Local and Regional

Anesthesia
Shandong University Operatology
Qi Feng

 Local and regional anesthetic techniques

are used to: decrease intraoperative
stimuli, thereby diminishing stress
response to surgical trauma.
Injected at or near the nerves of the
surgical site, the anesthetic drug temporarily
interrupts sensory nerve impulses during
manipulation of sensitive tissues.

 Regional blocks are useful for more

extensive procedures. Regional anesthesia
may be used, with or without IVCS, when
general anesthesia is contraindicated or
undesired.
Nerve blocks, intrathecal blocks,
peridural blocks, and epidural blocks are
examples of regional anesthesia techniques.

HISTORICAL BACKGROUND
Historically, the Incas used the coca leaf for local pain
relief. More formalized experimentation with cocaine
began in 1860. In 1885, spinal anesthesia was induced.
Epidural techniques were developed in 1901.
Refinement of other drugs followed and was strongly
enhanced by the isolation of epinephrine by John Abel
(1857-1938). Heinrich Braun (1847-1911) used
epinephrine mixed with cocaine for local anesthesia.
Local agents procaine (1904) and lidocaine(1948)
advanced the use of local anesthesia by many
practitioners.
Modern refinements and the development of additional
drugs for injection have increased the use of local and
regional anesthesia for surgical procedures

PREPARATION OF THE
PATIENT
Include:
careful preoperative assessment,
history taking,
a clear explanation of what to expect
are part of the preparatory process.

preoperative assessment:
Data that should be documented include the
following:
1. Baseline vital signs, blood pressure, laboratory
values, and results of ECG monitoring and any
other tests that were performed.
2. Weight, height, and age; dosage of some drugs
is calculated on the basis of body weight in
kilograms (mg/kg). Some drugs are contraindicated
for age extremes (i.e., pediatric or geriatric
patients).

 3. Current medical problem(s) and past history of

medical events, including a history of substance
abuse.
4. Current medications or drug therapy, such as
insulin for diabetes or hypertensive drugs.
5. Allergy, or hypersensitivity reactions to previous
anesthetics or other drugs.
6. Mental status, including emotional state and level
of consciousness.
7. Communication ability; a patient with hearing
impairment or language barrier may be unable to
understand verbal instructions during the procedure
or to respond appropriately.

Preoperative orders
regarding the time when the patient should cease
taking anything by mouth vary with the
circumstances; 6 to 8 hours before the surgical
procedure is the usual minimum for adults.
If possible, the adult patient is instructed to remain
on nothing-by-mouth (NPO) status after
midnight.
Many ambulatory surgical patients scheduled for
same-day procedures have no premedication and
are permitted to walk to the OR.

INTRAOPERATIVE
PATIENT CARE
The patient must be able to respond cooperatively
and to maintain respiration unassisted. The patient
needs careful observation throughout the surgical
procedure and for a period afterward for signs and
symptoms of delayed reaction or complications.

The care the patient will need depends on the type

and length of the procedure, the amount of
sedation given, and the type and amount of local
anesthetic used.

 Psychologic support and reassurance are

given before and during the surgical
procedure. The patient should be told what to
expect and what is expected of him or her.
The patient should be monitored by qualified
personnel and observed for adverse effects
of the medication or the procedure.

LOCAL ANESTHESIA
The surgeon injects the anesthetic drug or applies
it topically.The anesthesia provider is not in
attendance for this method.
Supplemental agents should be available for
analgesia or anesthesia, if necessary, or for adverse
reactions.
Resuscitative equipment, suction, and oxygen
must be at hand before administration of any
anesthetic.
Qualified personnel should be immediately
available to assist in the event of an emergency.

Administration of Local
Anesthesia
In the absence of an anesthesia provider, a
qualified registered nurse is responsible for
monitoring the patient's physiologic status
and safety during local anesthesia.
The patient who is under local anesthesia
requires observation of physiologic changes
in pulse, blood pressure, oxygenation, and
respiration.

Baseline data
Baseline data obtained during preoperative
assessment are compared with intraoperative and
postoperative findings.
The vital signs, including blood pressure, pulse,
and respirations, are continuously monitored.
Monitoring devices may include an ECG
electrocardiograph and pulse oximeter (SpO2).
The total amount of anesthetic and supplementary
drugs administered is also recorded in the patient's
record.

