Anaesthetics - Introduction to anaesthesia 2

Question 1

What are the main differences between general and local anaesthesia?

Answer 1

General anaesthesia prevents pain generated peripherally being interpreted as pain by the CNS. It does NOT stop transmission of pain from the source.

Local and regional anaesthetics prevents the transmission of painful stimuli reaching the CNS (via the thalamus).

Question 2

How are local anaesthetics classified?

Answer 2

Local anaesthetics are weak bases. They are divided into 2 groups depending on the linkage between an aromatic ring, and an amine group (which all agents have). This linkage is either an amide or an ester.

Ester - e.g. cocaine, procaine, amethocaine

• allergic reactions are common*
• metabolized by plasma and liver cholinesterase

Amides (more common) - e.g. bupivacaine, lidocaine

• allergic reactions are rare
• metabolized by the liver
• allergic reaction occurs because metabolism results in the production of para-amino-benzoate

Question 3

What is the mechanism of action of local anaesthetics?

Answer 3

LAs act by reversible inhibition of action potential propagation in all excitable tissues. They block voltage gated sodium channels on nerve cell membranes and prevent sodium influx and action potential propagation.

Only the uncharged or lipophilic form of the drug can cross the plasma membrane*. Once inside, the pH of the axon is more acidic which promotes ionization (i.e. the LA is now charged). This is the active component that blocks the Na channel. The higher the frequency of sodium channel opening the more susceptible the nerve is to blockade (use dependence) - sensory nerve fibres are blocked before motor nerves.

• physiological pH (7.4) promotes dissociation of the charged LA agent that is injected into H+ ions and an uncharged molecule

Question 4

What determines the speed of onset of local anaesthetics?

Answer 4

This is related to the amount of drug in the unionized form that can cross the cell membrane. This depends on its pKa (pH at which 50% of the drug is in the ionized form).

For example, lidocaine (pKa 7.9) has a quicker speed of onset than bupivacaine (pKa 8.1) because more lidocaine is unionized at physiological pH and hence can cross the cell membrane.

Additives effect the speed of onset. For example, bicarbonate raises extracellular pH and thus increases the unionized fraction of the drug which can then cross the cell membrane.

Question 5

What prolongs the duration of action of LAs?

Answer 5

Protein bound LAs have a longer duration of action. Ester LAs (e.g. cocaine) may have prolonged duration of action when plasma cholinesterase is reduced, for example in pregnancy, liver disease or when the enzyme is atypical or absent (e.g. pseudocholinesterase deficiency).

Question 6

Why are vasoconstrictors added to LAs? Does this affect their maximum safe dose?

Answer 6

Vasoconstrictors (e.g. adrenaline, or felypressin) prolongs the duration of action of LAs by reducing systemic absorption. These aim to keep the LA concentrated at the site of administration to prolong its action, reduce toxicity and maybe to enhance block quality.

When SOME LAs are used with a vasoconstrictor their maximum safe dose increases - e.g. lidocaine is normally 3mg/kg, with adrenaline this goes up to 7mg/kg. Others (e.g. bupivacaine) remain unchanged.

Question 7

When should LAs with a vasoconstrictor never be used?

Answer 7

They should never be used in areas with a terminal arterial blood supply where necrosis can occur - e.g. penis or digits.

Question 8

How do hyperbaric solutions affect LA spread?

Answer 8

Hyperbaric solutions (e.g. by the addition of dextrose) effect the spread of LA when they are injected into the CSF. Dextrose is denser than CSF, and when combined in solution causes the LA to sink to the most dependent part - i.e. to the left or right if the patient is lying on their side or to the caudal area if sitting upright.

Question 9

What causes toxicity of LAs?

Answer 9

This occurs as a result of membrane stabilisation of other excitable tissues (e.g. CNS, heart). Toxicity can be due to excessive dose of drug being given or due to a smaller dose being administered via the wrong route (e.g. IV).

Question 10

What are the features of LA toxicity?

Answer 10

These are concentration (dose dependent):

• circumoral tingling
• feeling of impending doom
• dysrhythmias
• CVS collapse
• LOC
• convulsions
• cardiac arrest

Question 11

How should LA toxicity be treated?

Answer 11

Treatment is supportive, including airway maintenance/ intubation if needed, IV fluids, and vasopressors (e.g. adrenaline) and control of seizures with benzodiazepines, thiopentol or propofol. If cardiac arrest occurs then CPR is performed.

IV lipid emulsion Intralipid 20% 1.5mL/kg is now recommended for LA toxicity/ cardiovascular collapse. But recovery can take over an hour so CPR may be prolonged.

Question 12

What determines the rate of systemic absorption of LAs?

Answer 12

This depends on the site of administration: mucous membranes > intercostals > major nerve block > infiltration.

Question 13

What is associated with prilocaine?

