Venous anatomy and pathophysiology
Helane S Fronek in The Fundamentals of Phlebology: Venous Disease for Clinicians, 2007
The introduction of tumescent local anesthesia by Dr Jeff Klein allowed phlebological surgery to move into the office setting.12 The tumescent local anesthetic is diluted, to allow the use of larger volumes in order to treat a wider area. Lidocaine concentrations as low as 0.1% can be quite effective, with less risk of reaching levels of toxicity, even when using up to 35 mg/kg. The typical Klein solution includes normal (0.9%) saline (1000 cm3), lidocaine 1% with epinephrine (100 cm3), and 8.4% sodium bicarbonate (10 cm3). In patients who are over 60 years of age, it may be advisable to use lidocaine without epinephrine.9 If the amount of local anesthesia to be used is more than the recommended maximum dose, the procedure must be staged into two or more sessions, which should be no longer than 1-2 weeks apart, as noted above. Infiltration of the local anesthetic is done immediately prior to the procedure. Standard syringes, pressure bags, or a mechanical pump may be utilized to assist with the administration of the tumescent local anesthesia. A ½-inch 30-gauge needle is used to raise a skin wheal, and a 1½-inch 25-gauge needle is used to infiltrate the subcutaneous tissue. A spinal needle may also be used to anesthetize the subcutaneous perivenous tissue, and is also used around the saphenous veins in the venous fascial compartment under ultrasound guidance. Infiltration is begun distally and progresses proximally, all the way to the groin if necessary.
Anesthesia and analgesia in pregnancy
Hung N. Winn, Frank A. Chervenak, Roberto Romero in Clinical Maternal-Fetal Medicine Online, 2021
A modification of conventional epidural analgesia, the combined spinal–epidural (CSE) technique, has also been gaining usage at major centers over the past decade. Following placement of the epidural needle in the epidural space, a small-gauge pencil-point spinal needle is passed through the epidural needle and the dura is punctured. A small dose of preservative-free opioid or opioid local anesthetic combination is injected intrathecally. The epidural catheter is then passed through the epidural needle and tested. Analgesia is achieved rapidly and there is no need for a bolus loading dose of local anesthetic via the epidural catheter (76,77). Following placement and testing of the epidural catheter, a maintenance infusion is begun. By the time the intrathecal dose has dissipated, the epidural infusion has reached a sufficient level to maintain satisfactory analgesia.
Anesthetic Considerations for Placenta Accreta
Robert M. Silver in Placenta Accreta Syndrome, 2017
For a CSE, the epidural space is accessed as above. Then, a spinal needle is placed through the epidural needle to puncture the dura and arachnoid membranes to administer IT medications. The spinal needle is then withdrawn, and a catheter is placed through the epidural needle into the epidural space. The CSE offers the benefits of both a spinal (fast, dense block) and an epidural (extended duration of action). Some practitioners administer opioids only into the IT space and then activate the epidural with local anesthetic, which allows for greater hemodynamic stability and adequate evaluation of the epidural prior to surgical incision.
Does esmolol infusion have an adjuvant effect on transversus abdominis plane block for pain control in laparoscopic cholecystectomy? A randomized controlled double-blind trial
Published in Egyptian Journal of Anaesthesia, 2021
Fatma Ahmed Abdelfatah, Samar Rafik Amin
Following skin disinfection and covering of the ultrasound probe and cable with a sterile sheath, a broad linear array probe was placed transverse to the abdomen (horizontal plane) between the iliac crest and the costal margin in the mid-axillary line. Three muscle layers can be visualized in the image. A 20 Gauge 90 or 120 mm sharp ended spinal needle was used. The needle was introduced in a sagittal plane nearly 3–4 cm medial to the probe of ultrasound (in-plane technique). To follow the needle superficial course after skin puncture; the probe was moved slightly anterior, then gradually posteriorly to the mid-axillary line position until the needle settled in its right position in the TAP. A small volume of local anaesthetic (1 mL) was initially injected to open the plane then 20 mL of 0.25% bupivacaine was injected in each side. The local anaesthetic injectant appeared hypoechoic on ultrasound imaging. The surgery was started after completion of the block.
The Effectiveness Of Non Invasive Hemodynamic Parameters In Detection Of Spinal Anesthesia Induced Hypotension During Cesarean Section
Published in Alexandria Journal of Medicine, 2021
Yasser Essam Elfeil, Ahmed Mohammed Alattar, Tamer Ahmed Ghoneim, Aliaa Rabie Abd Elaziz, Ehsan Akram Deghidy
In the sitting position spinal anesthesia was delivered under full sterilization. After skin local anesthetic injection with lidocaine 2%, a 25-gauge Quincke spinal needle was inserted at the L4-L5 vertebral interspace. After free flow of cerebrospinal fluid, 2.2 ml (11 mg) of hyperbaric bupivacaine 0.5% and 25 μg (0.5 ml) fentanyl was given, and the patient was returned back to the baseline position. At the start of local anesthetic injection, coload of lactated Ringer’s solution was started for the first 1 L, by fully opening the IV fluid set with the bag suspended at a height of approximately 1 m above the midpoint of the operating table. Then, maintenance fluids were limited to 10 ml/kg/hour. Block height was assessed using ice swap and considered adequate if at the T4 level or above. Also motor block was assessed using bromage score and considered adequate if grade IV unable to move legs or feet. If sensory or motor block were not adequate, the patient was excluded from the study. Surgery was started after the block adequacy was considered by anesthesiologist. After the delivery of baby, 3 IU oxytocin was administered as a slow bolus injection, and 7 IU was added to a second bag of Ringer’s lactate and infused over the remainder of the operation. Patients were monitored for (Systolic, diastolic and mean) blood pressure and heart rate every 2 min till the delivery of baby and every 3 min thereafter. No prophylactic ephedrine was administered.
Nerve root entrapment with pseudomeningocele after percutaneous endoscopic lumbar discectomy: A case report
Published in The Journal of Spinal Cord Medicine, 2020
Wei Shu, Haipeng Wang, Hongwei Zhu, Yongjie Li, Jiaxing Zhang, Guang Lu, Bing Ni
In this case, the improper operation of spinal needle is a probable reason for pseudomeningocele, even though most iatrogenic dural tears take place during the discectomy step. The surgeons had meticulously analyzed the surgical video record and didn’t detect any obvious problem under endoscopic in the first operation. Then, we presume that the dura sac may be breached by the adjustment of spinal needle. According to the X-ray image of the localized step, the spinal needle once entered the upper-medial aspect of the foramina, which may pierce the dural membrane. This secondary tiny dural tear is difficult to be observed, because the positive pressure irrigation may keep the nerve tissue in the thecae sac. Over time, the intraspinal pressure may gradually enlarge the dural tear and cause syndromes related to pseudomeningocele in the postoperative period. To avoid this complication, the surgeon must have careful preoperative planning and thorough understanding of 3-dimension anatomy for the transforaminal approach. Skilled puncturing technique and proper trajectory guided by the fluoroscopic image are required. The needle tip should be kept lateral to the medial margin of pedicle during the localized step. Aberrant placement or dissection of the spinal needle in the intervertebral foramen and spinal canal may cause unintended injuries.
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