Regional Spinal Anesthetic

Which is safer Spinal or General Anesthesia?

This is like asking which is better: a train or a bus? Both are forms of transportation and both will take you to your destination but it may be better to use one over the other sometimes.Spinal anaesthetics are particularly useful for procedures below the diaphragm - caesarian sections, transurethral prostatectomies, hip, knee and ankle surgery.Safety- wise, I can provide the figures I use when I speak to patients.Spinal anaesthesia carries a slight risk of a headache afterwards if there is a persistent CSF leak. There is around a 1:30000 risk of nerve damage. This could be permanent or temporary. This figure reflects something like a numb patch of skin or muscle weakness. The risk of paraplegia is about 1:250000. Happily such events are extremely rare and the figures for risks are extrapolated from large data sets. We lnow these events are rare as when they occur news travels rapidly throughout the anaesthetic community.With a GA the risks are similar but the risks are different. For example there is a risk of aspiration or difficult intubation with GA which is unlikely to be a consideration with neutraxial anaesthesia. (Nerve damage is unlikely with a GA).The most recent data on anaesthesia-related mortality in Australia 2005-2008 states that the risk of death is approximately 1:55000. This number hasn't changed much over the years but it is important to note that we cancel less patients now and we are providing care to older and sicker people.Anaesthesia is incredibly safe. It is safer than being a passenger or the driver of a vehicle.Both regional anesthesia and general anaesthesia carry risks, everything does. The likelihood of something bad happening is dependent on what the surgery is (urgent or elective? Major or minor?) and the underlying health of he patient.

Before a cesarean, a spinal regional anesthetic was administered. Is it negligence to operate without checking if the anesthetic has taken effect?

I’m not sure what the legal definition of “negligence” is. Certainly, the anesthesiologist should know whether the spinal has worked or not before the surgeon makes incision.There are plenty of ways to check this, most of which will not be noticed by the patient or other people in the operating room. For example, in the middle of the injection, and again at the end, I aspirate on the needle to assure free flow of CSF. No one but me sees this, but it confirms for me that the medication gets in the right spot. Once i see this, I am certain that the spinal will work. Next, as the nurses are prepping the patient, I will start to see the effects of the spinal. It causes a sympathectomy, which will cause the patient’s blood pressure to go down. I will also note the patient’s response to the sterile prep solution. If the spinal isn’t working, she will say it’s cold. If it is, then she won’t mention anything. At this point, I may ask the patient to wiggle her toes, or lift her leg.If there is any question about the spinal working, I will ask the surgeon to test the block by pinching the patient with a clamp before making incision. If the patient doesn’t scream, they are fine. Interestingly, all the OB/Gyn’s where I work do this without me prompting them too. So they feel they are also responsible to assure adequate anesthesia before starting surgery.So, in conclusion, the anesthesiologist is always checking to make sure the block is working, whether you realize it or not. To not realize the block has failed, and have the patient be in pain after incision, is poor practice. I don’t know if it qualifies as negligence.

What anesthetic (spinal or general) is safer if you’re overweight?

I would usually prefer to give a spinal anesthetic to an overweight patient, assuming the surgery was appropriate and there were no contraindications such as the use of blood thinners.Pretty much all surgery and all types of anesthesia are harder in overweight patients.It may be more difficult to find the right spot for the spinal injection but the worst case is that it is impossible to do a spinal and you convert to a GA.With a GA, maintaining an open airway and endotracheal intubation are more difficult. The most extreme and rare outcome is CVCI — Can’t intubate, can’t ventilate — which is fatal if it is not resolved within a few minutes, for example by creating a surgical airway. This is also more difficult in obese patients.One reason why I prefer to work in Canada rather than the USA is fewer really obese patients.

Can spinal anesthesia lead to death?

The way you ask the question the answer would have to be yes.The same answer would be valid if you substituted “spinal Anesthesia” with “taking two aspirins” or “going out for a walk in the neighborhood” and many other “fill in the blanks”Spinal anesthesia as compared to general anesthesia is safer bu less safe than local infiltration.IMO Transient drop in BP after a spinal is mostly a nuisance side effect but don’t pay attention to me ask your anesthesiologist.And please don’t phrase the question the way one of my patients did.She asked a very pragmatic anesthesiologist “Doctor what is the worse that can happen?”He calmly answered “You may die” and continued monitoring her vital signs.If I wasn’t scrubbed it would have been a Face Palm moment.

How many anesthesia doctors will give spinal anesthesia on patients taking clopidogrel?

Almost everything in Anesthesia decision-making comes down to a risk/benefit ratio, as well as the understanding of elective versus urgent situations.There is always a risk of epidural bleeding when performing a spinal or epidural, but even more so when there is anti-coagulation present.I have to admit I am not so fearful of an epidural hematoma forming from venous bleeding, as thousands of providers give an epidural blood patch every year, which is literaly pushing 15-20 mls of blood under pressure into the epidural space. However, I do follow the national guidelines and recommendations, and an elective spinal injection would be avoided.Additionally, an expertly placed small gauge spinal needle is unlikely to cause bleeding, especially in a non-pregnant person.Having said that, if there was an urgent need for a procedure, say an amputation in the lower extremity, and the patient had really bad cardiac or pulmonary disease, such that a general anesthetic was very high risk, then that would be a good argument to provide a spinal anesthetic even if there was therapeutic clopidogrel.Obviously, the risks and benefits are thoroughly vetted by the Surgeon and the Anesthesiologist, and the patient is engaged in that discussion.

I got inguinal hernia. Should I choose spinal anesthesia or general anesthesia?

Most hernia surgeries are done on an outpatient basis. This means patients need to be street ready in a few hours after recovery. In my experience spinal anesthesia works wonderfully but is associated with urinary retention problems. This is particularly a problem in young men who make up the majority of hernia patients. For this reason we have abandoned spinal anesthesia in outpatient surgeries.General anesthesia has the advantage of being rapid but upon awakening the pain is an immediate issue and nausea not an infrequent problem.A better option in my opinion is regional anesthesia combined with heavy sedation or light general anesthesia with a laryngeal mask airway. An ilioinguinal/iliohypogastric nerve block takes out the nerves that supply the area. It is a single injection that can be accomplished by any trained monkey including the surgeon. Sedation makes it easier to lie still and makes the block easy to tolerate.The biggest benefit of a combined regional and sedation is that depending on the type of local anesthetic used the patient can be kept comfortable for 8 to 48 hours with minimal narcotic used.This is what we have gone to in our institution and staff and patients seem pleased with the results. Cheers!