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General v/s Spinal – Epidural v/s Regional / Local

General v/s Spinal – Epidural v/s Regional / Local Dr. Prakash Ambardekar Senior Anaesthesiologist Dept of Anesthesia SL Raheja Hospital, Mumbai. Estimated population with diabetes

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General v/s Spinal – Epidural v/s Regional / Local

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  1. General v/s Spinal – Epidural v/s Regional / Local Dr. Prakash Ambardekar Senior Anaesthesiologist Dept of Anesthesia SL Raheja Hospital, Mumbai

  2. Estimated population with diabetes mellitus in this country is about 32 million. 15-20 % have foot problems 30% have P. V. D. Frequent CAUSE for hospitalisation One of the expensive complication of D.M.

  3. Diabetes Mellitus is not a simple endocrine disorder PATHOLOGICAL PROCESS AFFECTING PHYSIOLOGICAL PROCESS IN TURN AFFECTING VARIOUS END-ORGANS 1] Cardio-vascular system - Angina pectoris, - silent small to massive Myocardial Infarcts, - varying degrees of cardiomyopathies, - varying types of Conduction blocks etc - may be accompanied with Hypertension. - coronary heart disease four times more common in male and five times more common in women D M population Significance - Detailed Pre-Op Evaluation - Intense Peri-operative Monitoring

  4. 2] Reno-vascular system - Nephropathies leading to Chronic renal failure - Pt. on DIALYSIS Significance - Identify pts. With IMPENDING RENAL FAILURE - Correction of Electrolyte Imbalance - Correction Of Anaemia 3] Central nervous system - Secondary to Age Related - Septicaemia - Electrolyte Imbalance 4] Autonomic nervous system - Autonomic Imbalance Significance - Varying degrees of Hypotension - Arrhythmias

  5. 5] Immunological system - suppression - prone to infections 6] Septicaemia - following infection affecting various systems 7] Fluid & Electrolyte status - Hyponatraemia - Hypokalaemia - Hyperkalaemia - Altered pH 8] Pulmonary system - altered ventilation and perfusion - obesity - A R D S

  6. 9] G. I. system - slows gastric emptying - altered tone of G-O sphincter - aspiration 10] Skeleto-muscular system - stiff joint syndrome - prayer’s sign - fusion of upper cervical vertebrae with limited neck - movement and “Palm test “ - obesity - short neck. Thus, in Diabetes, the selection of Anesthesia becomes a tricky and highly skillful job.

  7. Special Problems 1] Aseptic technique is critical for all procedures in patients with DM to decrease the incidence of postoperative infection. 2] Surgical removal of infected tissue (ie amputation of gangrenous limb, incision of abscess, etc) results in dramatic reductions in Insulin requirement (and the danger of hypo-glycaemia) postoperatively. 3] Prabha Adhikari, Abraham Abey [2004] - It is well known that D M pts are at a greater risk of peri-operative mortality and morbidity after a major surgery especially with the presence of coexisting diseases. 4] David Rothenberg [2006] - Mortality rates in diabetic patients have been estimated to be up to 5 times greater than in nondiabetic patients, often related to the end-organ damage caused by the disease.

  8. 5] Fortunately, intensive glycemic control has been shown to have a profound effect on reducing the incidence of many of these complications in a variety of surgical populations. 6] O H G like sulfonylureas should be stopped pre-operatively as -can cause hypoglycemia -being associated with interfering with ischemic myocardial preconditioning and may increase risk of peri-operative myocardial ischemia and infarction. 7] Patients taking metformin should be advised to discontinue this drug because of the risk of developing lactic acidosis. 8] Hyperglycaemia at the time of cerebral ischaemic insults is associated with a poor outcome.

  9. RISK FACTORS DURING ANAESTHESIA 1] MALE / FEMALE – CARDIAC AFFECTION FOR CHD 2] CARDIAC AUTONOMIC NEUROPATHY 3] RENAL INVOLVEMENT 4] GLYCEMIC CONTROL 5] ASSOCIATED MEDICAL DISEASES 6] SMOKING, OBESITY etc.

  10. CHOICE OF ANAESTHESIA SELECTION : 1] General Anaesthesia 2] Regional Analgesia -Spinal - Epidural - one shot - continous - Nerve blocks in Thigh - sciatic - femoral - Nerve blocks in Leg - Ant. Tibial - Post. Tibial - Lat. Popliteal - Sural - Field block

  11. General Anaesthesia : Indications 1] Any Pt. on VENTILATOR 2] Any Pt. Hypersensitive to L. A. Agent 3] REFUSAL from Pt. 4] FAILURE of Regional Anaesthesia

  12. General Anesthesia: [besides usual precautions] a] Risk of Aspiration and PONV b] Difficult intubations c] Resistant hypotension which may last for longer time d] Management of ischaemic changes and arrhythmias e] Management of blood sugar

  13. Spinal & Epidural Anaesthesia a] Prevention and management of hypotension b] Cannot be repeated frequently [ except in continuous epidural analgesia ] especially for small but painful procedures.

