Spinal anesthesia

Spinal anesthesia lends itself for procedures below T9-10 (about the level of the umbilicus). The planned procedure should not last more than three hours at most. Patients perceive extended periods of time on the OR table as uncomfortable.

1. Indications

Typical indications for spinal anesthesia include:

  • Fracture treatment of the lower extremities, knee and hip arthroplasty
  • Inguinal hernia
  • Perineal surgery
  • Transurethral resection
  • Cesarean section

2. Contraindications

  • Patient refusal
  • Coagulation disorders
  • Lack of communication with the patient
  • Infection at puncture site
  • Certain neurologic disorders

3. Required

  • Detailed informed consent discussion
  • Physical examination and history
  • Patient informed consent not only for the regional anesthesia, but also general anesthesia in case of complications or if spinal anesthesia fails
  • Moderately dosed premedication ordered by anesthesiologist. The patients should not be sedated too much because they still must sit.

4. Workflow description

  • Upon transfer check patient identity and the planned procedure (patient file, informed consent documents)
  • Attach monitor leads for: ECG, NIBP, pulse oximetry
  • IV access and infusion
  • Document baseline measurements in anesthesia record
  • Prepare induction medication and materials for ventilation for possible emergency situations (e.g., extreme cardiovascular reaction, total spinal anesthesia)
  • Ready atropine and theodrenalin
  • Position patient sitting on OR table
  • Check lab panel, particularly INR, pTT and platelet count, WBC and CRP
  • Support sitting patient with hanging shoulders
  • Thoroughly prep the skin with disinfectant (single-shot contact time of 60 seconds is sufficient, no wiping, the skin must be wetted)
  • The anesthesiologist wears face mask and scrub cap
  • Thoroughly disinfect hands (contact time at least 30 seconds)
  • Sterile draping with fenestrated drape
  • Local anesthesia with 1-3 mL local anesthetic (e.g., scandicaine 1%)
  • Puncture spinal canal with 24G Sprotte cannula and introducer
  • Check CSF reflux for any blood
  • Record any paresthesia
  • Slowly inject local anesthetic (e.g., isobaric or hyperbaric 0.5 % carbostesin, hyperbaric 4% scandicaine) into the subarachnoid space without barbotage
  • Withdraw spinal cannula
  • Apply sterile adhesive
  • Position patient supine on OR table
  • Transport patient into OR
  • Check spread of anesthesia
  • Elevate upper body of patient, if needed
  • Avoid patient hypothermia
  • Document the procedure in the anesthesia record and the vital signs after spinal anesthesia has been performed
  • Release patient to OR team

5. Intraoperative monitoring

  • Single-channel ECG
  • NIBP
  • Pulse oximetry
  • Vigilance
  • Spread of spinal anesthesia

6. Hand over to recovery room

  • Patients are monitored in the recovery room until their spinal anesthesia begins to wear off (e.g., fading motor block).
  • Regular check of vital signs
  • Postoperative analgesia, e.g., with 1 g metamizole p.o.
  • Upon transfer to the ward patients may eat and drink without restriction, except in PONV
  • Ambulation is permitted once motor and sensory block have lapsed completely
  • Initial ambulation only aided by the nursing staff
  • Inform patient of possible post-spinal headache
  • Point out possible micturition disorders

Author: Prof.C. Diefenbach, MD

Head, Department of Anesthesiology and Surgical Intensive Care

St. Katharinen-Hospital Frechen GmbH, Germany