Intravenous Conscious Sedation

(IVCS) / Moderate Sedation
During procedures performed with the patient
under local anesthesia, mild sedation may be given
by IV infusion.
IVCS refers to a mild to moderate depressed
level of consciousness that allows the patient to
maintain a patent airway independently and to
respond appropriately to verbal instructions or
physical stimulation.

 A benzodiazepine, such as midazolam

(Versed) or diazepam (Valium), is most
commonly given either alone or in
combination with a narcotic and atropine
or scopolamine.
Benzodiazepines provide amnesia with
sedation, but they also may cause
respiratory depression and fluctuations in
blood pressure and heart rate and rhythm.

Monitoring the Patient

Receiving a Local Anesthetic
In the absence of an anesthesia provider,
a qualified, registered nurse should be
assigned to monitor the patient's
physiologic state.

The extent of monitoring:

determined in consultation with
physicians in the department of surgery
and anesthesiology where applicable,
depends on the seriousness of the
procedure, sedation required, and/or
patient's condition.

Parameters include but are not

limited to the following
1. Blood pressure (Bp)
2. Heart rate and rhythm (Bpm)
3. Respiratory rate (R)
4. SpO2 by pulse oximetry (SaO2)
5. Body temperature (T)
6. Skin condition and color
7. Mental status and level of consciousness

 Vital signs are taken continually before

injection of a drug and at 5-15min intervals
after injection.
Changes in the patient's condition are reported to
the surgeon immediately.
If an adverse reaction occurs, emergency,
measures should be instituted on request as per
policy.
(Include: maintaining a patent airway, starting
oxygen therapy when clinically indicated, and
administering IV therapy.)

Considerations of selecting Local

Anesthesia

Advantages:
1. Minimize the recovery period. The patient can
ambulate, eat and resume normal activity.
2.Use of local anesthetic requires minimal
equipment and is economical.
3.Loss of consciousness does not occur.
4.Local anesthesia avoids the undesirable effects of
general anesthesia.
5.Suitable for patients who recently ingested food or
fluids.
6.Local anesthesia is useful for ambulatory patients
having minor procedures.
7.Ideal for procedures in which it is desirable to
have the patient awake and cooperative.

Disadvantages
1. Local anesthesia is not practical for all types of
procedures.
2. There are individual variations in response to
local anesthetic drugs.
3. Rapid absorption of the drug into the
bloodstream can cause severe, potentially fatal
reactions.
4. Apprehension may be increased by the patient's
ability to see and hear. Some patients prefer to be
unconscious and unaware.

Contraindications
1. Allergic sensitivity to the local anesthetic drug.
2. Local infectious or malignancy at the site of
injection, which may be carried to and spread in
adjacent tissues by injection.
3. Septicemia.
4. Extreme nervousness, apprehension, excitability
or inability to cooperate because of mental state or
age.

SPINAL and EPIDURAL

ANESTHESIA
Intraspinal injection of an anesthetic drug is a technique
of regional anesthesia performed by a person who has
been properly trained and has acquired the necessary
skill.
Regional anesthesia is delivered to select areas,
referred to as dermatomes, to affect motor and
sensory, nerves as desired.
The patient's dermatome levels can be tested by touch
and by asking the patient to move his or her extremities.
Dermatome level T12 is near the iliac crest, T10 is near
the umbilicus, and T6 is near the xiphoid.

 Assessment of the patient's level of consciousness,

pulse, respirations, and blood pressure is essential
for early detection of hypotension associated with
high spinal anesthesia.
Choices in Regional Drugs
The choice of drug depends on factors such as: the
duration, intensity, and level of anesthesia desired;
the anticipated surgical position of the patient; and
the surgical procedure.
Patient factors include the anesthetic history,
physical condition, and preference of the patient
and surgeon.

Spinal Anesthesia
Spinal anesthesia, also referred to as an
intrathecal block, causes desensitization of
spinal ganglia and motor roots.
The agent is injected into the CSF in the
subarachnoid space of the meninges (the threelayered covering of the spinal cord) using a lumbar
interspace in the vertebral column.

