Test Out: Spinals

1. Patient Review

  • Choose appropriate anesthetic plan: Epidural, spinal, or combined epidural-spinal anesthesia.

  • Review H/P

    • Make sure anticoagulation therapy held for appropriate amount of time

    • Check platelet count >85-100k (which can lead to spinal hematoma that then compresses the spinal cord)

    • Other contraindications: infection at site of insertion, severe aortic stenosis, DIC, hemodynamic instability

  • Get consent for the procedure and general anesthesia

    • Possible risks: backache, PDPH, spinal hematoma, intrathecal/intravascular injection, conversion to general if patchy/not effective

2. Equipment Check

  • Basic machine check with positive pressure check and SCOMMLADIE********

  • Emergency drugs ready: 10 mg ephedrine and 100 mcg phenylephrine

    • ephedrine for hypotension AND bradycardia, or phenylephrine for hypotension AND tachycardia

  • 1 L IVF bolus in progress within 15 minutes of procedure start (preloads the patient to prevent spinal induced hypotension)

3. Pt Assessment*****************************

  • Put on EKG, Blood Pressure, and Pulse Ox to get baseline vital signs.

  • Administer O2 and sedation PRN

4. Positioning and Preparation

  • Set bed height to a comfortable working level.

  • Position the patient with their butt as close to the edge/you as possible, forming a “C” position with neck flexed forward, shoulders relaxed/dropped, lumbar spine pushed out towards you, and iliac crests parallel to the shoulders

  • Palpate the superior iliac crests (hip bones) that create Tuffier’s Line.

    • Parallel thumbs should meet to join at the L4 vertebrae, so now walk over it to feel the L3-L4 interspace

    • Be cautious marking the skin, as skin can move while vertebrae do not (false image)

    • If more obese, skin folds can form a divet that guides you to were to insert your needle

  • Ensure everyone is wearing a mask and scrub cap

5. Preparation of Equipment

  • Place the tray on your dominant side and open it

  • Don sterile gloves

  • Open the betadine/chloroprep cleaning solution

    • Chloroprep works by friction

    • Betadine works by drying

      • **Go from inner to outer circle, with handle pointed down to prevent dripping of the chloroprep/betadine onto your gloves, which could cause neurotoxicity if introduced into the spine

  • Drape the back

6. Kit Preparation

  • While cleaning solution dries, prepare your kit supplies in a sequential manner:

    1. Draw up 3 mL 1% Lidocaine with a filter needle in the 3 mL syringe; then switch out to the smallest 22 G needle. Loosen the cap.

    2. Inspect the spinal needle to confirm the stylet is in place and loosen the cap. It is commonly a Whitacre pencil-point (blunt tip, non-cutting) needle to prevent postdural puncture headache.

      1. NOT a Quincke, which is a cutting needle and has high incidence of postdural puncture headache.

    3. Draw up the LA with a filter needle into the largest syringe.

      1. For this specific kit, you will use 0.75% bupivacaine in 8% dextrose, which means it is hyperbaric and will sink down based on position.

      2. We are choosing this LA d/t duration of action (90-180 minutes)

      3. Draw up the appropriate amount of mLs (from math chart)

      4. Add adjuvents as deemed appropriate (e.g., bicarb, epi, precedex, or opioids)

      5. No needle attached.

7. Procedure

  • Blot any excess betadine with a sterile 4x4 gauze (no wiping needed for chloroprep).

  • Using the nondominant hand (over the sterile drape), palpate the iliac crest and reconfirm desired site (L3-4 interspace).

  • Maintain placement by keeping two fingers or a thumb at the confirmed spot.

  • Warn the patient, and then inject the small 3 mL syringe immediately superior to your finger marker and make a good skin wheal in all planes; insert it deeper to function as a seeker needle to confirm you are in the interspace (not meeting bone).

    • Remove but keep the finger marker in place

  • Instruct the patient to communicate any sensations of paresthesias (electrical shock feeling) and immediately stop if encountered

  • They may now feel pressure, but it should noy be sharp pain d/t the numbing of previous lidocaine syringe. Into the previously created hole, insert the spinal needle with the bevel facing up and slightly angled cephalad.

  • You will go through the supraspinous ligament, interspinous ligament, ligamentum flavum, until dura is penetrated, indicated by a “pop” sensation (you should now be in the subarachnoid space).

8. CSF Confirmation and LA

  • Withdraw the stylet and observe for free flow CSF

    • If it does not happen, try rotating the needle 90 degrees, re-inserting the stylet and advancing further, or re-attempting at another level

  • Attach the LA syringe to the spinal needle hub and aspirate 0.1-0.2 mL of CSF into the syringe

  • Continue injecting at 0.5 mL/sec, aspirating again halfway and at the end to remain sure you are in the correct space

  • Remove as one unit (including attached syringe)

9. Patient Positioning

  • Quickly maneuver the patient into the proper position for the necessary block/level

  • Check developing level with alcohol swab first at shoulder for comparison, then toes up until desired level is properly blocked

    • autonomic loss first (hypotension, warmth through blocking of B fibers), then sensory (decreased touch/pain through blocking of C/A-delta fibers), then motor/proprioception (through blocking of A-alpha fibers)

10. Safety

  • Continue monitoring VSS and maintain CV/airway

  • Monitor for symptoms of high spinal block:

    • Includes excess sensory and motor block associated with loss of consciousness, typically occurring within 3 minutes post-local anesthetic injection.

    • Treatment:

      • Initially position patient in a head-down position or flex neck.

      • If symptoms persist, prioritize airway maintenance, possibly requiring intubation, and support circulation with sympathomimetics and IVFs

  • Provide sedation PRN