SlideShare a Scribd company logo
1 of 51
Download to read offline
Technique of SPinAL
AneSTheSiA indicATion
And conTrAindicATion
Guided by: Dr. Shubhada Deshmukh(M.D.)
Presented by: Dr.Anurag Giri
 Spinal anesthesiaisalso called asspinal block
or subarachnoid block (sab). SAB isaregional
anesthesiainvolving injection of alocal
anesthesiainto thesubarachnoid spacewhich
extendsfrom theforamen magnum to S2 in
adultsand S3 in children. Injection of LA below
LI in adultsand L3 in children helpsto avoid
direct traumato thespinal cord , (anesthetic
agentsactson thespinal nerveand not on the
substanceof thecord)
SPinAL AneSTheSiA
Spinal anesthesia
 Corning in 1885 , accidently administered
cocaineintrathecally.
 Quinckein 1891 , madeuseof spinal puncture
in diagnosis.
 August bier of Germany in 1898 , introduced the
techniqueof spinal anesthesia.
 Pitkin popularized themethod of introducing
agent'sintrathecally.
hiSTory
 Informed consent.
 Physical examination , history (past surgical ).
 Laboratory test.
 Premedication
Diazepam 0.1-0.2 mg/kg Po
midazolam 1-3 mg I/M
PreoPerATive evALuATion And
PrePArATion
 Used both aloneand in combination with either
GA or sedation.
 Lower limb orthopedic surgery on thepelvis,
femur , tibiaand ankle.
 Total hip replacement.
 Total kneereplacement.
 Lower limb vascular surgery.
4) indicATion of SPinAL
AneSTheSiA
 Hernia(Ingunial or epigastric).
 Haemorrhoidectomy , fistula, fissure.
 Nephrectomy and cystectomy in combination with GA.
 Transurethral resection of theprostateand transurethral
resection of thebladder tumors.
 Abdominal and vaginal hysterectomies
 Laproscopic assisted vaginal hysterectomies(LAVH)
combined with GA.
 Caesarean sections.
 ABSOLUTE
Patient refusal
Infection at thesiteof injection
Coagulopathy or other bleeding diathesis
Severehypovolemia
Increased intracranial pressure
Severeaortic stenosis
Severemitral stenosis
 Post traumatic vertibral injuries, myocardial infract.
conTrAindicATion
∗ RELATIVE
∗ Sepsis
∗ Un co-operative patient
∗ Preexisting neurological deficit
∗ Stenotic valvular heart disease
∗ Severespinal deformity
∗ Spinal congenital anomalies
∗ Hypo tension
∗ Hyper tension
∗ Severeanaemia
∗ Shock(haemorragic,septic)
∗ Brain tumor
4 Ps
Preparation
Position
Projection
Puncture
recoMMendATionS for SAfe
SPinAL TechniqueS
1.Scrub handsaccording to aseptic surgical technique
2.Usesterileglows
3.Avoid contaminating blocking solutionswith solutionsused to
preparetheskin.
4.Useaseptic techniquewhen opening tray.
5.Clean theskin prior to needlepuncture.
6.Touch only sterilearticlesoncegloved.
7.Useintroducer prior to injection of small guagespinal needle.
8. Avoid repeated traumatic punctures.
9.Useapproved local anaesthetic agentsin standard concentration
∗ Clean theskin surfacetwicewith betadineand twicewith spirit
using window techniquewith sterilegauze
cLeAninG And
drAPPinG
∗NEEDLES
∗Thestandard spinal needle-
∗ThreepartsHub , cannula, stylet
∗Pointsof cannulaearebeveled and havesharp edgeCannulaemadeof stainlesssteel
should bestiff, flexibleand resistant to breakage.
∗Sizes- 16 G to 30 G
∗Length- 3.5 to 4 inches 
∗NEEDLES CLASSIFIED
∗1. Standard bevelled with cutting edges-
∗ Quincke,Babcock or Pitkin
∗2. Pencil point needlewith conical point with no cutting edges- Sprotte, Greene.
SPinAL AnASTheSiA Technique
• Large IV cannula
• IV fluids immediately before the spinal
• The volume of fluid given will vary with age and extent of
block
• Ideally – 10ml/kg
• Crystalloids like Ringerlactate , 0.9% normal saline are
used
• Now co-loading.
INTRAVENOUS PRELOADING
∗ L.P. ismost easily performed when thereismaximum flexion of
lumbar spine.By thisligamentsget stretched and spaceisopen
POSITIONS
∗ TWO ASPECTS
∗ 1. Spinal canal should beon horizontal plane
∗ 2. Operator should fix hisor her gazeon thehorizontal plane. 
POSITIONING
∗ Flexed lateral position- back should beparallel to theedgeof the
table, kneesareflexed on theabdomen, neck flexed.
∗ Jack knifeposition
LATERAL POSITION
Spinal anesthesia
Spinal anesthesia
∗ Theanatomic midlineisoften easier to aproach when thepatient is
in sitting position .Patient sit with their elbowsresting on their
thighsor bedsidetableor they can hug apillow. Flexon of spine
miximizesthetarget areabetween adjacent spinousprocessesand
bringsthespinecloser to skin surface
SITTING POSITION
Spinal anesthesia
∗ Thisposition isused for anorectal proceduresutilising ahypobaric
anasthetic solution
PRONE POSITION
• Vertebral Spinousprocessesand theiliac crests
• Spinousprocessesclearly definethemidline
• Linedrawn between theiliac crests- intercristineor Tuffier’s
linecrossesthe4th
lumber vertebrae.
LANDMARK
∗ Thedepression between thespinousprocessof thevertibraaboveand
below thelevel to beused ispalpated.Thiswill bethemiddleentry
site.
∗ Thespinousprocesscoursedownwardsfrom thespinetowardsthe
skin so theneedlewill bedirected cephalad
∗ Thesubcutaneoustissuegivesfeeling of littleresistanceto the
needle,after that needlewill enter thesupraspinousand infraspinous
ligamentsfelt asan increasein tissuedensity .
∗ Astheneedlemeetstheligamentum flavam an increasein resistanceis
encountered and on piercing it, lossof resistancecan befelt .The
needleisadvanced through theepidural spaceand penetratesthedura
(2nd
resistance) and subarachnoid membraneassignaled by free-
flowing CSF.
MIDLINE APPROACH
USE OF AN
INTRODUCER
•Concept of Introducer was that of
Lincoln Size.
•Modifications- Pitkin and by Lundy.
• Purpose- Spinal needle can be
inserted to the depth of the
interspace without touching the
skin, subcutaneous tissues and
ligaments.
• Grasping and stabilising
OBJECTIVES OF INTRODUCER
∀↓Infection