 The subarachnoid space is located

between the pia mater (the innermost
membranous layer covering the spinal cord)
and the arachnoid (the thin, vascular,
weblike layer immediately beneath the dura
mater, which is the outermost sheath
covering the spinal cord).
Absorption into nerve fibers is rapid.

 Spinal anesthesia is often used for

abdominal (mainly lower) or pelvic
procedures.
requiring relaxation, inguinal or lower
extremity procedures, surgical obstetrics
(cesarean section without effect on the
fetus), and urologic procedures.

The level of anesthesia

attained depends on various factors,
such as the patient's position during and immediately
after injection; CSF pressure; site and rate of
injection; volume, dosage, and specific gravity
(baricity) of the solution;
inclusion of a vasoconstrictor, such as epinephrine;
spinal curvature; interspace chosen; uterine
contractions with labor; and coughing or straining,
which can inadvertently raise the level.

 Spread of the anesthetic is controlled

mainly by solution baricity and patient
position.
The period immediately after injection is
decisive; the anesthetic is becoming
"fixed" (i.e., absorbed by the tissues and
unable to travel).

 Further control is attained by tilting the

operating bed at that time. The direction of
tilting depends on whether the drug is
hyperbaric or hypobaric, lsobaric
anesthetics.
Immediately after the anesthetic is
injected, the anesthesia provider carefully
tests the level of anesthesia by pinprick,
touch, or nerve stimulation, tilting the bed as
necessary, to achieve the desired level for the
surgical procedure.

 Choice of Agent. The drug used depends on

various factors such as the duration, intensity, and
level of anesthesia desired, the anticipated surgical
position of the patient, and the surgical procedure.

Duration of Agent. The variable duration of

anesthesia depends on physiologic and metabolic
factors. It is prolonged by the addition of a
vasoconstrictor. Anesthesia diminishes as the
agent is absorbed into the systemic, circulation.

Spinal Anesthesia Procedure

Lateral position:
The patient lies on the side with the back at
the edge of the operating bed.
The knees are flexed onto the abdomen, and
the head is flexed to the chest.
The hips and shoulders are vertical to the
operating bed to prevent rotation of the
spine.

Sitting position
The patient sits on the side of operating bed with
the feet resting on a stool. The spine is flexed,
with the chin lowered to the sternum; the arms are
crossed and supported on a pillow on an adjustable
table.
Attention to asepsis is extremely important.
Sterile disposable spinal trays eliminate the need
for cleaning and sterilizing of reusable equipment.
The BP is checked before, during, and after spinal
anesthesia, since hypotension is common.

Advantages
The patient is conscious if desired. The
procedure can be performed with IVCS as
necessary.
Throat reflexes are maintained; breathing is
quiet, without airway problems, because the
respiratory system is not irritated.
The bowel is contracted.
Muscle relaxation and anesthesia are excellent
if the procedure is properly executed.

Disadvantages
Spinal anesthesia produces a circulatory
depressant effect: hypotension.
A change in body position may be followed by a
sudden drop in blood pressure; after fixation of the
anesthetic, a slight elevation of the feet and legs
may increase venous return to the heart.
The agent cannot be removed after injection.
Nausea and emesis may accompany cerebral
ischemia, traction on viscera and peritoneum, or
premedication.

Complications
Transient or permanent neurologic sequelae
from cord trauma, irritation by the agent,
lack of asepsis, and loss of spinal fluid with
decreased intracranial pressure syndrome
are potential complications.
Examples include: spinal headache;
auditory and ocular disturbances, temporary
paresthesias, and urinary retention.

 Late complications: include nerve root lesions,

spinal cord lesions, and ruptured nucleus pulposus.
True spinal headache caused by a persistent CSF
leak through the needle hole in the dura usually
responds to supine bed rest, copious oral or IV
fluids, and systemic analgesia.
Refractory postspinal headache may be treated by
an epidural blood patch: 5 to 10ml of the patient's
own blood is administered at the puncture site. This
usually affords prompt relief.

 If a high level of anesthesia is reached, extreme

caution is essential to prevent respiratory paralysis
("total spinal"), an emergency situation requiring
mechanical ventilation until the level of anesthesia
has receded.
Respiratory arrest, although rare, is thought to be a
result of medullary hypoperfusion caused by a
sympathetic block.
Apnea also can be produced by respiratory center
ischemia resulting from precipitous hypotension.

