29204136 epidural and spinal anesthesia
TRANSCRIPT
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DEPARTMENT OF ANESTHESIA
OSPITAL NG MAYNILA MEDICAL CENTER
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EPIDURAL AND SPINAL
ANESTHESIA
No absolute indications
Clinical situations, patientphysiology, surgical procedure:
makes central neuraxial block
the technique of choice
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EPIDURAL AND SPINAL
ANESTHESIA
Blunt the stress response tosurgery
decrease intraoperative blood loss
lower the incidence ofpostoperative thromboembolic
eventsdecrease morbidity and mortality
in high-risk surgical patients
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extend analgesia into thepostoperative period
(provide better analgesia thancan be achieved with parenteral
opioids)
provide analgesia to non-
surgical patients
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VERTEBRAE
The spine consistsof 33 vertebrae
7 cervical
12 thoracic
5 lumbar
5 fused sacral
4 fused coccygeal
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Cervical (except C1),thoracic, and lumbarvertebrae: bodyanteriorly, twopedicles that projectposteriorly from thebody, and two laminaethat connect thepedicles ----form the
vertebral canal, whichcontains the spinalcord, spinal nerves,and epidural space
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Lamina: give rise to the
transverse processes (laterally);
spinous process (posteriorly) ---sites for muscle and ligament
attachments
Pedicles: contain a superior and
inferior vertebral notch through
which the spinal nerves exit the
vertebral canal
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5 sacralvertebrae fused
to form the
wedge-shapedsacrum (connectsthe spine with the
iliac wings of the
pelvis)
5th l
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5th sacralvertebra (not fusedposteriorly) give riseto a variablyshaped opening ---- sacral hiatusopening into thesacral canal(caudaltermination of theepidural space)
Sacral cornu
bony prominences on either side of thehiatus
aid in identification of sacral hiatus
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Coccyx fused 4 rudimentary coccygeal vertebrae
a narrow triangular bone that abuts the
sacral hiatus
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Tip of the coccyxcan often be
palpated in the
proximal gluteal
cleft and by runningones finger
cephalad along its
smooth surface, the
sacral cornu can beidentified at the 1st
bony prominence
encountered
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C7: 1st prominentspinous processencountered whilerunning the hand downthe back of the neck
T1 : most
prominentspinous process
T12 : can beidentified by
palpating the12th rib andtracing it back toits attachementto T12
Line drawn betweenthe iliac crests:
body ofL5 or the 4-5inters ace
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LIGAMENTS
Vertebralbodies arestabilizedby 5ligaments
thatincreasein sizebetweenthecervicalandlumbarvertebrae
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EPIDURAL SPACE
Space that lies between the spinal
meninges and the sides of thevertebral canal
Boundaries:
Cranially: foramen magnum
Caudally: sacrococcygeal ligament
covering the sacral hiatus
Anteriorly: posterior longitudinal ligamentLaterally: vertebral pedicles
Posteriorly: ligamentum flavum and
vertebral lamina
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Not a closed space butcommunicates with the
paravertebral space by way of the
intervertebral foramina Shallowest anteriorly where the
dura may in some places fuse with
the posterior longitudinal ligament Deepest posteriorly
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Composed of a series ofdiscontinuous compartments that
become continuous when the
potential space separating thecompartments is opened up by
injection of air or liquid
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MENINGES
Spinal meninges consist of 3protective membranes :
Dura mater
Arachnoid materPia mater
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Dura mater
Outermost and thickest meningeal
tissue
Begins at the foramen magnum;ends at approx S2 where it fuses
with the filum terminale
Inner surface abuts the arachnoidmater
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Arachnoid mater
Delicate, avascular membranecomposed of overlapping layers offlattened cells with connective
tissue fibers running between thecellular layers
Specialized connections (tight
junctions and occluding junctions)account for the fact that it is thephysiologic barrier for drugs movingbetween the epidural space and the
spinal cord
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Subarachnoid space lies betweenthe arachnoid mater and the piamater and contains the CSF
Spinal CSF is in continuity with thecranial CSF and provides an avenuefor drugs in the spinal CSF to reach
the brain Spinal nerve roots and rootlets runin the subarachnoid space
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Pia mater Adherent to the spinal cord and is
composed of a thin layer of
connective tissue cells interspersed
with collagen
Extends to the tip of the spinal cord
where it becomes the filum
terminale, which anchors the spinal
cord to the sacrum
Gives rise to the dentate ligaments
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NEEDLES
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NEEDLES
Spinal NeedlesWhitacre and
Sprotte:
pencil-point tip needle hole on the
side of the shaft
Greene and Quincke:
beveled tips with
cutting edges
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Spinal Needles
* pencil-point
needles requiremore force to insert
than the bevel-tip
needles but provide
better tactile feel;
not deflected* Size: 22-29 gauge larger
gauge smaller diameter
Epidural Needles
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Epidural Needles
Touhy: curved tip to
help control the
direction that the
catheter moves in
the epidural space
Hustead: lesscurved tip
Crawford: straight;
less suitable forcatheter insertion
*sizes: 16-19 gauge
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SEDATION Light sedation before placement of block
Successful spinal and epidural anesthesiarequires patient participation to:
maintain good position
evaluate block height
indicate paresthesias if needlecontacts neural elements
properly evaluate an epidural test