  14. Why regional anaesthesia ? 1] Ideal for day-care patients 2] Safety in high risk patients 3] No intra-op regurgitation & aspiration 4] No PONV 5] Minimal alteration in drug schedule -specially in diabetics

  15. Why regional anaesthesia ?Continued…. 6] Minimal effects on vital parameters 7] Safer in emergency situations 8] Can be repeated frequently 9] Conscious & arousable patient at the end of the surgery 10] Reduction in morbidity & mortality

  16. STRESS RELIEF Patients, coming to O. T., despite Good Counseling May be pretty APPREHENSIVE. This can be managed by 1] REASSURANCE - Verbal 2] REASSURANCE – Tactile 3] SEDATION – mild to moderate 4] REASSURANCE – under Light Sedation.

  17. Limitations 1] Surgical time limit is between 1-3 hrs. 2] Patient’s co-operation is must 3] Failure or partially acted block

  18. Statistics Total No. of PATIENTS - 1757 No. RECEIVED Leg Blocks - 1400 [ 79.68% ] - Low Leg Block - 1109 [ 79.21% ] - Mid Leg Block - 210 [ 15.00% ] - High Leg Block - 84 [ 6.00% ] Failure of the Block - 41 [ 2.93% ] { All were given TIVA or GA } No. did NOT RECEIVE Blocks - 357 [ 20.31%] - Spinal - 123 [ 7.00%] - Epidural{one shot/cont.} - 122 [ 6.94%] - General Anaesthesia - 112 [ 6.37%]

  19. Pre-block preparation • Besides usual instructions…. • Application of elastocrepe bandage • 2-3 days prior to surgery • Advantages :- • limb becomes soft & supple • reduced oedema , improved limb circulation • pH of tissue fluid alters • Success rate improves

  20. Pre-block preparation Counseling the patient regarding the procedure and the expectation from the patient (compliance and accurate replies regarding paresthesia)

  21. Lower leg block or modified ankle block Deep peroneal nerve – can be blocked by injecting subcutaneously 3-5 mm along the lat border of the shin with 2 ml 2% xylocaine with 24 g 1.5 inch needle

  22. Lower leg block or modified ankle block Post. Tibial nerve – Blocked by injecting 3-5 ml 2% xylocaine at the junction of proximal 1/3rd with distal 2/3rd of medial malleolus to calcaneum, where normally pulsations of post. Tibial artery is felt.

  23. Lower leg block or modified ankle block Sural nerve Inject 2% xylocaine between the tendoachilles and the calcaneaum on the lateral aspect

  24. Lower leg block or modified ankle block Ring block – 0.5 % xylocaine around the leg to block cutaneous nerves

  25. Lower leg block or modified ankle block Calcaneal nerve block 2 Finger breadths proximal to the medial malleolus Inject along the direction of the nerve

  26. Mid leg block Anterior Tibial nerve Inject 2- 4 ml 2% xylocaine subcutaneously 5-7 mm along the lateral border of the shin

  27. Mid leg block Posterior Tibial Nerve Spinal needle no 23 G is inserted from the lateral side of the leg over the ant. border of fibula going medially downwards just to slip the interosseous border of tibia , advance 1-2 mm & deposit 8-10 ml 2% xylocaine

  28. Mid leg block Sural nerve Inject 2 – 3 ml 2% xylocaine along a line extended proximally tangential to the lateral border of the tendo achilles

  29. Mid leg block Ring block 0.5 % xylocaine around the leg to block cutaneous nerves

  30. High leg block Anterior Tibial nerve Inject 3-4 ml 2% xylocaine 5-10 mm deep lateral to the upper end of shin

  31. High leg block Posterior Tibial nerve 2-4cm below the neck of the fibula Lateral approach – Spinal needle no 23 G is passed from the lateral side of the leg over the ant. border of fibula going medially downwards just to slip the interosseous border of tibia, advance 1-2 mm & deposit 8-10 ml 2% xylocaine.

  32. High leg block Lateral Popliteal Nerve 2- 4 ml 2% xylocaine injected around the neck of fibula

  33. High leg block Ring block 0.5 % xylocaine around the leg to block cutaneous nerves

  34. High leg block An alternate technique - • If patient has a pain-free leg, • then one may give sciatic nerve • block in the lower third of thigh alongwith • lat. Popliteal nerve block and ring block. • Posterior approach • Lateral approach

  35. CONCLUSION 1] EVALUATE THE PATIENT IN TOTO. 2] COUNSEL THE PATIENT & THE RELATIVES 3] PRACTICE WHAT YOU BELIEVE IS SAFE - - SAFE FOR YOU, YOUR PATIENT, YOUR TEAM. 4] ONCE YOU GET FAMILIAR WITH BLOCKS, YOU WILL FIND WIDER INDICATIONS AND GREATER SATISFACTION.

  36. Steps to success with local blocks Practice regularly Your patience The surgeons’ patience The patients’ patience! Patients’ comfort The surgeons comfort Your comfort AND SAFETY!!

  37. In Diabetic Foot Blocks are the way to the goal !!

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