 The anesthesia machine, oxygen, and IV

line must be in readiness before injection.
Constant vigilance of respiration and
circulation is critical.
The blood pressure and heart rate are
monitored and maintained at normal
levels.

Epidural Anesthesia
The terms epidural, peridural, and extradural are used
synonymously. The epidural space lies between the
dura mater, the outermost sheath covering the spinal
cord, and the walls of the vertebral column.
Injection is made into this space surrounding the dura
mater. The drug diffuses slowly through the dura
mater into CSF.
Anesthesia is prolonged while the drug is absorbed
from CSF into the bloodstream.
The spread of anesthetic and duration of action are
influenced by the concentration and volume of
solution injected (total drug mass) and the rate of
injection.

 In contrast to spinal anesthesia, patient

position, baricity, and gravity have little
influence on anesthetic distribution.
The high incidence of systemic reactions is
attributed to absorption of the agent from
the highly vascular peridural area and the
relatively large mass of anesthetic injected.
Epinephrine 1:200,000 is usually added to
retard absorption.

Approaches used for epidural

anesthesia and analgesia
including: thoracic, lumbar, and caudal
approaches.
The management and sequelae of epidural
anesthesia are similar to those of spinal anesthesia.
An epidural approach may be used for lower
extremity, abdominal, urologic, anorectal,
vaginal, or perineal procedures.
It is used commonly for postoperative pain
management and in obstetrics during labor and
delivery or during and after cesarean section.

 Vital signs should be monitored at regular

intervals, and any deviation of level of
consciousness, pulse, respirations, or blood
pressure should be reported immediately to
the anesthesiologist.

Epidural narcotic analgesia

may provide sustained postoperative relief or
control of pain in patients with intractable or
prolonged pain.
This may be administered by a percutaneous
indwelling epidural catheter, an implanted
epidural catheter with infusion port or reservoir
and pump, or an implantable infusion device.
A patient may come to the OR for placement of an
epidural catheter or pump device for ongoing pain
management.

Thoracic and Lumbar Approaches

The thoracic and lumbar approaches are
peridural blocks. Equipment is similar to
that for a spinal block.
Insertion of a catheter allows repeated
injections for continuous intraoperative and
postoperative epidural anesthesia, requiring
additional needles, stopcocks, and a plastic
catheter in the setup.

Caudal Approach
The caudal approach is an epidural sacral
block. Epidural injection is through the
caudal canal, desensitizing nerves emerging
from the dural sac.
The patient position for injection is prone
with the hips flexed, sacrum horizontal, and
heels turned outward to expose the injection
site.

 The sacral area is prepared and draped, with

care taken to protect the genitalia from
irritating solution.
The left lateral position is used in the
pregnant patient.
The spread of agents in epidural anesthesia
is enhanced in pregnancy, atherosclerosis,
and advanced age.

Advantages
Compared with spinal anesthesia,
Epidural anesthesia has a decreased
incidence of hypotension, headache, and
potential for neurologic complications.
Although a higher failure rate is reported.

Disadvantages
It is a more difficult technique; there is a
greater area of potential infection from
anaerobic organisms with the caudal
approach;
it is unpredictable; it is time-consuming (i.e.,
a longer time is required for complete
anesthesia);
a larger amount of agent injected continuous
technique may slow the first stage of labor.

Complications
IV injection, accidenta dural puncture and
total spinal anesthesia, blood vessel puncture
and hematoma, profound hypotention,
backache, and transient or permanent paralysis
are possible complications.
The patient may suffer hypoxia, respiratory
arrest, and/or cardiac arrest.

TECHNIQUES OF
ADHINISTRATION OF
LOCAL OR REGIONAL
ANESTHESIA

Topical Application
The anesthetic is applied directly to a mucous
membrane, to a serous surface, or into an open
wound.
A topical agent is often applied to the respiratory
passages to eliminate laryngeal reflexes and cough,
for insertion of airways before induction or during
light general anesthesia, or for therapeutic and
diagnostic procedures such as laryngoscopy or
bronchoscopy.
It is also used in the urethral meatus for
cystoscopy.

Preanesthetic anticholinergics
Atropine: are important before topical
application within the respiratory tract.
Also, a dry throat is necessary to prevent
aspiration until the anesthetic effect has
disappeared and throat reflexes have
returned.