Once the block is placed and adequateblock height assured, patient can besedated as deemed appropriate
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SPINAL ANESTHESIA
POSITION
Patient positioning is critical to
successful spinal puncture
lateral decubitus
sitting position
prone jackknife position
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POSITION
Lateral decubitus
patient lies with the operative side
down (hyperbaric LA)
or with operative side up (hypobaric
LA) ---most dense block occurs on
the operative side
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POSITION
back at the edge of the table
patients shoulders and hips
positioned perpendicular to the bed
knees drawn to the chest; neck
flexed; patient instructed to curve
the back outward
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MIDLINE APPROACH
Skin overlying the desired
interspace is infiltrated with a small
amount of LA (1-2 ml) to a depth of1-2 inches to prevent pain when
inserting the spinal needle
Slight cephalad angulation (10-15degrees)
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MIDLINE APPROACH
Needle is then advanced subcutaneous tissue
supraspinous ligament interspinous ligament
ligamentum flavum
epidural space
dura mater
arachnoid mater
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MIDLINE APPROACH
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MIDLINE APPROACH
Penetration of the dura mater produces
a subtle pop
detection of dural penetration
prevent inserting the needle all the way
through the subarachnoid space and
contacting the vertebral body;
insert spinal needle quickly withouthaving to stop every few mm and remove
the stylet to look for CSF at the needle
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MIDLINE APPROACH
Once the needle tip is believed to be in
the subarachnoid space, stylet is
removed to see if CSF appears at the
needle hub
Small diameter needles (26-29 gauge)
requires 5-10 sec or >/= 1 minute
Failure to obtain CSF suggests thatthe needle orifice is not in the
subarachnoid space and must be
reinserted
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MIDLINE APPROACH
Once the needle is correctly inserted
into the subarachnoid space, it is
fixed in position and the syringe
containing LA is attached
CSF is gently aspirated to confirm that
the needle tip remained in the
subarachnoid space and LA slowlyinjected (
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MIDLINE APPROACH
After completing the injection, a
small volume of CSF is again
aspirated to confirm that the needletip remained in the subarachnoid
space while the LA was deposited
This CSF is then reinjected and theneedle, syringe, and any introducer
removed together as a unit
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MIDLINE APPROACH
strict attention to patients
hemodynamic status with BP and/or
HR supportedblock height should also be assessed
early
pin pricktemperature sensation
Table may be tilted as appropriate toinfluence further spread of localanesthetics
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PARAMEDIAN APPROACH
useful in situations where the
patients anatomy does not favor
the midline approachinability to flex the spine
heavily calcified interspinous ligaments
Patient in any position; bestapproach for the patient in the
prone jackknife position
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PARAMEDIAN APPROACH Identify the spinous process forming
the lower border of the desired
interspace Needle inserted
~1 cm lateral
directed toward middle of the
interspace ~45 degrees cephalad
medial angulation (~15 degrees) tocompensate for the lateral insertionpoint
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PARAMEDIAN APPROACH
Needle inserted ~1 cm lateral, directed toward middle of theinterspace ~45 degrees cephalad with just enough medial angulation(~15 degrees) to compensate for the lateral insertion point
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PARAMEDIAN APPROACH1st significant resistance encountered:
ligamentum flavum
Alternative method:
insert needle perpendicular to the skin in all
planes until the lamina is contacted; needle is
then walked off the superior edge of the lamina
and into the subarachnoid space
**Lamina provides a valuable landmark that
facilitates correct needle placement
EPIDURAL ANESTHESIA
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EPIDURAL ANESTHESIA
May be performed at
any intervertebral
space
LA skin wheal is
raised to the point ofneedle insertion
Pierce the skin with a
>/=18 G hypodermicneedle
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Epidural needle
inserted through
the subcutaneous
tissue and into the
interspinousligament gritty
feel
Needle is advanced
slowly until an
increase in
resistance is felt :
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Techniques toidentify epidural
space:Loss of resistance
technique(fluid/air)
Glass syringe: 2-3ml saline + 0.1-0.3ml air bubble
Hanging drop
technique
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After entering the epidural space,stop advancing the needle
heightens the risk of meningeal
puncture wet tap LA test dose should be administered
to help rule out undectected
subarachoid or IV needle placement After a negative test dose, desired
volume should be administered in
small increments
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EPIDURAL TEST DOSETo identify epidural needles or
catheters that have entered an epiduralvein or the subarachnoid space
Failure to perform: IV injection or totalspinal block
3 ml of LA + 1:200,000 epinephrine IV: epinephrine
HR increases 20-40 sec after
BP increase of >/=20 mmHg
Subarachnoid: motor block ---LA
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Spinal anesthesia interrupts sensory,motor, and sympathetic nervous system
Classic concept:Conduction blockade through small diameter
unmyelinated (sympathetic) fibers beforeinterrupting conduction via large myelinated(sensory & motor) fibers
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Block of afferent impulses from thesurgical site leads to absence of
adrenocortical response to pain
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Vasodilatation of resistance and
capacitance vessels occurs:
hypovolaemia, tachycardia, drop in blood
pressure
exacerbated by blockade of the
sympathetic nerve supply to the
adrenal glands, preventing the releaseof catecholamines.
