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Brown: Atlas of Regional Anesthesia, 3rd ed., Copyright © 2006 Saunders, An Imprint of Elsevier
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PEARLS

Probably the most important factor contributing to success with spinal anesthesia in the day-to-day life of an anesthesiologist is the time efficiency of the technique. Use of spinal anesthesia cannot measurably add to the surgical day if nurses and surgeons are to be co-advocates of this technique. Thus, one should plan ahead to maximize efficiency. Often overlooked in this maxim is the fact that patient preparation for the operation can begin almost as soon as the block is administered if the patient is properly sedated.

Intraoperatively, during high spinal anesthesia (often during cesarean section) patients occasionally complain excessively of dyspnea. This often appears to be a result of loss of chest wall sensation rather than of significantly decreased inspiratory capacity. The loss of chest wall sensation does not allow the patient to experience the reassurance of a deep breath. This impediment to patient acceptance can often be overcome simply by asking the patient to raise a hand in front of the mouth and exhale forcefully. The tactile appreciation of a deep exhalation often seems to provide the needed reassurance.

If spinal anesthesia has been used and a neurologic complication is noted postoperatively, it is essential to obtain neurologic consultation early. In this way, an unbiased consultant can examine the patient and determine whether the “new” neurologic finding was preexistent, related to a peripheral neuropathy, or, more rarely, potentially related to the spinal anesthetic. The latency in electromyographic (EMG) alterations associated with denervation due to neurologic injury takes time to develop in the lower extremities (14–21 days). Therefore with a potentially spinal-related lesion, EMG studies should be obtained early to establish a preblock baseline and then serially over time.

It is also useful to consider adding fentanyl (15–25 μg) rather than epinephrine to some shorter-acting spinal local anesthetic mixtures (lidocaine) because the length of the effective sensory block is prolonged without measurably adding to the length of the motor block or the time to voiding. This is an especially useful technique in selected outpatient surgical patients.

Another way to titrate spinal anesthesia for outpatients or any surgical procedure in which the length of surgery is difficult to predict is to use a combined spinal-epidural technique. With this technique an epidural needle is placed in the epidural space in standard fashion, and then a small-gauge spinal needle is advanced through the epidural needle into the CSF. A spinal local anesthetic mixture is then injected and matched to the projected length of the shortest surgical procedure planned. After removal of the spinal needle, an epidural catheter is inserted into the epidural space. At this point, if the surgical procedure lasts longer than anticipated, the epidural catheter can be injected with a local anesthetic appropriate for the anticipated surgical needs. This combined spinal-epidural technique allows flexibility for both spinal and epidural anesthesia in selected patients.

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