∀↓ Contamination
•Facilitate introduction of Spinal
needle.
•Minimize introduction of skin and
tissue fragments
•Avoid development of SAB
epitheliomas and epidural tumors.
∗ Theparamedian approach may beselected if SAB isdifficult(severe
arthritisor prior LSspinesurgery) Theskin wheal for theparamedian
approach israised 2cm lateral to theinferior aspect of thesuperior
spinousprocessof thedesired level.Theneedleisdirected and
advanced at a10-25degreeangletowardsthemidline
PARAMEDIAN/ LATERAL
APROAch
Spinal anesthesia
∗ Thisisavery useful method in casesof spinefusion, arthritic spine,
opisthotones, skin infection in thelumbar region , or in other
conditionsin which theusual approach isdifficult or impossible.
∗ Largest interspaseL5-S1.
∗ A skin wheal is made1cm medially and 1cm below thelowest
prominenceof theposterior-superior spine. A 12-cm , needleis
directed upward , medially and forward at an angleof about 50degree,
approximating forward at an anglethat thedorsal aspect of thesacrum
makeswith theskin. Theneedlethen isadvanced so that it’spoint
entersthelumbosacral spacebetween thesacrum and thelast lumbar
vertebra. Asthespaceisentered , thereusually an immediateflow of
CSF , although gentleaspiration may benecessary.
Taylor Technique
Spinal anesthesia
The spinal needle feels as if it is in the right position but no CSF
appears. Wait at least 30 seconds, then try rotating theneedle90
degreesand wait again. If thereisstill no CSF, attach an empty 2ml
syringeand inject 0.5-1ml of air to ensuretheneedleisnot blocked then
usethesyringeto aspiratewhilst slowly withdrawing thespinal needle.
Stop assoon asCSF appearsin thesyringe.
Blood flows from the spinal needle. Wait ashort time. If theblood
becomespinkish and finally clear, all iswell. If blood only continuesto
drip, then it islikely that theneedletip isin an epidural vein and it
should beadvanced alittlefurther to piercethedura.
The patient complains of sharp, stabbing leg pain. Theneedlehas
hit anerveroot becauseit hasdeviated laterally. Withdraw theneedle
and redirect it moremedially away from theaffected side.
PracTical Problems
The patient complains of pain during needle insertion. This
suggeststhat thespinal needleispassing through themuscleon either
sideof theligaments. Redirect your needleaway from thesideof the
pain to get back into themidlineor inject somelocal anaesthetic.
Whereverthe needle is directed, it seems to strike bone. Make
surethepatient isstill properly positioned with asmuch lumbar flexion
aspossibleand that theneedleisstill in themid-line. It might bebetter
to attempt aparamedian approach to thedura.
PrinciPles in aDminisTraTinG
anaesTheTic
soluTions
Main aim of anaesthetists is to secure anaesthesia of
• Sufficient duration
• Sufficient Height.
STOUT’S PRINCIPLES FORSPREADOFSOLUTIONS
Height of anaesthesia is
1. Directly proportional to concentration of thedrug
2. Inversely proportional to rapidity of fixation
3. Directly to speed of injection
4. Directly proportional to thevolumeof fluid.
5. Inversely proportional to spinal fluid pressure.
6. Directly proportional to specific gravity for hyper baric solution.
FacTors PosTulaTeD To be relaTeD To sPinal
anaesTheTic blocK heiGhT
PATIENTCHARACTERISTICS
• Age, Height, Weight, Intraabdominal pressure, position, anatomic
configuration of spinal column.
TECHNIQUEOFINJECTION
• Siteof injection, direction of injection, rateof injection.
CHARACTERISTICS OFSPINALFLUID
• Volume, Pressure, density.
CHARACTERISTICS OFANAESTHETIC SOLUTIONS
• Density, Amount, Concentration, temperature, volume.
∗ This is the technique of stirring up to increase
turbulence , mixing of injected solutions and
increasing the distribution in the subarachnoid space.
The technique first was described by Bier and consists
of the injection of the anesthetic solution into the
subarachnoid space, immediate withdrawal of a
portion of the solution and reinjection. This may be
repeated. The to-and-fro movement agitates the
injectate in the spinal fluid, and the currents mix the
agent more completely and carry the agent more
extensively and to higher levels. Caution must be
observed and each operator must learn the results of
his barbotage
barboTaGe
PaTienT FacTors
AGE
• Spinal spacebecomesmaller with ↑ age- distribution greater.
OBESITY
• Increaseintra-abdominal pressure
• increasepressurein epidural space.
• Decreasesubarachnoid space
PREGNANCY
• Increaseintra-abdominal pressure
• Increasevolumeof epidural venousplexus- Small subarachnoid
spaces.
INTRAABDOMINAL PRESSURE
• Changesresulting from direct pressureof increased intra-abdominal
pressureon epidural and subarachnoid spaces.
• Collateral flow through epidural venousplexusexpand- SA spacesmall
SPINALCURVATURE
• Abnormal curvaturehavean effect on technical aspects
• Changesthecontour of Subarachnioid space
RATEOFINJECTION
• Slow injections- low levels
• Rapid injections- high level
CHARACHTERISTICS OF ANAESTHETIC
SOLUTIONS
∗ AMOUNTOFDRUG
•Increaseamount- increaseDuration
∗ EFFECTOFTEMPERATURE
•DecreaseTemperature- increaseBaricity
charachTerisTics oF
anaesTheTic soluTions
DENSITY /SPECIFIC GRAVITY ANDBARICITY
• Density of any solution istheweight in gramsof 1 ml of thesolution at a
standard temperature. Density variesinversely with temperature.
• Specific gravity isthedensity of asolutionscompared in aratio with the
density of water.
• Baricity isaratio comparing thedensity of onesolution to another.
• Density of normal human. CSF at 370
C is1.0001 to 1.0005
• Specific gravity of spinal fluid 1.003 to 1.008
ISOBARIC SOLUTIONS
• Densitiesbetween 0.9998 and 1.0008
• Solutionsaremixed with physiological saline
• Solutionswith out added glucose