Simple Local Infiltration

The agent is injected intracutaneously
and subcutaneouslv into tissues at and
around the incisional site to block
peripheral sensory nerve stimuli at their
origin.
It is used before suturing superficial
lacerations or excising minor lesions.

Regional Injection
The agent is injected into or around a
specific nerve or group of nerves to
depress the entire sensory nervous system
of a limited, localized area of the body.
The injection is at a distance from the
surgical site.
A wider, deeper area is anesthetized than
with simple infiltration.

Nerve Block
Nerve blocks are performed to interrupt
sensory, motor, and/or sympathetic
transmission.
Blocks may be used preoperatively,
intraoperatively, and postoperatively to
prevent pain of the procedure;
Diagnostically to ascertain the cause of pain;
or therapeutically to relieve chronic pain.

Some examples of blocks follows

1. Surgical blocks
a. Paravertebral block of the cervical plexus for
procedures in the area between the jaw and the
clavicle.
b. Intercostal block for relatively superficial
intraabdominal procedures, such as drain placement.
c. Branchial plexus or axillary block for arm
procedures.
d. Median, radial, or ulnar nerve block for the
elbow or wrist.
e. Hand and digital block for fingers.
f. Blocks in other specific areas, such as a penile
block for circumcision in adults.

2. Diagnostic or therapeutic
blocks
a. Sympathetic nerve ganglion block.
b. Stellate ganglion block to increase
circulation in peripheral vascular disease
in the head, neck, arm, or hand.
c. Paravertebral lumbar block to increase
circulation in the lower extremities.
d. Celiac block for relief of abdominal pain
of pancreatic origin.

Local and Regional Anesthetic

Agents
---------------------------------------------------------------------------------------------------------Concentration Duration(hr) Maximum Dosage
AMINO AMIDES
Bupivacaine Marcaine Local infiltration 0.25% to 0.50% 2 to 3 400mg
Surgical epidural
0.75%
Lidocaine Xytocaine
Topical
2% to 4% 1/2 to 2
200 mg
Infiltration
0.5%
500 mg
Peripheral nerves 1% to 2%
Mepivacaine Carbocaine Infiltration
0.5% to 1% 1/2 to 2
500 mg
Ropivacaine Naropin nerve block
0.75%
Epidural
1%
6 to 10
AMINO ESTERS
Chloroprocaine
Nerve block
2%
1/4 to 1/2 1000 mg
Cocaine
Topical
4% or 10% 72 200 mg or 4 mg/kg
Procaine Novocain
Infiltration
0.5%
1/4 to 1/2 1000 mg
Tetracaine Cetacaine
Topical
2%
2 to 4
20 mg
--------------------------------------------------------------------------------------------------

COMPLICATIONS OF LOCAL AND

REGIONAL ANESTHESIA
Minor or transient complications of local
and regional anesthesia are common.
Serious complications, although rare, are
usually permanent.
Complications of local and regional
anesthesia may be summarized briefly as:
local effects, systemic effects, and effects
unrelated to the anesthetic drug.

Local Effects
Tissue trauma, hematoma, ischemia, drug
sensitivity, and infection can be minimized
by the use of proper drugs and equipment,
sterile technique,
Avoidance of local anesthetics with
vasoconstrictors in sites with smaller
vascular structures (digits, penis).
Avoidance of repetitive injection that
promotes trauma, edema, tissue necrosis,
and infection.

Systemic Effects
Systemic effects are primarily
cardiovascular, neurologic, or
respiratory, (e.g., hypotension,
seizure, respiratory depression).

Predisposing Factors for

Hypersensitivity
True hypersensitivity that produces an
allergic response can occur, but it is less
frequent than reactions from overdosage
of pharmacologic agents.
1. True allergy, mediated by antigenantibody reaction, can cause anaphylaxis,
urticaria (skin wheals), dermatitis, itching,
laryngeal edema, and possibly
cardiovascular collapse.

 2. Overdosage:
An excessive amount of drug may
enter the bloodstream if the injection
exceeds maximum dose or is absorbed
too rapidly. The IV route is the most
dangerous route of injection.
Hazardous sites involve vascular
areas of tracheo-bronchial mucosa, and
tissues of the head, neck, and
paravertebral region.

