Friday, September 27, 2013

ANETHESIA 10 Spinal anesthesia Objectives Position steps procedure


Spinal Anesthesia
Objective
To provide reversible anesthesia for procedures and surgical interventions in the pelvic region and lower extremities (like urological, gynecological, obstetrical, surgical and orthopedic cases) by giving local anesthetics into the subarachnoid space.
     Written consent for procedure required.
Position
•   Performed in sitting posture
•   Making the patient sit on the operating table and placing the feet on a stool. Patient’s forearms on the thighs. Lateral decubitus position patient lying on the side with hips and knees maximally flexed
•   Assistant stands in front of the patient to help in maintaining the patient in a comfortable curled position
•   The main aim of proper positioning is to obtain maximum flexion of the lumbar spine (Figs 4.2A to D).
Procedure on a Tiltable Table
1.  Patient adequately prepared, procedure fully explained; oral premedication given (Tablet Diazepam 5-10 mg - orally 90 minutes prior to procedure).
2.  Intravenous line started and preload with 500 ml of 5% dextrose in water or Ringer’s lactate solution.
   3.  ECG, NIBP, SpO2 - monitoring attached to the patient.
   4.  Scrub and wear sterile gown and gloves.
   5.  Check the spinal equipment on the sterile trolley like the items required; proper size needle and stylet. Tip of stylet should not project out from needle.
   6.  Read the label of local anesthetic to be injected into CSF-for name, percentage, expiry date. Confirm it with another person. Draw this into a 5 ml syringe.
   7.  Fill the local anesthetic to be used for skin infiltration into a 2 ml syringe.
  8.  Cover the drug tray with sterile towel to avoid conta­mination during cleaning.
   9.  Clean the patient’s back with antiseptic swabs (savlon, iodine and spirit).
10.  Swab eliptically from the proposed site radially outwards; cephalad to caudal direction (Fig. 4.2).
11.  Sufficiently large area is cleaned.
12.  Allow the iodine to dry on the skin.
13.  If the glove is smeared with antiseptic, change them.
14.  Drape the area with sterile towels.
15.  Highest point of iliac crest palpated and corresponding level (L4) space located (Fig. 4.2A).
16.  At the proposed L4 space raise an intradermal wheel with local anesthetic with a disposable 25 G needle.
17.  Spinal needles are 8-10 cm long and each needle is provided with a stylet.
18.  The distal end of spinal needle is sharp and short bevelled.
19.  The size varies from 20 G to 26 G.
20.  Thin needles are difficult to insert sometime so introducer used.
21.  Introducers are short length, thick needle with or without flange.
22.  Insert the introducer if using a thin 24-25 gauge needle upto interspinous ligament.
23.  Insert the spinal needle through the introducer into the space.
24.  Increased resistance will be felt as the needle enters the ligamentum flavum followed by loss of resistance in epidural space.
25.  Advance the needle further, another loss of resistance as the dura is pierced.
26.  Stylet is removed from the needle and CSF flow is observed
27.  Spinal needle is secured firmly by resting the back of left hand on the patients’ back and using the thumb and index finger to hold the hub of needle.
28.  Attach the syringe with appropriate quantity of drug to be injected into CSF.
29.  Aspirate gently to check the needle position and inject the local anesthetic.
30.  After injection, withdraw the needle, introducer (if used) and the syringe.
31.  Apply sterile dry gauze over the puncture site and cover it with sticking plaster.
32.  Patient placed supine on the table.
33.  Onset of action within few seconds.

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