• Bupivacaine, ropivacaine, levobupivacaine
• Spread not influenced by position
HYPOBARIC SOLUTIONS
• Baricity lessthan 0.9998 at 370
C
• Prepared by diluting with distilled water
HYPERBARIC SOLUTIONS
• Solutionsat 370
c with baricity greater than 1.0008
• Madeby addition of 5-9.5% dextrose.
Problems with the block
No apparent sab at all. If after10 minutes the patient still has full
powerin the legs and normal sensation, then the block has failed
probably because the injection was not intrathecal. Try again.
The sab is one-sided oris not high enough on one side. lie the patient
on the side that is inadequately blocked fora few minutes and adjust
the table so that the patient is slightly "head down".
sab not high enough. tilt the patient head down while they are supine
(lying on the back), so that the solution can run up the lumbar
curvature. Flatten the lumbarcurvature by raising the patient's knees.
Block too high. The patient may complain of difficulty in breathing or
of tingling in the arms orhands. Do not tilt the table "head up".
∗ CLASSIFIED INTO:
∗ Singleinjection technique
a)Hyperbaric
b)Isobaric
c)Hypobaric
Continuousinjection method
a)Intermittant or fractional
b)Differential block
c)Continuousdrip
Segmental method
sPiNAl ANAsthesiA techNiQUe
1. Procaine-Anaesthetic solution used isprocainemixed each 50mg of
procainecrystal with each 1ml of CSF
∗Dosage-For lower extremitiesand perinium 50-100mg
For lower abdomen 100-150 mg
For upper abdomen 150-200mg
2. Lidocaine dextrose-Premixed solution is available lidocaine
5% in 5% dextrose orlidocaine 5% in 7.5% dextrose to a
volume of 2.5ml or50mg/ml of lidocaine.
∗Dosage-Forlowerextremities and periniom 40-60mg
Forlowerabdominal 75mg .
For
upper abdominal 100-150mg
hYPerbAric
∗ 3. Bupivacaine dextrose- An optimal concerntration of
bupivacaine is 0.5% in 5% dextrose
∗ Dosage-Forlowerextrimities and perinium 1.5 -2.5ml(7.5
-12.5mg of bupivacaine)
∗ 1.5ml will provide level of T10. 2ml will provide
level of T8
∗ Forlowerabdomen 2.5ml-3.0ml(12.5-
17.5mg)3.0ml provides anesthesia to T6 level
∗ Forupperabdomen (high spinal) 3.5 to 4.5 ml
(17.5-25mg) 4ml will provide anasthesia usually upto T4
level
∗ 4. Teracainedextrose- Rarely used in practice
∗ 1.Dibucaine-Anasthetic solution 1:1000 or 0.1% dibucainesolution is
used.To makethissolution minimum 1vol. of 0.5% dibucainein a
buffered phosphatesodium chloridesolution with 4vol. Of CSF.
∗ For lower extrimitiesand perinium 0.5 to 1ml
∗ For lower abdomen 1to 1.5 ml
∗ For upper abdomen 1.5 to 2ml
∗ 2. Bupivacaine isobaric-0.5% bupivacaine solution in isotonic
saline.
∗ Forlowerextrimities and perinium 1-2mlof bupivacaine
achieved level upto T10 -T12
∗ Forlowerabdomen 2.5 -3.0ml level upto T8 – T6.
∗ Forupperabdomen 3.5-5.0ml level upto T6-T4.
isobAric
∗ 1.Tetracainein distilled water 0.1% tetracainehydrochloridesolution
iscommonly used.
∗ Hypobaric tetracaine(naphanoid) crystallinepowder in asterile
ampoulecontaining 20mg of tetracaineisdissolved in steriledistilled
water for injection
∗ Dosage-For lower extremitiesand perinium 5-10mg
∗ For lower abdomen 10-15mg
∗ For upper abdomen 15-20mg
∗ 2. Dibucainehypobaric-Anasthetic sloution dibucaine1;1500 in 0.5%
salineeach 1.5ml contains1mg of dibucaine.
∗ Dosage-For lower extremitiesand perinium 5-10ml
∗ For lower abdomen 10-15ml
∗ For upper abdomen 15-20 ml
hYPobAric
∗ inserting acatheter into thesubarachnoid spaceincreasestheutility
of spinal anesthesiaby permitting continuousor repeated drug
delivery in order to expand thelevel or duration of spinal block dural
punctureisdonewith an epidural needle. After thesubarachnoid
placement of theneedleand ascertaining freeflow of csf ,thecatheter
isthreaded 2-3 cm in to thesubarachnoid space.thecatheter should
never bepulled back in to theneedleshaft becauseof therisk of
shearing thecatheter off into thesubarachnonid space
∗ If thecatheter needsto beremoved both needleand catheter should be
removed asaunit . 18 G epidural needle&20 G epidural catheter are
used
∗ Stimulation of nerveroot by thecatheter tip ispainful and catheter can
enter subarachnoid vessel
coNtiNUoUs iNJectioN methoD
∗ Sensation of temperature- Ice, Alcohol
∗ Sensation of Pin-prick – Blunt tipped / Forcep
∗ Motor power – Bromage scale
0 – No motor block
1 – Can flex knee, move foot, but cannot raise leg
2 – Can move foot only
3 – Cannot move foot or knee
Testing of Effect
∗ Sedation only isrecommended in infantsolder than 6-8 weeks.
∗ Conceptual ageof 48weeksor moreto permit quiteand safefor
spinal tap.
∗ Generally thepreterm neonateor infant of aconceptual agelessthan
48 weekswill not need sedation but clinical judgement will
determinetheneed.
∗ Ketamine1-2mg/kg with atropine15-20 micro gram /kg
∗ Midazolam 50-100 micro gram/kg.
sPiNAl ANAsthesiA iN iNFANts
AND chilDreN
Thelateral position ispreferred with thetabletilted and thehead up at
100degreeto faster filling of thelumber subarachnoid space.
Thesitting position may also beused.
Thepunctureat L3 –L4 vertibrainterspacefor children of 1-18yrsand
L5 for infants.
Thespinal needledirected perpendicular to planeof theback.
A standard 24-26G needleisused.
Dosage-Minimum vol. of 0.2ml isnecessary in thepreterm or newborn
infant
Infant under 3000gm requiresthelargest dosesbecauselarger vol. of
CSF and absorption dosesupto 0.6mg/kg may begiven to infant of 2-
3kg of weight
For infant over 3kg thedoseisstablised at 0.35 mg/kg upto 1yr of age.
PositioN
∗ After administration of spinal anasthesiaiv linemay beeasily
started in afoot vein becauseof venousdilatation. Monitoring of
pulse,BPand Oxygen saturation isan additional standard.
moNitoriNg
THANKS ALL