Signs and Symptoms of

Systemic Reactions

 CNS stimulation or depression

may be followed by depression and
cardiovascular collapse.
The cardiovascular system seems
more resistant than the CNS to
toxic effects of local anesthetics.

 1.Stimulation: Talkativeness, restlessness,

incoherence, excitation, tachycardia,
bounding pulse, flushed face, hyperpyrexia,
tremors, hyperactive reflexes, muscular
twitching, convulsions
2. Depression: Drowsiness; disorientation;
decreased hearing ability; stupor; syncope;
rapid, thready pulse or bradycardia;
apprehension; hypotension; pale or
cyanotic, moist skin; coma

 3. Other signs and symptoms: Nausea,

vomiting, dizziness, blurred vision, sudden
severe headache, precordial pain, extreme
pulse rate or blood pressure change,
angioneurotic edema (wheeze, laryngeal
edema, bronchospasm), rashes, urticaria,
severe local tissue reaction.
4. IVCS may include: slurred speech,
agitation, combativeness, unarousable sleep,
hypotension, hypoventilation, airway
obstruction, and apnea.

Treatment of Adverse
Reactions
Treatment of an adverse reaction is aimed at
preventing respiratory and cardiac arrest.
Treatment must be promptly.
Administration of the agent thought to
produce the reaction is stopped immediately
at the first indication of reaction.
Therapy is generally supportive, the specifics
dictated by clinical manifestations.

 Treatment consists of the following:

1.Maintaining oxygenation of vital
organs and tissues with ventilation by
manual or mechanical assistance to give
100% oxygen with positive pressure.
Tracheal intubation may be indicated.

2.Reversing myocardial depression

and peripheral vasodilation.
The patient is supine with the legs elevated. IV
fluid therapy is begun, and a vasoconstrictor
drug may be given IV or IM for hypotension or
a weak pulse.
Drugs include:
a. Epinephrine, b. Ephedrine and other
vasoconstrictors such as phenylephrine or
mephentermine, c. Antihistamines, d. Steroids,
e. Isoproterenol (Isuprel), f. Antagonist drug.

 3.Stopping muscle tremors or convulsions if

they are present, since they constitute a hazard
for further hypoxia, aspiration, or bodily injury.
Diazepam in 5mg doses or a short-acting
barbiturate is given IV to inhibit cortical
irritation.
4.An emergency cart with emergency
resuscitative drugs and a defibrillator should
be immediately available.

The following equipment:

Oxygen and positive pressure breathing
device (e.g., Ambu bag and mask)
Oral and nasopharyngeal airways and
endotracheal tubes in an assortment of sizes
Cardiac and oxygen saturation monitoring
equipment
Suction

Toxic Reaction
symptoms vary depending on the drug.
SUBIECTIVE: Dizziness, somnolence
paresthesia, nausea, visual/speech problems
OBJECTIVE: Decreased breathing rate and
depth, muscle twitches, tremors, slurred speech
seizures, vomiting unconsciousness, coma

 VASOVAGAL: Dysrhythmia, bradycardia,

vasodilation, hypotension, myocardial
depression, Cardiac arrest
TREATHENT: Supportive, airway
management; intravenous (IV) line;
Trendelenburg position; muscular contractions
are treated with diazepam (Valium)

Allergic Reaction
SUBIECTIVE: Sense of uneasiness, pruritus,
agitation, paresthesia
OBJECTIVE: Erythema, urticaria, wheals
VASOVAGAL: Coughing, sneezing, wheezing,
bronchospasm, hypotension, hypovolemia,
vasodilation, Cardiovascular collapse, Cardiac
arrest
TREATHENT: Especially with amino ester type:
airway management, IV fluids, epinephrine,
diphenhydramine, and steroids as needed

Unrelated Effects
A nerve deficit, such as pain or neuritis, may
occurs in the postoperative period may be related to
a preexisting condition such as multiple sclerosis.
Alternatively, it may be from a cause unrelated to
the anesthetic drug, such as faulty positioning;
trauma from retractors; a tourniquet inflated for
an inordinately long period, resulting in ischemia or
pressure on peripheral nerves; or an improperly
applied cast.
Less common causes involve bleeding around the
nerve or reaction to epinephrine.

End