1. Epidural anesthesia has existed for several decades, during which time the safest of its variants have been worked out. Follow the simplest methods for beginners — and you will have maximum success and minimum complications.
2. Experienced “durilitsiki” do everything easily and quickly, as if effortlessly, sometimes neglecting aspiration and test dose. Quod licet Jovi, non licet bovi — that is allowed to Jupiter, then the bull is not allowed. Beginner saves caution. Do not be in a hurry — anyway, anesthesia will come no earlier than 15 minutes.
3. Do not insert a catheter if a single injection of a local anesthetic is sufficient for a short operation. Catheterization has its own, additional, complications.
4. Although for the most effective anesthesia, an experienced “durilshik” can inject the anesthetic as close as possible to the desired segments (sacral — for operations on the perineum, the lower thoracic for abdominal operations), it is safer to begin an epidural puncture only where there is no spinal cord. brain (below L2). A higher level of anesthesia can be achieved not by the level of the injection, but by advancing the catheter or (more simply) by the volume of a local anesthetic.
5. Avoid the temptation to prick above L1! Although median access at T10-T12 levels is much easier than at the mid-thoracic level (the spinous processes do not overlap each other), the lower thoracic (between T9 and 772) epidural puncture causes a solid puncture
shell than between TZN T7 \ RMGiebleretal., 1997]. 6. Puncture at the lumbar level (between L2 and L5) and a volume of 20 ml of anesthetic standard concentration (2% lidocaine or 0.5 % bupivacaine) will provide even the largest patient with sufficient anesthesia for almost all abdominal operations (for the lower limbs and perineum). may be enough smaller volume). Very old and weakened patients require even smaller volumes (up to 16 ml, and
lower limbs — up to 10 ml).
7. Motoneurons of intercostal muscles and the first sympathetic neurons
The nervous system is located in the thoracic region. With the upper border of the anesthesia — before the navel ( T10), pressure reduction and respiratory disorders will be minimal, and with the upper boundary of the anesthesia — before the pubis (L1) there may be no such violations at all. Avoid too high anesthesia during operations on the perineum and lower limbs.
8. “No vein , on the block!” – no blockades without a vein! —This rule is especially important for epidural anesthesia. Even at its lowest level, cannulate the vein, put a dropper, have solutions for infusions and sympathomimetics ready.
9. Planning an epidural anesthesia ^ o, prepare for an intubation. Then you can not be afraid of either the worst complications, or unsuccessful anesthesia, or the expansion of the volume of the operation.
10. It is better to do the first epidural punctures with a midway patient, in the patient’s sitting posture. In the initial stages, it will be difficult for you to ensure that the needle moves all the time in the patient’s sagittal plane.
And In the lateral pose, at first it is difficult to determine the sagittal plane. Either it is necessary to ensure that the back is exactly perpendicular to the table, or when moving the needle it is necessary to make allowance for the deviation of the back from the vertical.
- Having passed the needle through the suprastate ligament, release it (remove your hands) and see if the needle remains in the sagittal plane. If not – it will not come out in the middle, no matter what you do. Pull the needle tip to the exit of the supraspastic ligament, slide it forward, and then let it go and check again.
- Do not use force — you will not pierce anyway, and the needle or periosteum of the arms can be damaged.
- Do not add mezaton to solutions of local anesthetics. It prolongs well the action of spinal anesthesia, while the general resorptive effect of even 0.3 ml of 1% mesatone is negligible due to the insignificant vascularization of the subarachnoid space. But the epidural space is very vascularized, and the introduction of even mezaton drops into it can lead to a hypertensive crisis, and in elderly patients even to a stroke.
- Adding of adrenaline in the minimum amount (1: 200.000) to the solution of a local anesthetic, on the contrary, provides several advantages: acceleration, deepening and prolongation of anesthesia, less risk of intoxication, etc.
- Introduction of a test dose (3 ml) of a local anesthetic is necessary to detect signs of subarachnoid administration (warming, numbness and weakness in the legs) and signs of intravasal administration of local anesthetic (numbness of the lips or tongue, metallic taste in the mouth, tinnitus, dizziness). ) or adrenaline (tachycardia, arterial hypertension).
- The main dose should be administered slowly, better — by maintaining speech contact with the patient: then the possibility of both mosaic and too high epidural block, total spinal anesthesia, and intoxication from intravasal administration will be less.