More Related Content

What's hot

What's hot (20)

Spinal anesthesia
Spinal anesthesiaSpinal anesthesia
Spinal anesthesia
 
Laryngeal mask-airway
Laryngeal mask-airwayLaryngeal mask-airway
Laryngeal mask-airway
 
Regional Anesthesia
Regional AnesthesiaRegional Anesthesia
Regional Anesthesia
 
Pre-Anesthetic Checkup
Pre-Anesthetic Checkup Pre-Anesthetic Checkup
Pre-Anesthetic Checkup
 
Propofol
PropofolPropofol
Propofol
 
Spinal Anaesthesia. by Dr. Shailendra
Spinal Anaesthesia. by Dr. ShailendraSpinal Anaesthesia. by Dr. Shailendra
Spinal Anaesthesia. by Dr. Shailendra
 
Emergency drugs used in anaesthesia
Emergency drugs used in anaesthesiaEmergency drugs used in anaesthesia
Emergency drugs used in anaesthesia
 
Glycopyrrolate
Glycopyrrolate Glycopyrrolate
Glycopyrrolate
 
Propofol ppt nandini
Propofol ppt nandiniPropofol ppt nandini
Propofol ppt nandini
 
Facemask , oral and nasal airways
Facemask , oral and nasal airwaysFacemask , oral and nasal airways
Facemask , oral and nasal airways
 
Supraglottic airway device
Supraglottic airway deviceSupraglottic airway device
Supraglottic airway device
 
epidural anesthesia
epidural anesthesiaepidural anesthesia
epidural anesthesia
 
Monitoring in anaesthesia ro
Monitoring in anaesthesia roMonitoring in anaesthesia ro
Monitoring in anaesthesia ro
 
Muscle relaxant and reversal agents
Muscle relaxant and reversal agentsMuscle relaxant and reversal agents
Muscle relaxant and reversal agents
 
Rapid sequence intubation
Rapid sequence intubationRapid sequence intubation
Rapid sequence intubation
 
Caudal anesthesia
Caudal anesthesiaCaudal anesthesia
Caudal anesthesia
 
Bougie, trachlite , laryngeal tube , combitube , i gel ,truview
Bougie, trachlite , laryngeal tube , combitube , i gel ,truviewBougie, trachlite , laryngeal tube , combitube , i gel ,truview
Bougie, trachlite , laryngeal tube , combitube , i gel ,truview
 
caudal anesthesia.pdf
caudal anesthesia.pdfcaudal anesthesia.pdf
caudal anesthesia.pdf
 
Thiopentone and propofol
Thiopentone and propofolThiopentone and propofol
Thiopentone and propofol
 
Vecuronium
VecuroniumVecuronium
Vecuronium
 

Similar to Spinal anesthesia

SPINAL & EPIDURAL ANAESTHESIA DR OYETUNDE.pptx
SPINAL & EPIDURAL ANAESTHESIA DR OYETUNDE.pptxSPINAL & EPIDURAL ANAESTHESIA DR OYETUNDE.pptx
SPINAL & EPIDURAL ANAESTHESIA DR OYETUNDE.pptxOlaideOyetunde1
 
neuroaxialanaesthesia-160620135003.pptx
neuroaxialanaesthesia-160620135003.pptxneuroaxialanaesthesia-160620135003.pptx
neuroaxialanaesthesia-160620135003.pptxshirinparveen66is
 
Spinal and Epidural Anaesthesia.pptx
Spinal and Epidural Anaesthesia.pptxSpinal and Epidural Anaesthesia.pptx
Spinal and Epidural Anaesthesia.pptxSwatiChoudhary97
 
Optic Nerve Sheath Diameter (ONSD) Measurement for Intracranial Pressure Moni...
Optic Nerve Sheath Diameter (ONSD) Measurement for Intracranial Pressure Moni...Optic Nerve Sheath Diameter (ONSD) Measurement for Intracranial Pressure Moni...
Optic Nerve Sheath Diameter (ONSD) Measurement for Intracranial Pressure Moni...Ade Wijaya
 
Lumbar puncture and bone marrow aspiration
Lumbar puncture and bone marrow aspirationLumbar puncture and bone marrow aspiration
Lumbar puncture and bone marrow aspirationPratik Kumar
 
Spinal Anesthesia - A Comprehensive Approach
Spinal Anesthesia - A Comprehensive ApproachSpinal Anesthesia - A Comprehensive Approach
Spinal Anesthesia - A Comprehensive ApproachMohtasib Madaoo
 
Techniques of the spinal anaesthesia.pptx
Techniques of the spinal anaesthesia.pptxTechniques of the spinal anaesthesia.pptx
Techniques of the spinal anaesthesia.pptxMinaz Patel
 
Ultrasound-Guided Thoracic Paravertebral Block
Ultrasound-Guided Thoracic Paravertebral BlockUltrasound-Guided Thoracic Paravertebral Block
Ultrasound-Guided Thoracic Paravertebral BlockSaeid Safari
 
Lacrimal sac surgery
Lacrimal sac surgeryLacrimal sac surgery
Lacrimal sac surgerySSSIHMS-PG
 
USG Guiding Iliohypogastric Nerve Block.pptx
USG Guiding Iliohypogastric Nerve Block.pptxUSG Guiding Iliohypogastric Nerve Block.pptx
USG Guiding Iliohypogastric Nerve Block.pptxWirjapratamaPutra2
 
lacrimalsacsurgery-PRANAV.pptx
lacrimalsacsurgery-PRANAV.pptxlacrimalsacsurgery-PRANAV.pptx
lacrimalsacsurgery-PRANAV.pptxPranavKohli7
 
Ganglion Impar Block- Dr Minhaj Akhter ppt.pdf
Ganglion Impar Block- Dr Minhaj Akhter ppt.pdfGanglion Impar Block- Dr Minhaj Akhter ppt.pdf
Ganglion Impar Block- Dr Minhaj Akhter ppt.pdfMinhaj Akhter
 
Caudal epidural injection
Caudal epidural  injection Caudal epidural  injection
Caudal epidural injection Novian Dokter
 
Discograpgy (intradiscal procedure)
Discograpgy (intradiscal procedure)Discograpgy (intradiscal procedure)
Discograpgy (intradiscal procedure)SKSHAHWAZ
 
