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Anesthetic Techniques: Regional Anthony R. Plunkett and Brian C. McLean Chapter 13 For maximum impact, it is recommended that the case study and questions found on page xxiii are reviewed before reading this chapter. Key Learning Objectives ● Understand the different types of regional anesthetics (neuraxial, peripheral, intravenous) ● Learn indications, techniques, and potential complications associated with regional anesthesia ● Review the relevant anatomy for regional anesthesia Introduction Regional anesthesia includes a variety of anesthetic approaches such as neuraxial (epidural and spinal anesthesia), peripheral, and intravenous techniques. Regional anesthesia plays an important role both inside and outside of the operating room. In addition to its use for surgical anesthesia, it is also gaining widespread use for postoperative pain control. In this chapter, we will review the basic tenets of neuraxial, peripheral, and intravenous regional anesthesia. Neuraxial Anatomy The vertebral column extends from the foramen magnum to the sacral hiatus. The spinal cord is contained within this bony framework. There are 24 vertebrae (7 cervical, 12 thoracic, 5 lumbar, and 5 fused vertebrae forming the sacrum). Each vertebrae is composed of a lateral transverse process and a posterior spinous process (which is what we feel when we palpate a patient’s back). J.M. Ehrenfeld et al. (eds.), Anesthesia Student Survival Guide: A Case-Based Approach, DOI 10.1007/978-0-387-09709-1_13, © Springer Science+Business Media, LLC 2010 173
174 ● AnesthesiA student survivAl Guide Figure 13.1 Vertebral anatomy. (Reproduced with permission from J. Mathias, Percutaneous Vertebroplasty and Kyphoplasty. Springer. 2nd Edition. 2006). The spinous process and transverse process are connected via bilateral lamina, while the transverse process is connected to the vertebral body via the pedicles (see Fig. 13.1). The spinal cord is contained within the spinal canal and covered by three layers called the meninges. The pia mater is closely adherent to the spinal cord, while the arachnoid mater is more closely adherent to the outer dura mater. Cerebral spinal fluid (CSF) is contained within the space between the pia mater and arachnoid mater, called the subarachnoid space. This is the site of injection when performing spinal anesthetic. The spinal cord normally extends from the foramen magnum to the level of L1 in adults and L3 in children. As a result, performing a spinal (subarachnoid block) below the level of L3 avoids potential trauma to the spinal cord. An important surface landmark when performing neuraxial anesthesia is the level of the iliac crest, which most commonly corresponds to the level of L4–L5 (Fig. 13.2). The spinal cord has a rich vascular supply from a single anterior spinal artery and paired posterior spinal arteries. The anterior spinal artery supplies approximately 2/3 of the spinal cord, while the paired posterior spinal arteries provide the remaining 1/3. There is a prominent feeder artery called the artery of Adamkiewicz or Radicularis Magna that provides blood supply to the anterior, lower 2/3 of the spinal cord. Trauma or ischemia of this artery can
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Anesthesia Student Survival Guide
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Editors Jesse M. Ehrenfeld, MD, MPH
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Foreword As anesthesiologists and H
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Contents Case Studies xvii Section
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ContEntS ● xi 19 Physiology and A
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Contributors Basem Abdelmalak, MD S
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David C. Lai, MD Partner, Allenmore
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CASE STUDIES In order to focus your
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CASE StUDIES ● xix inhalation ane
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CASE StUDIES ● xxi around the job
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CASE StUDIES ● xxiii ● Although
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CASE StUDIES ● xxv ● You plan a
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CASE StUDIES ● xxvii ● What oth
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CASE StUDIES ● xxix Chapter 23 Ca
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CASE StUDIES ● xxxi of her left h
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CASE StUDIES ● xxxiii speechless.
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CASE StUDIES ● xxxv things go ver
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How to Be a “Star” Student, Car
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hOw tO Be A “stAr” student, CAr
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Pre-Op Holding Area Preoperative Ev
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History of Anesthesia and Introduct
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history of AnesthesiA And introduct
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Pharmacology Section II
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The Preoperative Patient Evaluation
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THe PreoPerATIve PATIenT evAluATIon
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Therapy-based indications radiation
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Table 8.5 Formulation an anesthetic
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Chapter 15 IV, Gastric Tube, Arteri
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iv, GAstric tube, ArteriAl & centrA
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Common Intraoperative Problems Fran
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Pneumothorax Uncommon, but may spon
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COMMON INTRAOPERATIVE PROBLEMS ●
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Table 16.3 Common intraoperative dy
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Table 16.3 (continued) Problem Diff
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Systems Physiology and Anesthetic S
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Chapter 20 Physiology and Anesthesi
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PhysioloGy And AnesthesiA for Gener
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Anesthesia for Urological Surgery P
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AnesthesiA for uroloGicAl surGery
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Physiology and Anesthesia for Pedia
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PhysioloGy And AnesthesiA for PediA
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Table 22.6 Common pediatric emergen
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Physiology and Anesthesia for Elder
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PhysioloGy And AnesthesiA for elder
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Chapter 24 Ambulatory Surgery and O
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AmbulAtOry Surgery ANd Out-Of-Or (O
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Perioperative Acute and Chronic Pai
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PerioPerAtive ACute And ChroniC PAi
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Chapter 27 Postoperative Anesthesia
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POstOPerAtive AnesthesiA CAre unit
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Introduction to Critical Care Bever
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introduction to criticAl cAre ● 4
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SVR = [(MAP - CVP)/CO] ´ 80 introd
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● ● ● ● ● introduction to
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Chapter 29 Professionalism, Safety,
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ProfessionAlism, sAfety, And teAmwo
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Chapter 30 Quality Assurance, Patie
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QuAlity AssurAnce, PAtient And Prov
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Chapter 32 Clinical Simulation in A
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Table 32.1 Matrix of categories of
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CliniCAl simulAtion in AnesthesiA e
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ASA Difficult Airway Algorithm Appe
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518 ● ANESTHESIA STUDENT SURVIVAL
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