Factors affecting distribution of spinal anesthesia影响脊髓麻醉分布的因素.pptxVIP

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Factors affecting distribution of spinal anesthesia影响脊髓麻醉分布的因素.pptx

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Factors affecting distribution of spinal anesthesia Vivianne Tawfik, MD, PhD CA-1 Department of Anesthesia Overview Case presentation Literature review Summary Recommendations Case presentation 59yo F s/f L total knee replacement PMHx: HTN, tobacco use (15 pack-years), chronic knee pain, obesity Allergies: Tetracycline- hives Meds: Atenolol, lisinopril, HCTZ, ASA, tramadol, tylenol, naprosyn Case (cont) ECG: NSR TTE: overall normal, EF 65%, mod LVH Pre-op labs: WNL Vitals: 62, 140/84, 5’6”, 117 kg Airway: Mal 4, limited mouth opening but normal ROM Case (cont) Anesthesia plan: Femoral nerve catheter + spinal + MAC Spinal difficult to place 2/2 obesity requiring multiple attempts Spinal drugs delivered: Isobaric bupivicaine 0.5% 2.5 cc + astromorph 200 mcg Case (cont) Immediately after spinal, pt positioned supine, O2 by FM, propofol infusion started Kefzol 2g IV given Nurses placing foley, pt responsive, breathing comfortably… Case (cont) Three minutes later, patient spitting up saliva, eyes roll back, unresponsive, apneic, hypotensive (BP 65/42) Bag mask ventilation started, oral airway placed with good air movement After ~5 minutes patient responsive, complaining of need to clear her throat and difficulty breathing Decision made to intubate and initiate GA Intrathecal drug spread Interpatient variability in LA spread noted by August Bier in 1899 Termed “Lauenhaft” or “waywardness” Methods used to test level (back in 1899): ‘‘ . . . sensual perception of needle pricks to the thigh, tickling of the soles of the feet, a small incision in the thigh, pushing a large helved needle down to the femur, strong pinching with dental forceps, application of a burning cigar, pulling out pubic hairs, a strong blow with an iron hammer against the tibia, vigorous blows with the knuckles against the tibia, and strong pressure on a testicle’’ LA spread Stage 1: Spread of LA by CSF displacement and local currents caused by injection Stage 2: Interplay between densities of CSF and