Radiotherapy in CA Penis
Radiotherapy in CA PenisRadiotherapy in CA Penis
Radiotherapy in CA PenisDrAyush Garg
 
Arthrocentesis and Injection of Joints.pptx
Arthrocentesis and Injection of Joints.pptxArthrocentesis and Injection of Joints.pptx
Arthrocentesis and Injection of Joints.pptxnugraha65
 
surgicalmxofotosclerosis-191105164030.pptx
surgicalmxofotosclerosis-191105164030.pptxsurgicalmxofotosclerosis-191105164030.pptx
surgicalmxofotosclerosis-191105164030.pptxSravanSagar4
 

Similar to Spinal anesthesia (20)

SPINAL & EPIDURAL ANAESTHESIA DR OYETUNDE.pptx
SPINAL & EPIDURAL ANAESTHESIA DR OYETUNDE.pptxSPINAL & EPIDURAL ANAESTHESIA DR OYETUNDE.pptx
SPINAL & EPIDURAL ANAESTHESIA DR OYETUNDE.pptx
 
Neuraxial anesthesia
Neuraxial anesthesiaNeuraxial anesthesia
Neuraxial anesthesia
 
neuroaxialanaesthesia-160620135003.pptx
neuroaxialanaesthesia-160620135003.pptxneuroaxialanaesthesia-160620135003.pptx
neuroaxialanaesthesia-160620135003.pptx
 
Spinal and Epidural Anaesthesia.pptx
Spinal and Epidural Anaesthesia.pptxSpinal and Epidural Anaesthesia.pptx
Spinal and Epidural Anaesthesia.pptx
 
Optic Nerve Sheath Diameter (ONSD) Measurement for Intracranial Pressure Moni...
Optic Nerve Sheath Diameter (ONSD) Measurement for Intracranial Pressure Moni...Optic Nerve Sheath Diameter (ONSD) Measurement for Intracranial Pressure Moni...
Optic Nerve Sheath Diameter (ONSD) Measurement for Intracranial Pressure Moni...
 
Lumbar puncture and bone marrow aspiration
Lumbar puncture and bone marrow aspirationLumbar puncture and bone marrow aspiration
Lumbar puncture and bone marrow aspiration
 
Spinal Anesthesia - A Comprehensive Approach
Spinal Anesthesia - A Comprehensive ApproachSpinal Anesthesia - A Comprehensive Approach
Spinal Anesthesia - A Comprehensive Approach
 
Techniques of the spinal anaesthesia.pptx
Techniques of the spinal anaesthesia.pptxTechniques of the spinal anaesthesia.pptx
Techniques of the spinal anaesthesia.pptx
 
Ultrasound-Guided Thoracic Paravertebral Block
Ultrasound-Guided Thoracic Paravertebral BlockUltrasound-Guided Thoracic Paravertebral Block
Ultrasound-Guided Thoracic Paravertebral Block
 
Lacrimal sac surgery
Lacrimal sac surgeryLacrimal sac surgery
Lacrimal sac surgery
 
USG Guiding Iliohypogastric Nerve Block.pptx
USG Guiding Iliohypogastric Nerve Block.pptxUSG Guiding Iliohypogastric Nerve Block.pptx
USG Guiding Iliohypogastric Nerve Block.pptx
 
spinal 2.pptx
spinal 2.pptxspinal 2.pptx
spinal 2.pptx
 
lacrimalsacsurgery-PRANAV.pptx
lacrimalsacsurgery-PRANAV.pptxlacrimalsacsurgery-PRANAV.pptx
lacrimalsacsurgery-PRANAV.pptx
 
Spinal block
Spinal blockSpinal block
Spinal block
 
Ganglion Impar Block- Dr Minhaj Akhter ppt.pdf
Ganglion Impar Block- Dr Minhaj Akhter ppt.pdfGanglion Impar Block- Dr Minhaj Akhter ppt.pdf
Ganglion Impar Block- Dr Minhaj Akhter ppt.pdf
 
Caudal epidural injection
Caudal epidural  injection Caudal epidural  injection
Caudal epidural injection
 
Discograpgy (intradiscal procedure)
Discograpgy (intradiscal procedure)Discograpgy (intradiscal procedure)
Discograpgy (intradiscal procedure)
 
Radiotherapy in CA Penis
Radiotherapy in CA PenisRadiotherapy in CA Penis
Radiotherapy in CA Penis
 
Arthrocentesis and Injection of Joints.pptx
Arthrocentesis and Injection of Joints.pptxArthrocentesis and Injection of Joints.pptx
Arthrocentesis and Injection of Joints.pptx
 
surgicalmxofotosclerosis-191105164030.pptx
surgicalmxofotosclerosis-191105164030.pptxsurgicalmxofotosclerosis-191105164030.pptx
surgicalmxofotosclerosis-191105164030.pptx
 

More from dr anurag giri

More from dr anurag giri (20)

Spinal anesthesia
Spinal anesthesiaSpinal anesthesia
Spinal anesthesia
 
Monitoring depth of anaesthesia
Monitoring depth of anaesthesiaMonitoring depth of anaesthesia
Monitoring depth of anaesthesia
 
Vinayak atropine glyco
Vinayak atropine glycoVinayak atropine glyco
Vinayak atropine glyco
 
Thiopentone upendra
Thiopentone upendraThiopentone upendra
Thiopentone upendra
 
The autonomic nervous system and its implications in
The autonomic nervous system and its implications inThe autonomic nervous system and its implications in
The autonomic nervous system and its implications in
 
Spinal, dalal madam
Spinal, dalal madamSpinal, dalal madam
Spinal, dalal madam
 
Soares ans
Soares ansSoares ans
Soares ans
 
Pac premedication -dr.vaidya
Pac  premedication  -dr.vaidyaPac  premedication  -dr.vaidya
Pac premedication -dr.vaidya
 
L a agents
L a agentsL a agents
L a agents
 
Ketamine poonam
Ketamine poonamKetamine poonam
Ketamine poonam
 
Ans physiology
Ans physiologyAns physiology
Ans physiology
 
Soares ans
Soares ansSoares ans
Soares ans
 
Pathophysio of pain
Pathophysio of painPathophysio of pain
Pathophysio of pain
 
Pac premedication -dr.vaidya
Pac  premedication  -dr.vaidyaPac  premedication  -dr.vaidya
Pac premedication -dr.vaidya
 
