BJA Advance Access originally published online on June 25, 2004
British Journal of Anaesthesia 2004 93(4):568-578; doi:10.1093/bja/aeh204
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© The Board of Management and Trustees of the British Journal of Anaesthesia 2004
Intrathecal drug spread
University Department of Anaesthesia, Ninewells Hospital and Medical School, Dundee, DD1 9SY, Scotland, UK
* Corresponding author: Nuffield Department of Anaesthesia, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, UK. Email: ghocking@doctors.org.uk
Keywords: anaesthetic techniques, regional; anaesthetic techniques, subarachnoid, intrathecal
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Introduction |
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Spinal anaesthesia has the definitive advantage that profound nerve block can be produced in a large part of the body by the relatively simple injection of a small amount of local anaesthetic. However, the greatest challenge of the technique is to control the spread of that local anaesthetic through the cerebrospinal fluid (CSF), to provide block that is adequate (in both extent and degree) for the proposed surgery but without producing unnecessarily extensive spread and so increasing the risk of complications. The great interpatient variability in spread was observed and described as ‘lauenhaft’ (waywardness) by August Bier,10 the first person to use the technique clinically, and has challenged many subsequent workers. In fact, the definitive studies were performed nearly 100 years ago by Arthur Barker, a London surgeon who was the first to use solutions made hyperbaric by the addition of glucose,7 but his principles have had to be re-learned
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General considerations |
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Assessment of intrathecal drug spread
Afferent function
Efferent function
Routine methods
Mechanisms of drug spread
CSF characteristics
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Factors affecting intrathecal spread |
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Characteristics of the injected solution
Baricity
Volume/dose/concentration injected
Temperature of the solution
Viscosity
Local anaesthetic drugs and additives
Clinical technique
Patient position
Level of injection
Needle type and alignment
Intrathecal catheters
Fluid currents
Epidural injection
Patient characteristics
Age
Height
Weight
Sex
Intra-abdominal pressure
Spinal anatomy
Lumbosacral CSF volume
Pregnancy
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Summary |
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