continuous spinal anesthesia

CONTINUOUS SPINAL
Prof. Dr. Armando Fortuna, TSA

CONTINUOUS SPINAL
History:
• Dean, 1907, needle.
• Lemmon, 1940, malleable needle.
• Tuohy, 1944, Rubber Uretheral catheter, 15G needle.
• Hingson and al: polyethylene, later vinyl, nylon.
• Needles 16, 17, and finally, 18G, Tuohy or Crawford.
• 80’s: micro catheters, 32 e 28, abandoned in 91 (FDA).

CONTINUOUS SPINAL

CONTINUOUS SPINAL

CSA - INDICATION: (1/2)
• Individuals over 60 years (none or minimum incidence
of PSPH: post spinal puncture headache)
• Poor risk cases: Especially over 60 years of age
• Surgery below T10, in patients over 60 years, in the
following conditions:
• Procedures scheduled for over 2 hours
• Classified with risk equal or over ASA III, not
counting the duration of surgery
CSA = Precise doses.
• Emergency surgery, full stomach (over 60)
Long duration Intervention. Consider awake intubation
• Patients with metabolic problems: diabetes, kidney
insufficiency and hepatic disease.

CSA - INDICATION: (2/2)
• Upper Abdomen - procedure below T4: stomach,
intestines, spleen, liver, gyn, urological or vascular
interventions. Some demand Narcoanalgesia.
• Perineum and lower limbs, especially orthopedics, hip
and femur prosthesis
• Patients under 60 years, ASA III or higher, where the
benefits surpass the risks (hypotension, post-dural
puncture headache, etc).
• CSA as a Combined Method: (GA complementation)
• Intra or extra abdominal surgery, below T10, long
duration at uncomfortable decubitus (Sedation,
Narcoanalgesia)
• Intra-abdominal surgery over T10, in any duration, it is
a must

CSA – CONTRAINDICATION:
• Patient refusal
• Diseases of the CNS
• Cardio-vascular instability (shock, hypovolemia,
dehydration)
• Chronic Back Pain (risk of exacerbation, malpractice),
• Skin and tissue infection at the puncture level
• Abnormality of Blood Clotting Mechanisms
use of anticoagulants drugs
• Gross spinal deviations (relative)
• Lack of experience with the CSA technique
• Lack of standard resuscitation equipment
• Poor aseptic technique. LA ampoules not sterilized

CSA - TECHNIQUE (1/7)
a) Basic care before the procedure:
• Monitoring of Vital Signs - Monitors on:
Oximeter, Cardioscope.
• Vital Signs Noted. Precordial stethoscope.
• Thermometer. Automatic blood pressure
device.
• Two venous lines/arterial line, “poor risk”.
• 500 to 1.000 ml preload infusion, Ringer 1/6M.
• Routine use of O 2 in all procedures (face mask,
endotracheal tube)

CSA - TECHNIQUE (2/7)
b) For the Block:
1) Needle: Tuohy or its modification (Halstead), 18G or
19G. TAYLOR Technique: longer Tuohy needle
2) Puncture: lateral or sitting - L3-L4, L4-L5, L5-S1
(Taylor).
3) Type of catheter: 20 or 21G, nylon, without guide
4) Orientation: cephalic, threaded up to 2 cm in the
subdural space
5) Continuous epidural kits are satisfactory

CSA - TECHNIQUE (3/7)
6) Local Anesthetic:
• isobaric bupivacaine 0,5% (recent with good results)
• lidocaine at 2%: dilute 5% hyperbaric lidocaine (7,5%
glucose), in CFS
7) Dorsal decubitus - 0,5% isobaric bupivacaine,
• 2,5 to 5 mg through the spinal catheter
• 3 - 5 min: evaluate spread and autonomic block:
If BP falls about 40 mmHg systolic:
Metaraminol 0,5 to 1 mg I.V. (bradycardia)
Ephedrine 5 to 10 mg.
Phenylephrine 10 mg in 250 ml of Ringer (tachycardia)

CSA - TECHNIQUE (4/7)
c) Maintenance:
• Interval between injections: # 90 min (bupivacaine)
• Increases in BP, muscular tonus or signs of
discomfort, are indications for a further dose of the
agent
1) Sedation:
• 0 2 by face mask (50%)
• Fentanyl (10 a 20 mcg)
• Midazolam ( 0,75 to 1,5 mg IV)

CSA - TECHNIQUE (4/7)
2) Narcoanalgesia:
• IV Induction (Thiopental, Ketamine, Propofol) plus
succylcholine to facilitate endotracheal intubation, 2 or 3
min. after the block. Awake intubation in high risk cases
(topical + transtraqueal)
• Traqueal Intubation: procedures expected to last over two
hours or for the ones requiring uncomfortable decubitus,
upper abdominal procedures or emergency
• Controlled Ventilation: Intra abdominal procedures or at
decubitus that impairs spontaneous ventilation. Low doses
of muscular relaxants to help setting the patient, if
necessary
• Even for short cases, when in doubt about the airway
patency or ventilation, Intubation or LM is a must.
• LM - Laryngeal Mask in selected cases (empty stomach,
with no other contraindication for its use)