Airway anatomy
Airway anatomyAirway anatomy
Airway anatomy
 
Liver function test
Liver function testLiver function test
Liver function test
 
L a agents
L a agentsL a agents
L a agents
 
Ketamine poonam
Ketamine poonamKetamine poonam
Ketamine poonam
 
Ecg 1
Ecg 1Ecg 1
Ecg 1
 
Ans physiology
Ans physiologyAns physiology
Ans physiology
 

Spinal anesthesia

  • 1. Technique of SPinAL AneSTheSiA indicATion And conTrAindicATion Guided by: Dr. Shubhada Deshmukh(M.D.) Presented by: Dr.Anurag Giri
  • 2.  Spinal anesthesiaisalso called asspinal block or subarachnoid block (sab). SAB isaregional anesthesiainvolving injection of alocal anesthesiainto thesubarachnoid spacewhich extendsfrom theforamen magnum to S2 in adultsand S3 in children. Injection of LA below LI in adultsand L3 in children helpsto avoid direct traumato thespinal cord , (anesthetic agentsactson thespinal nerveand not on the substanceof thecord) SPinAL AneSTheSiA
  • 4.  Corning in 1885 , accidently administered cocaineintrathecally.  Quinckein 1891 , madeuseof spinal puncture in diagnosis.  August bier of Germany in 1898 , introduced the techniqueof spinal anesthesia.  Pitkin popularized themethod of introducing agent'sintrathecally. hiSTory
  • 5.  Informed consent.  Physical examination , history (past surgical ).  Laboratory test.  Premedication Diazepam 0.1-0.2 mg/kg Po midazolam 1-3 mg I/M PreoPerATive evALuATion And PrePArATion
  • 6.  Used both aloneand in combination with either GA or sedation.  Lower limb orthopedic surgery on thepelvis, femur , tibiaand ankle.  Total hip replacement.  Total kneereplacement.  Lower limb vascular surgery. 4) indicATion of SPinAL AneSTheSiA
  • 7.  Hernia(Ingunial or epigastric).  Haemorrhoidectomy , fistula, fissure.  Nephrectomy and cystectomy in combination with GA.  Transurethral resection of theprostateand transurethral resection of thebladder tumors.  Abdominal and vaginal hysterectomies  Laproscopic assisted vaginal hysterectomies(LAVH) combined with GA.  Caesarean sections.
  • 8.  ABSOLUTE Patient refusal Infection at thesiteof injection Coagulopathy or other bleeding diathesis Severehypovolemia Increased intracranial pressure Severeaortic stenosis Severemitral stenosis  Post traumatic vertibral injuries, myocardial infract. conTrAindicATion
  • 9. ∗ RELATIVE ∗ Sepsis ∗ Un co-operative patient ∗ Preexisting neurological deficit ∗ Stenotic valvular heart disease ∗ Severespinal deformity ∗ Spinal congenital anomalies ∗ Hypo tension ∗ Hyper tension ∗ Severeanaemia ∗ Shock(haemorragic,septic) ∗ Brain tumor
  • 11. 1.Scrub handsaccording to aseptic surgical technique 2.Usesterileglows 3.Avoid contaminating blocking solutionswith solutionsused to preparetheskin. 4.Useaseptic techniquewhen opening tray. 5.Clean theskin prior to needlepuncture. 6.Touch only sterilearticlesoncegloved. 7.Useintroducer prior to injection of small guagespinal needle. 8. Avoid repeated traumatic punctures. 9.Useapproved local anaesthetic agentsin standard concentration
  • 12. ∗ Clean theskin surfacetwicewith betadineand twicewith spirit using window techniquewith sterilegauze cLeAninG And drAPPinG
  • 13. ∗NEEDLES ∗Thestandard spinal needle- ∗ThreepartsHub , cannula, stylet ∗Pointsof cannulaearebeveled and havesharp edgeCannulaemadeof stainlesssteel should bestiff, flexibleand resistant to breakage. ∗Sizes- 16 G to 30 G ∗Length- 3.5 to 4 inches  ∗NEEDLES CLASSIFIED ∗1. Standard bevelled with cutting edges- ∗ Quincke,Babcock or Pitkin ∗2. Pencil point needlewith conical point with no cutting edges- Sprotte, Greene. SPinAL AnASTheSiA Technique
  • 14. • Large IV cannula • IV fluids immediately before the spinal • The volume of fluid given will vary with age and extent of block • Ideally – 10ml/kg • Crystalloids like Ringerlactate , 0.9% normal saline are used • Now co-loading. INTRAVENOUS PRELOADING
  • 15. ∗ L.P. ismost easily performed when thereismaximum flexion of lumbar spine.By thisligamentsget stretched and spaceisopen POSITIONS
  • 16. ∗ TWO ASPECTS ∗ 1. Spinal canal should beon horizontal plane ∗ 2. Operator should fix hisor her gazeon thehorizontal plane.  POSITIONING ∗ Flexed lateral position- back should beparallel to theedgeof the table, kneesareflexed on theabdomen, neck flexed. ∗ Jack knifeposition LATERAL POSITION
  • 19. ∗ Theanatomic midlineisoften easier to aproach when thepatient is in sitting position .Patient sit with their elbowsresting on their thighsor bedsidetableor they can hug apillow. Flexon of spine miximizesthetarget areabetween adjacent spinousprocessesand bringsthespinecloser to skin surface SITTING POSITION
  • 21. ∗ Thisposition isused for anorectal proceduresutilising ahypobaric anasthetic solution PRONE POSITION
  • 22. • Vertebral Spinousprocessesand theiliac crests • Spinousprocessesclearly definethemidline • Linedrawn between theiliac crests- intercristineor Tuffier’s linecrossesthe4th lumber vertebrae. LANDMARK
  • 23. ∗ Thedepression between thespinousprocessof thevertibraaboveand below thelevel to beused ispalpated.Thiswill bethemiddleentry site. ∗ Thespinousprocesscoursedownwardsfrom thespinetowardsthe skin so theneedlewill bedirected cephalad ∗ Thesubcutaneoustissuegivesfeeling of littleresistanceto the needle,after that needlewill enter thesupraspinousand infraspinous ligamentsfelt asan increasein tissuedensity . ∗ Astheneedlemeetstheligamentum flavam an increasein resistanceis encountered and on piercing it, lossof resistancecan befelt .The needleisadvanced through theepidural spaceand penetratesthedura (2nd resistance) and subarachnoid membraneassignaled by free- flowing CSF. MIDLINE APPROACH
  • 24. USE OF AN INTRODUCER •Concept of Introducer was that of Lincoln Size. •Modifications- Pitkin and by Lundy. • Purpose- Spinal needle can be inserted to the depth of the interspace without touching the skin, subcutaneous tissues and ligaments. • Grasping and stabilising
