration of mixed [alpha]- and [beta]-agonists, & vagolytic therapy have all been advocated to decrease the frequency of and improve the survival associated with cardiac arrest during neuraxial block.
10. Urinary retention :Neuraxial anaesthesia blocking S2-S4 nerve root fibres decreases the urinary bladder tone and inhibits the voiding reflex. Urinary retention is common after anaesthesia & surgery. Co morbidities, type of surgery, and type of anaesthesia influence the development of postoperative urinary retention.
11. Drug Toxicity :All local anaesthetics can cause CNS toxicity & cardiovascular toxicity if their plasma concentrations are increased by accidental intravenous injection, with the CNS affected at
lower blood levels. All local anaesthetic agents block neuronal voltage-gated sodium channels, and thus suppress conduction in peripheral nerves. Systemic accumulation of local anaesthetic agents may affect the functional integrity of these structures.
Initially, these toxic mechanisms are due to a selective blockade of cortical inhibitory neurons, which enables the formation of seizure potentials within sub cortical structures. Excitation of the CNS may be manifested by numbness of the tongue and perioral area, and restlessness, which may progress to seizures, respiratory failure and coma.
Treatment of CNS toxicity includes maintaining adequate ventilation & oxygenation, & controlling seizures with the administration of thiopental sodium or benzodiazepines.
Cardiovascular toxicity generally begins after signs of CNS toxicity have occurred. Bupivacaine and etidocaine appear to be more cardio toxic than most other commonly used local anaesthetics.
Direct cardiac effects of local anaesthetics can be divided into (i) stereo specific inhibition of intracardiac conduction and (ii) unspecific inhibition of myocardial energy supply and ion channels.
The corresponding spectrum of symptoms is not uniform and may range from extreme bradycardia, (malignant) ventricular arrhythmia to refractory cardiac arrest.
Cardiac arrest caused by local anaesthetics should be treated with cardiopulmonary resuscitation procedures, but bupivacaine-induced dysrhythmias may be refractory to treatment.
In contrast to bupivacaine, the hyperbaric Lidocaine (lignocaine) formulation carries a substantial risk of neurotoxicity when given intrathecally.
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A°ZoñWo{e`mMo à_wI VrZ àH$ma AmhoV.
1) bmoH$b A°ZoñWo{e`m : ̀ mMm Cn`moJ earamÀ`m {d{eï> OmJodarb g§doXZm ~Yra H$aÊ`mgmR>r Ho$bm OmVmo. CXmhaUmW©, XmV H$mT>VmZm {Xbobm A°ZoñWo{e`m.
2) [aOZb A°ZoñWo{e`m : earamMm ^mJ Am{U _‚mma‚my (ñnmB©Zb H$m°S>©) `m§À`m_Ü`o _‚mmV§V§yZr _|XÿH$S>o nmR>{dbobo g§Xoe AS>dyZ earamMm _moR>m ^mJ g§doXZma{hV H$aUo. CXmhaUmW©, ñnmB©Zb A°ZoñWo{e`m Am{U E{nS>çyab A°ZoñWo{e`m.
3) OZab A°ZoñWo{e`m : g§nyU© eara g§doXZmhrZ H$aUo.
A°ZoñWo{e`m H$moU XoVmV : A°ZoñWo{eAm°bm°Or _Yrb A{V[aŠV Ah©VmYmaH$ nmÌ d¡ÚH$s` S>m°ŠQ>am§H$Sy>Z A°ZoñWo{e`m {Xbm OmVmo. Á`m§Zm A°ZoñWo{Q>ñQ²> qH$dm A°ZoñWo{eAm°bm°{OñQ²> Agohr åhUVmV.
ê$½Umbm A°ZoñWo[e`m XoÊ`mnyduMo _hËdmMo Xhm {ZH$f :l eó{H«$`onydu earamÀ`m EHy$UM V§Xþê$ñVr_Ü`o
gwYmaUm H$aUo.l eó{H«$`onydu 1 _{hZm AJmoXa Yy_«nmZ gmoSy>Z XoUo.l gÜ`m H$moUVohr Am¡fY KoV Agë`mg Ë`mg§~§YrMr
_m{hVr é½UmZo S>m°ŠQ>am§Zm gm§JUo.
*Consultant Anaesthesiologist, E-mail : [email protected] , Cell : 9823219497.
l H$moUË`mhr àH$mamMr A°bOu qH$dm Xþîn[aUm_m g§~§Yr A°ZoñWo{Q>ñQ²>Zm gm§JUo.
l _Úm_wio A°ZoñWoQ>rH$ Am¡fYm§Mo n[aUm_ CbQ> hmoD$ eH$V Agë`mZo _ÚgodZ H$_r H$aUo.
l eó{H«$`onydu 24 Vmg AmYr H$moUË`mhr àH$maMo _Ú godZ H$ê$ ZH$m.
l eó{H«$`onydu H$moUË`mhr àH$maMr [a{H«$EeZb Am¡fYo KoD$ ZH$m H$maU Ë`m§Mm A°ZoñWo{Q>H$da n[aUm_ hmoD$ eH$Vmo.
l Oa EImÚmmbm ì`gZ Agob Va A°ZoñWo{Q>ñQ>bm gm§Jm.
l Oa ê$½U J^©{ZamoYH$ Jmoù`m KoV Agob Va Ë`m{df`r ^yb XoUmao S>m°ŠQ>a `m§Zm gm§Jm.
ê$½Umb`mVrb S>m°ŠQ>a d A°ZoñWo{Q>ñQ²>g `m§Zm nwT>rb ~m~t{df`r _m{hVr AgbrM nm{hOo. 1. Amamo½`m g§~§YrÀ`m g_ñ`m, 2. g§gJ©OÝ` amoJ, 3. nydu Ho$boë`m eó{H«$`m, 4. J§^ra AmOma, 5. ZH$br XmV, H°$ßg, hbUmao XmV qH$dm XmVmg§~§YrÀ`m AÝ` g_ñ`m, 6. _Yw_oh, CÀM aŠVXm~ Am{U XrK©H$mi AgUmè`m d¡ÚH$s` g_ñ`m, 7. H$moUË`mhr àH$maMr A°bOu / AghZerbVm.
A°ZoñWo{e`mÀ`m OmoI_r Am{U Xþîn[aUm_.l _i_i Am{U CbQ>çm.l S>moHo$XþIr.l B§OoŠeZÀ`m OmJoda doXZm qH$dm gyO.l H$moaS>m Kgm Am[U doXZm.l Yyga Ñï>r qH$dm ^modi `oUo.
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