Bradycardia: If blockade is as high as T2,
sympathetic supply to the heart (T2-T5)
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overall result: inadequate perfusion ofvital organs
measures: restore blood pressure and
cardiac output (fluid administration,
vasoconstrictors)
Sympathetic outflow extends from T1 - L2
(blockade of nerve roots below this level,
knee surgery, is less likely to causesignificant sympathetic blockade,
compared with procedures requiring
blockade above the umbilicus)
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usually unaffected unless blockade is
high enough to affect intercostal muscle
nerve supply (thoracic nerve roots)
leading to reliance on diaphragmaticbreathing alone
distress to the patient, as they may feel
unable to breathe adequately
decreased ability to cough and expel
secretions
if patients cannot breathe, ventilate (face
mask and bag
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Blockade of sympathetic outflow (T5-L1),
leads to predominance of
parasympathetic (vagus and sacral
parasympathetic outflow)
leading to active peristalsis and relaxed
sphincters, and a small, contracted gut, which
enhances surgical access
Splenic enlargement (2-3 fold) occurs
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If above T5, inhibits sympatheticinnervation to the GIT, resulting in
unopposed parasympathetic nervous
system activity
Contracted intestines and relaxed sphincter;
if not on NPO, tendency to develop vomiting
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urinary retention is a common problem
severe drop in blood pressure may affect
glomerular filtration in the kidney (ifsympathetic blockade extends high
enough to cause significant
vasodilatation)
ureters are contracted and ureterovesicalorifice is relaxed
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Decreased bleeding may be areflection of decreased BP
Increased blood flow to lower
extremities ---- decreased incidenceof thromboembolism
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BLOCK HEIGHT
Perianal
Perirectal
L1-2 Hyperbaric/sitting pos
Hypobaric/jackknife pos
Lower extremity/
Hip
TURP
Vaginal/ cervical
T10 Isobaric
HerniorrhaphyPelvic procedures
Appendectomy
T6-8 Hyperbaric/ horizontal
Abdominal
Cesarean section
T4-6 Hyperbaric/ horizontal
FACTORS THAT AFFECT SPREAD OF
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LOCAL ANESTHETIC SOLUTIONS
Characteristics of the local anesthetic
solution ratio of density (mass/vol) of LA div
density of CSF
Local anesthetic dose
Local anesthetic concentration
Volume injected
Patient characteristics
Age
WeightHeight
Gender
Pregnancy
Patient position
FACTORS THAT AFFECT SPREAD OF
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LOCAL ANESTHETIC SOLUTIONS
Technique
Site of injection
Diffusion
Speed of injection
Barbotage
Direction of needle bevel
Addition of vasoconstrictors
LOCAL ANESTHETIC
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SOLUTION
HYPERBARIC: solution more dense thanCSF; >/=1.0015Add glucose (5-8% dextrose) of increase the
density
LA solution settles to dependent region HYPOBARIC: solution less dense than
CSF;
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Hypotension Postdural puncture headache
Hearing loss
Total spinal
Backache
nausea
Urinary retention
Systemic toxicity Neurologic injury
Spinal hematoma
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HypotensionDue to sympathetic nervous system
blockade
a.Decreased venous return to heart,decreased cardiac output
b.Decreased systemic vascular
resistance
c.Bradycardia due to blockade of
cardioaccelerator fibers (T1-3),
decreased cardiac output
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HypotensionTreatment: restore venous return to
incrase cardiac output
Position head-down: autotransfusionHydration before spinal anesthesia
Sympathomimetics
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Postdural puncture headacheFrontal/occipitalWorsened by sitting, improved by supine
position
Due to decreased CSF pressure and resulting
tension on meningeal vessels and nerves as aresult of leakage of CSF through the duralhole
Diplopia due to traction on abducens nerve
Treatment: bed rest, analgesics
Hydration (>/= 3L/day) to increase CSF production Epidural patch (10-20 ml) to seal dura
Caffeine-sodium benzoate (by vasoconstriction)
Hearing loss
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High Spinal Undesired excessive level of sensory
and motor anesthesia associated with
difficulty of breathing or apnea ---arterial hypoxemia or hypercarbia
Apnea reflects ischemic paralysis of
medullary ventilatory centers due to
profound hypotension and associatedwith decreased cerebral blood flow
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High Spinal Treatment: support breathing and
circulationa.Positive pressure ventilation with face