  • 25. OBJECTIVES OF INTRODUCER ∀↓Infection ∀↓ Contamination •Facilitate introduction of Spinal needle. •Minimize introduction of skin and tissue fragments •Avoid development of SAB epitheliomas and epidural tumors.
  • 26. ∗ Theparamedian approach may beselected if SAB isdifficult(severe arthritisor prior LSspinesurgery) Theskin wheal for theparamedian approach israised 2cm lateral to theinferior aspect of thesuperior spinousprocessof thedesired level.Theneedleisdirected and advanced at a10-25degreeangletowardsthemidline PARAMEDIAN/ LATERAL APROAch
  • 28. ∗ Thisisavery useful method in casesof spinefusion, arthritic spine, opisthotones, skin infection in thelumbar region , or in other conditionsin which theusual approach isdifficult or impossible. ∗ Largest interspaseL5-S1. ∗ A skin wheal is made1cm medially and 1cm below thelowest prominenceof theposterior-superior spine. A 12-cm , needleis directed upward , medially and forward at an angleof about 50degree, approximating forward at an anglethat thedorsal aspect of thesacrum makeswith theskin. Theneedlethen isadvanced so that it’spoint entersthelumbosacral spacebetween thesacrum and thelast lumbar vertebra. Asthespaceisentered , thereusually an immediateflow of CSF , although gentleaspiration may benecessary. Taylor Technique
  • 30. The spinal needle feels as if it is in the right position but no CSF appears. Wait at least 30 seconds, then try rotating theneedle90 degreesand wait again. If thereisstill no CSF, attach an empty 2ml syringeand inject 0.5-1ml of air to ensuretheneedleisnot blocked then usethesyringeto aspiratewhilst slowly withdrawing thespinal needle. Stop assoon asCSF appearsin thesyringe. Blood flows from the spinal needle. Wait ashort time. If theblood becomespinkish and finally clear, all iswell. If blood only continuesto drip, then it islikely that theneedletip isin an epidural vein and it should beadvanced alittlefurther to piercethedura. The patient complains of sharp, stabbing leg pain. Theneedlehas hit anerveroot becauseit hasdeviated laterally. Withdraw theneedle and redirect it moremedially away from theaffected side. PracTical Problems
  • 31. The patient complains of pain during needle insertion. This suggeststhat thespinal needleispassing through themuscleon either sideof theligaments. Redirect your needleaway from thesideof the pain to get back into themidlineor inject somelocal anaesthetic. Whereverthe needle is directed, it seems to strike bone. Make surethepatient isstill properly positioned with asmuch lumbar flexion aspossibleand that theneedleisstill in themid-line. It might bebetter to attempt aparamedian approach to thedura.
  • 32. PrinciPles in aDminisTraTinG anaesTheTic soluTions Main aim of anaesthetists is to secure anaesthesia of • Sufficient duration • Sufficient Height. STOUT’S PRINCIPLES FORSPREADOFSOLUTIONS Height of anaesthesia is 1. Directly proportional to concentration of thedrug 2. Inversely proportional to rapidity of fixation 3. Directly to speed of injection 4. Directly proportional to thevolumeof fluid. 5. Inversely proportional to spinal fluid pressure. 6. Directly proportional to specific gravity for hyper baric solution.
  • 33. FacTors PosTulaTeD To be relaTeD To sPinal anaesTheTic blocK heiGhT PATIENTCHARACTERISTICS • Age, Height, Weight, Intraabdominal pressure, position, anatomic configuration of spinal column. TECHNIQUEOFINJECTION • Siteof injection, direction of injection, rateof injection. CHARACTERISTICS OFSPINALFLUID • Volume, Pressure, density. CHARACTERISTICS OFANAESTHETIC SOLUTIONS • Density, Amount, Concentration, temperature, volume.
  • 34. ∗ This is the technique of stirring up to increase turbulence , mixing of injected solutions and increasing the distribution in the subarachnoid space. The technique first was described by Bier and consists of the injection of the anesthetic solution into the subarachnoid space, immediate withdrawal of a portion of the solution and reinjection. This may be repeated. The to-and-fro movement agitates the injectate in the spinal fluid, and the currents mix the agent more completely and carry the agent more extensively and to higher levels. Caution must be observed and each operator must learn the results of his barbotage barboTaGe
  • 35. PaTienT FacTors AGE • Spinal spacebecomesmaller with ↑ age- distribution greater. OBESITY • Increaseintra-abdominal pressure • increasepressurein epidural space. • Decreasesubarachnoid space PREGNANCY • Increaseintra-abdominal pressure • Increasevolumeof epidural venousplexus- Small subarachnoid spaces.
  • 36. INTRAABDOMINAL PRESSURE • Changesresulting from direct pressureof increased intra-abdominal pressureon epidural and subarachnoid spaces. • Collateral flow through epidural venousplexusexpand- SA spacesmall SPINALCURVATURE • Abnormal curvaturehavean effect on technical aspects • Changesthecontour of Subarachnioid space RATEOFINJECTION • Slow injections- low levels • Rapid injections- high level
  • 37. CHARACHTERISTICS OF ANAESTHETIC SOLUTIONS ∗ AMOUNTOFDRUG •Increaseamount- increaseDuration ∗ EFFECTOFTEMPERATURE •DecreaseTemperature- increaseBaricity charachTerisTics oF anaesTheTic soluTions
  • 38. DENSITY /SPECIFIC GRAVITY ANDBARICITY • Density of any solution istheweight in gramsof 1 ml of thesolution at a standard temperature. Density variesinversely with temperature. • Specific gravity isthedensity of asolutionscompared in aratio with the density of water. • Baricity isaratio comparing thedensity of onesolution to another. • Density of normal human. CSF at 370 C is1.0001 to 1.0005 • Specific gravity of spinal fluid 1.003 to 1.008 ISOBARIC SOLUTIONS • Densitiesbetween 0.9998 and 1.0008 • Solutionsaremixed with physiological saline • Solutionswith out added glucose • Bupivacaine, ropivacaine, levobupivacaine • Spread not influenced by position