Answer 13

Prilocaine metabolism produces toludine, which reduces Hb to metHb. Excess prilocaine can therefore cause methaemoglobinaemia. It is treated with methylene blue.

Question 14

What is the maximum safe dose of bupivicaine, lignocaine and prilocaine?

Answer 14

Bupivicaine = 2mg/kg
Lignocaine = 3mg/kg 
Prilocaine = 6mg/kg 

Bupivicaine has a lower CVS collapse: convulsion meaning that if it is injected intravenously it is particularly dangerous.

Question 15

How can LAs be administered?

Answer 15

1) Topical application - EMLA ( = Eutetic mixture of local anaesthetics) - this is an emulsion of equal amounts of the base forms of prilocaine and lidocaine. Each drug lowers the melting point of the other. It takes about 45 mins to work though; lignocaine spray

2) Infiltration - e.g. cannulae, sutures
- Field block = larger injection of LA for inguinal hernias
- Wound infiltration - usually with adrenaline, watch total dose

Question 16

At what level is spinal anaesthesia administered? How is it performed?

Answer 16

Usually L3-4 (because the cord has terminated by this level) and is administered using a 25-27g needle.

The anaesthetic is injected directly into the CSF with the needle having passed through all the dural layers. Small volumes of bupivocaine are often used, and there is a very rapid effect.

Unlike an epidural, a total block is usually achieved with motor and sensory loss.

Opioids such as fentanyl can also be given.

Question 17

How is an epidural anaesthetic given?

Answer 17

A Tuohy needle is used to pierce through the ligaments of the spine to access the epidural “space” (this is a potential space). An LOR (loss of resistance technique) is used whereby saline is slowly forced through the needle until it can be injected into the space.

A catheter is then inserted and large volumes can be administered into the extradural space. It can be given in the thoracic, lumbar or sacral regions (esp. children) but should not produce a motor block.

• Both spinal and epidural are examples of regional anaesthesia

Question 18

What are nerve blocks?

Answer 18

These are another example of regional anaesthesia. LA is injected close to a nerve which can run within a sheath alongside arteries and veins. It is important to avoid injecting anaesthetic into these.

If injecting for the brachial or sacral plexuses then up to 30mls of fluid may be required.

Single nerves (e.g. femoral) or multiple nerves (e.g. brachial plexus) can be blocked.

Question 19

How is a Biers block performed and when is it used?

Answer 19

(Intravenous regional anaesthesia). A BP cuff is applied to the upper arm after placement of a cannula in the hand. After exsanguination of the limb by either elevation or the use of a compression bandage the BP cuff (or double torniquet) is inflated to 100mmHg above systolic BP.

Prilocaine is the preferred drug and is injected IV. It is unable to spread beyond the cuff and thus acts within a confined area. It provides good anaesthesia for distal limb procedures (e.g. fracture manipulation).

The cuff must be let down after 20 mins to allow the LA to spread into the adjacent tissues in order to prevent toxic plasma levels of LA following systemic absorption.

Question 20

What is regional anaesthesia?

Answer 20

This involves the injection of a local anaesthetic and sometimes other drugs (e.g. opioids) targeted at specific nerves or nerve plexus to numb the area that the nerve innervates, including the spinal cord and its nerve roots.

Question 21

What are the indications for nerve block?

Answer 21

Sole form of anaesthesia during an operation
Combined with general anaesthesia or sedation
Postoperative anaesthesia
Chronic pain conditions

Question 22

What is a central (or neuraxial) blockade?

Answer 22

Central blockade is the introduction of drugs into the CSF within the subarachnoid space (spinal blockade) or the surrounding epidural space (epidural blockade). Anaesthesia is provided for surgery below the level of the umbilicus (T10).

Question 23

What are the advantages of a central blockade?

Answer 23

Avoidance of GA in at risk patients - e.g. severe respiratory disease, difficult intubation, diabetic, myopathies, pregnant, malignant hyperthermia
Good post operative analgesia
Avoids sedation/ N&V, e.g. by morphine
Reduction in pulmonary embolism due to sympathetic blockade
Reduced blood loss
Reduced stress response to surgery

Question 24

What are the side effects of central blockade?

Answer 24

Hypotension (sympathetic block)
N&V (hypotension, opiates)
Lower limb motor block
Post dural puncture headache (more likely with a large needle, non pencil point tip, inadvertent Tuohy needle puncture of the dura, young age)
High block can affect upper limb power and respiration (C3-5)
Loss of consciousness (total spinal)
Nerve damage (rare)

Question 25

What are the contraindications to central blockade?

Answer 25

Patient refusal 
No i.v. access
Severe CVS disease 
Hypovolaemia 
Sepsis 
LA allergy
Coagulopathy (INR needs to be <1.5)
Caution must be exercised if there has been previous major spinal surgery or ongoing CNS disease

Question 26

Where is a spinal block inserted? What landmarks can be used?