maskb.IVF and sympathomimetics
c.Head down to increase venous return
(head up will jeopardize cerebral blood flow --
- medullary ischemiad. Intubation of trachea in those at risk for
aspiration
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rare complication
profound hypotension
apneaunconsciousness
dilated pupils as a result of the action
of local anesthetic on the brainstem
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Airwaysecure, administer 100% oxygen
Breathing - ventilate by facemask, intubate
Circulation - treat with iv fluids and
vasopressorContinue to ventilate until the block wears off
(2 - 4 hours)
As the block recedes the patient will begin
recovering consciousness followed bybreathing and then movement of the arms and
finally legs. Consider some sedation
(diazepam 5 - 10mg i/v) when the patient
begins to recover consciousness but is still
intubated and requiring ventilation
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Backache May be related to position required for
surgery
More likely due to ligamentous strainwhen in an uncomfortable position
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Nausea May be due to hypotension --- cerebral
ischemia; tx sympathomimetics
May be due to predominance ofparasympathetic nervous system
activity; tx atropine 0.4 mg IV
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Urinary RetentionBecause spinal anesthesia interferes
with innervation of the bladder
Administration of large amounts of fluid--- bladder distention requiring catheter
drainage
Systemic toxicity
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Neurologic injuryVery rare due to small dose of LA
employed
In the absence of hematoma orabscess, treatment is symptomatic
Spinal hematoma
Rare; present with numbness or LE
weakness
Risk factor: coagulation defects
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due to an excessively large dose of
local anesthetic
hypotension, nausea, sensory loss orparesthesia of high thoracic or even
cervical nerve roots (arms), or difficulty
breathing
most severe cases may requireinduction of GA with securing of the
airway, while treating hypotension
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If patient has a clear airway and isbreathing adequately: reassurance and
any hypotension immediately treated
Difficulty in talking (small tidal volumes
due to phrenic block) and drowsiness
are signs that the block is becoming
excessively high and should be
managed as an emergency
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excessive dose of local anaesthetic
moderate dose of LA, injected directly
into a blood vesselepidural catheter is inadvertently
advanced into one of the many epidural
veins. It is therefore vital to aspirate
from the epidural catheter prior toinjecting local anaesthetic
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symptoms: light-headedness, tinnitus,
circumoral tingling or numbness and a
feeling of anxiety or "impending doom",
followed by confusion, tremor,
convulsions, coma and CPR arrestearly recognition: discontinue further
administration of local anesthetic
drugs
treatment: supportive,sedative/anticonvulsants,
cardiopulmonary resuscitation if
required
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Patient refusal: only absolute contraindication Conditions that increase the apparentrisk of central neuraxial block- Hypovolemia or shock increase the risk of
hypotension
- Increased ICP increases the risk of brainherniation when CSF is lost through theneedle, or if a further increase in ICP followsinjection of large volumes of solution into theepidural or subarachnoid spaces
- Coagulopathy or thrombocytopenia increasethe risk of epidural hematoma
- Sepsis increases the risk of meningitis
- Infection at the puncture site increases therisk of meningitis
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Pre-existing neurologic disease(multiple sclerosis) : considered CI
No evidence to suggest that spinal or
epidural anesthesia alters the course ofany preexisting neurologic disease
Recommendations to avoid RA stem
largely from a medicolegal concern
that the anesthetic may be incorrectlyblamed for any subsequent worsening
of the patients preexisting condition
SPINAL OR EPIDURALANESTHESIA?
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ANESTHESIA?
Spinal AnesthesiaLess time to
perform
Produces morerapid onset of
better quality
sensorimotor
blockLess pain during
surgery
SPINAL OR EPIDURALANESTHESIA?
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ANESTHESIA?
Epidural Anesthesia
Lower risk of PDPH
Less hypotension if epinephrine is notadded to the LA
Ability to prolong or extend the block
via an indwelling catheter
Option of using an epidural catheter to
provide postoperative analgesia
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