CSA - TECHNIQUE (5/7)
• Maintenance with N 2 0/0 2 , reinforced by low
concentration of halogenated agent, associated
to opioids or Midazolam, when necessary
• Controled Ventilation should be stopped 15 to
20 minutes before the end of the surgery.
Anesthetic agents, except N 2 0 interrupted at this
point
• Hypotension: vasopressors immediately
• Bradycardia: ephedrine or atropine

CSA - TECHNIQUE (7/7)
• Extubation only with all laryngeal reflexes present
• Usually the patient is awake, up to 15 minutes after
the surgery is over
• Careful control of BP with vasopressors and IV fluids
in the PACU
• 0 2 by facial mask (Venturi type 50% )
• Depending on the PACU facilities, consider injection
of 5 micrograms of Sufentanyl or 100 to 200
micrograms of morphine, before taken out the
catheter

CSA – COMPLICATIONS (1/2)
# PER-OPERATIVE:
• From the Sympathetic Blockade:
hypotension, bradycardia
• Nausea and Vomiting (risk of aspiration)
• Possibility of hypoventilation (Intercostals
nerve paralysis)
• Minor: Backache, Urinary Retention

CSA – COMPLICATIONS (2/2)
# POST-OPERATIVE:
• Neurologic Sequelae
• Risk of meningeal infections
• Headache (PSPH): very unusual in older age.
• Lombalgia: position at the table. Air cushion or
pillow.
• Neurological sequela: rare
• Cauda equina: withdraw of the micro-catheters.
(FDA 91)
• Hematomas extra or intradural.

CSA – ADVANTAGES (1/2)
• Regional anesthesia tailored to the patient’s needs:
duration and for the needed metameres.
• Decrease of the surgical stress - Anoci-association
(Crile 1914), Stress free anesthesia (Kehlet,H 1982)
• Less bleeding – sympathetic block (Scott, 1969)
• Airway protection, Effective ventilation (Narcoanalgesia)
• Absence of toxic reactions to the local anesthetic (low
dose).
• Avoids the mandatory use of muscular relaxants and its
needed reversion. (Aitkenhead 1982)
• Awake and fast recovery, pain free.

CSA – ADVANTAGES (2/2)
• Reduction of thromboembolism (Modig 1982)
• Conscience present, except when sedation or hypnosis
are indicated.
• Sedation or “Narcoanalgesia” to avoid problems with
uncomfortable position at the surgical table and fatigue
due to the procedure duration. Careful of the “sedation
trap”.
• Possibility of postoperative analgesia (filter), opioids or
local anesthetics.
• Early ambulation and less incidence of embolism.

CSA - DISADVANTAGES
• Potential Hazards of Severe HYPOTENSION
• Postdural Puncture HEADACHE (young patients)
• Potential Hazards of NEUROLOGICAL SEQUELAE
• Potential Hazards of INFECTIONS
• More time consuming: two techniques required.
• Potential Hazards of INTRA or EXTRADURAL
BLEEDING in patients receiving anti-coagulant
medication. Special attention to low molecular
heparin
• May need SUPPLEMENTATION:
NARCOANALGESIA (specially in mid-upper
abdominal procedures)

CSA - RESULTS
1. No deaths due exclusively to this technique in
over 1.300 cases (820 + recent cases) in our
Anesthesia Department
2. No severe headaches in patients over 60
3. Blood transfusions cut by 1/3.
4. Fast recovery, with the patient alert and with no
mental impairment.

CONTINUOUS SPINAL
Local Anesthetic:
• Tetracaine 0,5%
Distr. in 820 cases
• Lidocaine 2 to 3,3%
• Bupivacaine 0,5%
%
100
80
60
40
20
Tetra
Lidoc
Bupi
- 9%
- 90%
- 1%
0
patients

CONTINUOUS SPINAL
Intercurrences: (in 820 cases)
54%
12%
34%
• Hypotension (systolic)
< 20 20-50 > 50 mmHg
%
• Use of Vasopressor
66%
• Bradicardia (below 50 bpm)
0 50 100
%
2%
0 50 100

CONTINUOUS SPINAL
Associated Methods to CSA: (820 cases)
# NONE (CSA as a single technique) [ 33%]
# INTRAVENOUS (sedation) [ 11%]
# INHALATION: [ 56%]
• Endotracheal tube ( 89%)
• Awake Intubation ( 2%)
• Facial Mask ( 4%)
• Laryngeal Mask ( 5%)
* MECHANICAL Ventilation [ 85%]
• assisted/controlled ( 76%)
• low doses muscle relaxant to facilitate
controlled ventilation ( 24%)
* SPONTANEOUS Ventilation [ 15%]

Dr. ZHEN-GANG ZHAN
• 5034 Pediatric Epidurals
• World Congress HAIA 1992
• BEIJIN, CHINA

Spinals in Children
Wilms tumor:
• 2yrs old girl
• Spinal (tetracaine 3mg)
• Narcoanalgesia (Intub)

Spinals in Children
Direct approach

Difficult Punction:
The “TAYLOR” Approach

The “TAYLOR” Approach (L5/S1)

The “TAYLOR” Approach (L5/S1)

CSA – Hip Replacement 85yr (1986)

SANTOS – BRAZIL