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TECHNIQUES FOR REGIONAL ANAESTHESIA

Posted by SAMUEL ISABIRYE on February 18, 2013 at 8:40 AM

Detailed knowledge of anatomy, technique, and

possible complications is important for correct

injection placement.

 

 

Preoperative assessment and preparation of the

 

 

patient should be done.

Patient refusal and local sepsis are the only

absolute contraindications.

 

 

Select the appropriate technique for operation.

 

 

Precautions:

 

Discuss the procedure with the patient

Identify the injection site using appropriate

landmarks

Observe aseptic conditions

Use small bore needle which cause less pain

during injection

Select concentration and volume of drug

according to the technique

Aspirate before injection to avoid accidental

intravascular injection

Inject slowly and allow 5-10 min. for onset of

drug action

Confirm desired block effect before surgery

commences

The patient must be monitored throughout the

procedure

Note:

 

Supplemental agents should be available for

analgesia or anaesthesia if technique is

inadequate.

Resuscitative equipment, drugs and oxygen

must be at hand before administration of any

anaesthetic.

 

UCG 2010

430

 

 

 

18. Miscellaneous conditions

Management of the surgical patient with

special condition

 

1. Internal haemorrhage

As may occur in ruptured spleen, ruptured tubal

pregnancy

An emergency condition with unstable vital

signs

Invasive surgical intervention in whatever state

the patient is in is life saving

Do not delay operation in attempt to stabilize

the patient as this may not be achieved

Prompt resuscitative operation is required which

includes:

1.

Establish an IV line and infuse fluids rapidly

2.

Rapid sequence induction of general

anaesthesia

-Use drugs with no or minimal cardiac

depression

 

3.

Laparotomy to achieve surgical haemostasis

2. Intestinal obstruction

Preoperative fluid therapy

 

Fluid deficit, the electrolyte abnormalities and

acid-base disturbances must be corrected

Replace on going fluid losses e.g. vomit,

fistula, NG- tube drainage

Give maintenance fluid

Duration, depending on urgency of surgery,

may be as long as 6 hours to achieve cellular

hydration

Monitoring outcome

The following signs will show the effectiveness

of the therapy

-

Pulse rate a gradual decline

-

BP may rise

-

Urine output good if it is 0.5 to 1ml /kg/hr

 

UCG 2010

431

 

 

 

18. Miscellaneous conditions

-

CVP arise of 2-3 cmH20 with rehydration

-

CNS patient more rational

-

Mouth less dry

-

Skin turgor increased

 

The fluid to use: balanced solution e.g. Ringers

Lactate. Physiological saline may be used.

Operative fluid therapy

 

Blood loss, fluid aspirated from the gut and

other fluid losses must be replaced

Maintenance fluid be given 5ml/kg/hr

Postoperative fluid therapy

 

Replace all fluid losses

Maintenance fluid

Monitor for adequate rehydration

3. Co-existing medical conditions

Principle:

The medical condition must be stabilized as much

as possible before surgery

Preoperative management

 

Establish whether condition is stable or

unstable

If unstable then control or correct the

condition

Operative and postoperative management

 

Anaesthesia technique based on condition

and nature of surgery

Maintain the stable condition

4. Hypertension

Diastolic of 90 mmHg is acceptable

If poorly controlled patient may have

 

Vasoconstriction and hypovolaemia

Exaggerated vasoactive response to stress

leading to hypotension or hypertension

Hypertensive complications under

anaesthesia

UCG 2010

432

 

 

 

18. Miscellaneous conditions

Management

 

Control hypertension preoperatively

Take antihypertensive drugs on schedule

even on the day of operation

General anaesthesia technique is preferred

Ensure adequate-depth of anaesthesia and

analgesia

- oxygenation

 

 

-ventilation

- circulatory volume replacement

5. Anaemia

Condition of reduced 02 carrying capacity, patient

prone to hypoxia

Heart failure may occur

Hypotension or hypoxia can cause cardiac arrest

This should be corrected to acceptable level

depending on urgency of surgery

Regional anaesthesia is the preferred method

If general anaesthesia - is used avoid myocardial

depressant e.g. Thiopentone

-

use small doses of drugs

-

use high oxygen concentration

-

intubate and ventilate except for very short

 

procedures

-

replace blood very carefully

-

extubate patient when fully awake

-

give o2 in the postoperative period

 

For the sickle cell anaemia the above also apply as

well as avoiding use of tourniquet

 

6. Asthma

Avoid drugs and other factors likely to trigger

bronchospasms e.g. Thiopentone

Regional anaesthesia is the preferred method

If general anaesthesia selects drugs accordingly,

maintain adequate depth of anaesthesia

 

UCG 2010

433

 

 

 

18. Miscellaneous conditions

7. Diabetes mellitus

Achieve control using standard treatment

preoperatively

If diabetic ketoacidosis -delay surgery even in

emergency for 8-12 hours

 

- correct and control all associated disturbances

Hyperglycaemia under general anaesthesia is safer

than hypoglycaemia.

 

Patient should be operated early in the morning

 

where possible.

Regional anaesthsia is the method of choice where

applicable

 

a) Minor surgery

 

Stop usual antidiabetic dose on the morning of

surgery

Start infusion of 5%dextrose infusion rate of

2ml/min in theatre

Monitor blood sugar

Usual medication is resumed as soon as the patient

is able to take orally

 

b) Major surgery

 

Control on sliding scale of insulin

Infusion of 5%dextrose started on the morning of

surgery

Or

Glucose insulin potassium infusion

Monitor blood sugar =200mg/

 

UCG 2010 434

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