Answer 26

The spinal cord terminates at the lower border of L1 or upper border of L2. A needle must be inserted at or below the L2/3 interspace. Tuffier’s line is a useful landmark, that is a line drawn between the iliac crests corresponding to the level of L4/5.

Spinal needles are narrow gauged so as to make as small a hole in the dura mater as possible. The most commonly used needle is the blunt “pencil point tip”, which separates the dural fibres rather than cuts them, reducing the incidence of CSF leak related headache.

Question 27

How is a spinal block performed?

Answer 27

The patient lies on their side. The back must be curled forward in order to widen the intervertebral disc spaces. LA ampules for spinal block often contain dextrose as well, to increase the baricity in relation to the CSF. Once injected, the “heavy” LA sinks, allowing a denser block on one side if required (e.g. with the patient lying on their side, heavy local anaesthetic will affect the dependent side more). Plain LA is hypobaric and will affect the non dependent side more.

Question 28

What is an epidural block? What kind of needle is used?

Answer 28

This involves the placement of a catheter into the epidural space, followed by continuous or intermittent drug administration. It is used for analgesia during labour as well as during surgery and for postoperative analgesia. Positioning is as for a spinal block. A Tuohy needle is advanced towards the epidural space, with continuous or intermittent pressure applied to a saline filled syringe attached to the distal end of the need. As the ligamentum flavum is breached there is a sudden loss of resistance. An epidural catheter is threaded down the needle, which is then removed and discarded.

Question 29

What is a combined spinal epidural?

Answer 29

Combined spinal epidural (CSE) block is when both procedures are performed at the same time, either as a “needle through needle” technique or as two separate procedures at different vertebral levels. It has the advantage of rapid onset (spinal) and the ability to supplement with the epidural component as the spinal analgesia wears off. The injected drugs act directly on the spinal cord and nerve roots, blocking sensory, motor and autonomic nerve transmission. LA and opiates have synergistic effects.

Question 30

What is a nerve plexus blockade? What complications can occur?

Answer 30

This is injecting local anaesthetic into a specific nerve or nerve plexus. The two mains ways of identify a target nerve are to use a nerve stimulator or ultrasound. Although rare, inadvertent i.v. injection of LA and/or LA toxicity are recognised complications. Full resuscitation facilities must be available wherever the block is performed. Repeated syringe aspiration on injecting LA is important to prevent inadvertent i.v. injection. Nerve damage is rare, but the issue should be discussed with the patient.

Question 31

What is a nerve stimulator?

Answer 31

A needle is attached to a variable electric current. It is initially set to 1-2mA with a frequency of 1-2Hz. As the nerve is approached, a motor response in the muscles supplied by the nerve is elicited. The current is reduced as the nerve is approached, aiming to produce the best motor response at the LOWEST current. When the needle is in the correct position, muscle twitch will usually disappear at a current of 02-0.3mA. If twitches persist down to very low current, it suggests that the needle is intraneural and should be repositioned.

Question 32

What is an interscalene block?

Answer 32

Provides surgical anaesthesia to shoulder, upper arm and forearm. The upper, middle and lower trunks of the brachial plexus are blocked as they lie in the interscalene groove (between the scalenus anterior and scalenus medius), within the fascial sheath. The groove is located at the level of C6 (corresponding to the cricoid cartilage) at the lateral border of SCM.

Question 33

What is an axillary block?

Answer 33

This is used for surgery to the elbow, forearm and hand. It blocks the radial (C5-T1), ulnar (C7-T1), median (C6-T1) and musculocutaneous (C5-7) nerves high in the axilla, lateral to pectoralis minor. The nerves lie within a fascial sheath with the axillary artery and vein (the latter is not always within the sheath).

Question 34

What is a femoral nerve block?

Answer 34

This is used for surgery to the anterior thigh, knee and quadriceps tendon. The femoral nerve (L2-4) is the largest branch arising arising from the lumbar plexus. It is located lateral to the femoral artery, in the inguinal crease just distal to the inguinal ligament. Stimulation of quadriceps (patella twitch) indicates correct needle placement. If used in combination with a sciatic nerve block, total anaesthesia distal to the mid thigh is produced.

Question 35

What area is affected by a popliteal nerve block?

Answer 35

Popliteal nerve block affects the sciatic nerve (L4-S3) proximal to its bifurcation into the common peroneal nerve (L4-S2) and tibial nerve (L4-S3). It provides anaesthesia below the knee, excluding that provided by the saphenous nerve (a terminal branch of the femoral nerve). The injection is at the apex of a triangle where the popliteal crease is the base and the sides are composed of the tendons of biceps femoris (lateral) and semintendinosus and semimembranosus (medial).