Spinal Anaesthesia in Theatre
Summary
This is a summary that discusses how to give spinal anaesthesia in theatre to an obstetric patient.
Before the spinal
- Ensure you have clerked the patient and you know the patient well. Find out any co-morbidities or medications that the patient might be on. Explain the procedure to the patient, alleviate anxiety and respond any questions that the patient might have.
- Ensure that consent has been taken for the correct procedure.
- Review any investigations required for a successful procedure. This will depend on the patient’s age, comorbidities, or type of procedure.
- Ensure that the premedications have been prescribed and given to the patient.
- Ranitidine 150mg 2 before the operation.
- Sodium citrate 30ml 15min before the operation.
- Metoclopramide 10mg IVI 20 min before the operation.
- Prophylactic antibiotic of choice 30-60mins before the incision of the skin.
- Commonly, Cefazolin is used.
- In theatre:
- Ensure you request the necessary medications to be used during the procedure. Remember, you might need to convert to general anaesthesia and hence all the important medications should be easily available to you.
- Prepare the emergency drugs/medications and keep them readily available.
- Suxamethonium, Ephedrine, Phenylephrine, Oxytocin, Adrenaline, and Atropine.
- Ensure that all the necessary equipment is available and working.
- Infusion pressure bag (sometimes not available).
- OT table is working. The patient should be in a left lateral tilt with a wedge underneath her right buttock. This will reduce aortocaval compression and reduce the incidence of hypotension during your procedure.
- Machine checks should be performed.
- The necessary equipment for general anaesthesia should be available: Endotracheal tubes of different sizes, laryngoscopes with blades of different sizes, oropharyngeal airways of different sizes as well as other equipment needed for the management of a difficult airway.
- A facemask to provide oxygen should also be available.
- Ensure that the patient has a large bore (18G Green) IV cannula, that is running. Make sure you flush the line.
- Pre-load the patient with 10-20 ml/kg of intravenous fluids around 20 minutes before the administration of the spinal anaesthesia.
- This will reduce the incidence of hypotension that occurs in the first 5 minutes after the spinal anaesthesia is administered.
- Pre-load the patient with 10-20 ml/kg of intravenous fluids around 20 minutes before the administration of the spinal anaesthesia.
- Attach monitors to the patient: Pulse oxymetry, ECG, and NIBP. Record the readings. Make sure that you know the blood pressure of your patient before giving spinal anaesthesia.
Spinal and afterwards
- Position: Put the patient in a sitting position or in the left lateral position.
- Confirm that the patient is aware of the procedure you are about to perform and the steps involved.
- Ensure that your “Spinal Trolley” is organized correclty.
- Before doing the procedure, palpate the L3-L4 region and get familiar with the region best appropriate for your injections.
- Follow a sterile technique.
- Clean and drape the patient.
- Locate the L3-L4 interspace, and keep this spot in mind.
- Lignocaine syringe: Infiltrate around 1-5ml of 2% lignocaine subcutaneously at L3-L4 (the level of iliac crests).
- Use a spinal needle with the following properties:
- Should ideally be a pencil-point (looks blunt) and low gauge – 25 or 26G best.
- However, most of the time you will be using a Quincke (sharp, cutting).
- This difference is important to decrease the incidence of post-dural puncture headaches.
- Spinal syringe: Using a 2ml syringe, draw 1.8ml of 0.5% heavy bupivacaine and 0.2ml (10mcg) of 50mcg/ml fentanyl.
- Inject when subarachnoid space entered over 30 seconds. Some doctors aspirate before injecting, and then they aspirate after 1ml has been injected already. This is to ensure that you are still in the subarachnoid space. However, one should avoid multiple aspirations as this barbotage may result in a high spinal.
- Once, you are done place an adhesive dressing over the injection site.
- Then the patient is quickly placed in a supine with the wedge under the right buttocks. The table may also be tilted to provide a left later displacement of the uterus the wedge under the right hip to cause left lateral tilt.
- Monitor: Change the interval at which the blood pressure is monitored to 1-minute intervals. This is done because the blood pressure is likely to drop and this will help you pick up the changes earlier. However, it is always advised to talk to your patient throughout this process as this helps you pick up symptoms of a potential complication. Once the vitals have been normalized, you can change the intervals to 2.5 minutes.
- Blood pressure control:
- Respond to a drop in blood pressure as required. Do not let the blood pressure drop by more than 20% from the initial blood pressure reading.
- It’s a common teaching that if the blood pressure drops and the heart rate is:
- >80bpm: Use phenylephrine as it may cause reflex bradycardia.
- <80bpm: Use ephedrine, adrenaline.
- Other medications that you may need to use will be discussed in another article.
- These agents are titrated to effect.
- Level test: The level of sensory loss should be tested after 5-10 minutes using a cold object such as ice. The level of the block (T4) is required for the cesarean section.
- Ensure you monitor the vital’s throughout the operation. Also, communicate with the surgeon throughout the operation. This is very important because you may realize that the patient is bleeding because they are becoming hemodynamically unstable and you may inform the surgeon. However, the surgeon may also warn you of potential complications encountered during the surgery.
- Once the baby is out, communicated with the surgeon and ensure that oxytocin can be given.
- Oxytocin 5IU IV stat, then also 15-20IU in 1 liter of Normal Saline to run over 6 hours.
- Continue monitoring the patient.
- Keep in mind that throughout the operation you should replace fluids as required. Blood transfusions may be necessary depending on the case. Ensure you keep count of the total blood loss and document it.
- Once the operation is done, ensure the last vitals are recorded and if stable (within 20% of the starting blood pressure) you may move the patient to the recovery room.
References and Further Reading
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