  • 39. HYPOBARIC SOLUTIONS • Baricity lessthan 0.9998 at 370 C • Prepared by diluting with distilled water HYPERBARIC SOLUTIONS • Solutionsat 370 c with baricity greater than 1.0008 • Madeby addition of 5-9.5% dextrose.
  • 40. Problems with the block No apparent sab at all. If after10 minutes the patient still has full powerin the legs and normal sensation, then the block has failed probably because the injection was not intrathecal. Try again. The sab is one-sided oris not high enough on one side. lie the patient on the side that is inadequately blocked fora few minutes and adjust the table so that the patient is slightly "head down". sab not high enough. tilt the patient head down while they are supine (lying on the back), so that the solution can run up the lumbar curvature. Flatten the lumbarcurvature by raising the patient's knees. Block too high. The patient may complain of difficulty in breathing or of tingling in the arms orhands. Do not tilt the table "head up".
  • 41. ∗ CLASSIFIED INTO: ∗ Singleinjection technique a)Hyperbaric b)Isobaric c)Hypobaric Continuousinjection method a)Intermittant or fractional b)Differential block c)Continuousdrip Segmental method sPiNAl ANAsthesiA techNiQUe
  • 42. 1. Procaine-Anaesthetic solution used isprocainemixed each 50mg of procainecrystal with each 1ml of CSF ∗Dosage-For lower extremitiesand perinium 50-100mg For lower abdomen 100-150 mg For upper abdomen 150-200mg 2. Lidocaine dextrose-Premixed solution is available lidocaine 5% in 5% dextrose orlidocaine 5% in 7.5% dextrose to a volume of 2.5ml or50mg/ml of lidocaine. ∗Dosage-Forlowerextremities and periniom 40-60mg Forlowerabdominal 75mg . For upper abdominal 100-150mg hYPerbAric
  • 43. ∗ 3. Bupivacaine dextrose- An optimal concerntration of bupivacaine is 0.5% in 5% dextrose ∗ Dosage-Forlowerextrimities and perinium 1.5 -2.5ml(7.5 -12.5mg of bupivacaine) ∗ 1.5ml will provide level of T10. 2ml will provide level of T8 ∗ Forlowerabdomen 2.5ml-3.0ml(12.5- 17.5mg)3.0ml provides anesthesia to T6 level ∗ Forupperabdomen (high spinal) 3.5 to 4.5 ml (17.5-25mg) 4ml will provide anasthesia usually upto T4 level ∗ 4. Teracainedextrose- Rarely used in practice
  • 44. ∗ 1.Dibucaine-Anasthetic solution 1:1000 or 0.1% dibucainesolution is used.To makethissolution minimum 1vol. of 0.5% dibucainein a buffered phosphatesodium chloridesolution with 4vol. Of CSF. ∗ For lower extrimitiesand perinium 0.5 to 1ml ∗ For lower abdomen 1to 1.5 ml ∗ For upper abdomen 1.5 to 2ml ∗ 2. Bupivacaine isobaric-0.5% bupivacaine solution in isotonic saline. ∗ Forlowerextrimities and perinium 1-2mlof bupivacaine achieved level upto T10 -T12 ∗ Forlowerabdomen 2.5 -3.0ml level upto T8 – T6. ∗ Forupperabdomen 3.5-5.0ml level upto T6-T4. isobAric
  • 45. ∗ 1.Tetracainein distilled water 0.1% tetracainehydrochloridesolution iscommonly used. ∗ Hypobaric tetracaine(naphanoid) crystallinepowder in asterile ampoulecontaining 20mg of tetracaineisdissolved in steriledistilled water for injection ∗ Dosage-For lower extremitiesand perinium 5-10mg ∗ For lower abdomen 10-15mg ∗ For upper abdomen 15-20mg ∗ 2. Dibucainehypobaric-Anasthetic sloution dibucaine1;1500 in 0.5% salineeach 1.5ml contains1mg of dibucaine. ∗ Dosage-For lower extremitiesand perinium 5-10ml ∗ For lower abdomen 10-15ml ∗ For upper abdomen 15-20 ml hYPobAric
  • 46. ∗ inserting acatheter into thesubarachnoid spaceincreasestheutility of spinal anesthesiaby permitting continuousor repeated drug delivery in order to expand thelevel or duration of spinal block dural punctureisdonewith an epidural needle. After thesubarachnoid placement of theneedleand ascertaining freeflow of csf ,thecatheter isthreaded 2-3 cm in to thesubarachnoid space.thecatheter should never bepulled back in to theneedleshaft becauseof therisk of shearing thecatheter off into thesubarachnonid space ∗ If thecatheter needsto beremoved both needleand catheter should be removed asaunit . 18 G epidural needle&20 G epidural catheter are used ∗ Stimulation of nerveroot by thecatheter tip ispainful and catheter can enter subarachnoid vessel coNtiNUoUs iNJectioN methoD
  • 47. ∗ Sensation of temperature- Ice, Alcohol ∗ Sensation of Pin-prick – Blunt tipped / Forcep ∗ Motor power – Bromage scale 0 – No motor block 1 – Can flex knee, move foot, but cannot raise leg 2 – Can move foot only 3 – Cannot move foot or knee Testing of Effect
  • 48. ∗ Sedation only isrecommended in infantsolder than 6-8 weeks. ∗ Conceptual ageof 48weeksor moreto permit quiteand safefor spinal tap. ∗ Generally thepreterm neonateor infant of aconceptual agelessthan 48 weekswill not need sedation but clinical judgement will determinetheneed. ∗ Ketamine1-2mg/kg with atropine15-20 micro gram /kg ∗ Midazolam 50-100 micro gram/kg. sPiNAl ANAsthesiA iN iNFANts AND chilDreN
  • 49. Thelateral position ispreferred with thetabletilted and thehead up at 100degreeto faster filling of thelumber subarachnoid space. Thesitting position may also beused. Thepunctureat L3 –L4 vertibrainterspacefor children of 1-18yrsand L5 for infants. Thespinal needledirected perpendicular to planeof theback. A standard 24-26G needleisused. Dosage-Minimum vol. of 0.2ml isnecessary in thepreterm or newborn infant Infant under 3000gm requiresthelargest dosesbecauselarger vol. of CSF and absorption dosesupto 0.6mg/kg may begiven to infant of 2- 3kg of weight For infant over 3kg thedoseisstablised at 0.35 mg/kg upto 1yr of age. PositioN
  • 50. ∗ After administration of spinal anasthesiaiv linemay beeasily started in afoot vein becauseof venousdilatation. Monitoring of pulse,BPand Oxygen saturation isan additional standard. moNitoriNg