A RANDOMIZED STUDY COMPARING CEPHALAD, CAUDAD AND LATERAL ORIENTATION OF SPINAL

NEEDLE IN THE SPREAD OF SPINAL BUPIVACAINE HEAVY DURING SUBARACHNOID BLOCK IN

PARTURIENT PATIENTS WHO WILL UNDERGO CEASAREN SECTION IN REGION 1 MEDICAL CENTER

AMY D. SORIANO, MD
DEPARTMENT OF ANESTHESIOLOGY
REGION 1 MEDICAL CENTER
DAGUPAN CITY

Introduction

Subarachnoid Injection is an established method of providing anesthesia for patients undergoing

caesarean section.1 It is not uncommon to observe resident anesthesiologists performing the

subarachnoid block to rotate the spinal needle (after obtaining CSF flow) such that the bevel faces

cephalad .3 Variables capable of influencing the spread of sensory blockade following injection of local

anesthetic in the term parturient are not well defined.2 Of the several factors that determine the spread

of local anesthetic (LA) solutions in the cerebrospinal fluid (CSF), the direction in which the bevel of the

lumbar puncture needle faces is one such factor.3

Significance of the Study

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. The great inter-

patient variability in spread was observed and described as ‘lauenhaft’ (waywardness) by August Bier,

the first person to use the technique clinically, and has challenged many subsequent workers. 4

Many factors are said to affect the mechanism of drug spread. These include the physical characteristics

of CSF and the solution injected, the clinical technique used and the patient's general features.4

Among these it has been suggested that direction of spinal needle aperture may be important.5

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Objectives
Among these, it has been suggested that the direction

1. This study aims to determine the effect of direction of the spinal needle aperture(Quincke) on

the spread of hyperbaric bupivacaine during subarachnoid block in parturient patients

2. To determine whether the cephalad, caudad or lateral orientation of the spinal needle aperture

will affect the onset and height of block.

Methodology

1. This study is subject for approval from Institutional Review Board.

2. A written and signed consent will be facilitated from all subjects who will participate in the

study.

3. Patients will be randomly allocated into one of the three groups: (I) cephalad orifice group,

(II) lateral group or (III) caudad orifice group.

4. Inclusion Criteria

a. Singleton Term parturient patients who belong to the age group 21-30.

b. Patients who will undergo low transverse caesarean section secondary to cephalopelvic

disproportion.

c. ASA Classification II due to pregnancy only

5. Exclusion criteria6

a. Patients who have a documented allergy to bupivacaine

b. Patient with a body weight exceeding the 20 kg when compared with the body

weight before pregnancy

c. Parturient patients with non-reassuring fetal status

d. Subjects with pre- or eclampsia, hypertension, diabetes, in vitrofertilization

e. ASA physical status of more than II.

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 f. Subjects with central or peripheral nervous system disease

6. Conduct of Anesthesia

a. After informed consent has been obtained, demographic data which include age,

weight, ASA II physical class will be collected and recorded in a data collection sheet.

b. In the operating room, patient will be hooked to O2 at 2-3 lpm via nasal cannula, non-

invasive bp cuff, pulse oximeter, ecg. .

c. Subjects will be prehydrated with a 10cc/kg of plain lactated ringer’s solution. Anxiolytic

medication midazolam of 1mg IV will be given prior to lumbar puncture. She will be

placed on a left lateral decubitus position; the subject’s back is examined and cleansed

with a povidone iodine. Sterile drape is applied and the skin is infiltrated with 1-2ml of

2% lidocaine to provide anesthesia between L4-L5 interspace. Once skin anesthesia is

established , a 25 gauge needle (Quincke) is inserted and advanced until clear csf flows

with good barbotage and no paresthesia noted. After which, the needle will be oriented

to cephalad, lateral and caudad as determined by the random group assignment. A local

anesthetic agent bupivacaine 0.5% heavy with 8% dextrose at a dose of 12mg is injected

at a rate of 0.5ml/sec. The spinal needle and syringe will then be removed and patient

will be placed back to supine flat position.

d. The time of induction will be recorded on the collection data sheet. BP, ECG, O2

saturation will be recorded immediately following induction and every 3 minutes within

20 minutes and every 5 minutes thereafter during operation.

e. Sensory anesthesia is determined by pin prick using a needle. This assessment will be

performed and is recorded by an observer who is blinded to the direction of needle

aperture immediately after induction and every 2 minutes until T4 is reached within 20

minutes.

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 f. Motor blockade will be assessed immediately after induction according to Bromage

scale (Table 3) and every 3 minutes within 20 minutes and every 5 minutes thereafter

during operation.

g. All subjects will be monitored for hypotension, bradycardia, nausea, vomiting, anxiety

and pain throughout the procedure.

i. Ephedrine 5-10mg IV will be given once systolic BP decreased by 20% from the

baseline occurs. Atropine 0.5mg IV may also be given for bradycardia and

midazolam 1-2mg IV as needed for anxiety. Metoclopramide 10 mg IV is given if

necessary for nausea and vomiting and Nalbuphine 5mg IV for pain

management.

7. Statistical Analysis of Data

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Results

Group I Group II GroupIII

Cephalad Lateral Caudad
Age (yr)
Weight(Kg)
Height(ft)
Table 1: Demographic data and variables

Time (min) Group I Group II Group III

Cephalad Lateral Caudad
0(baseline)
2
4
6
8
10
12
14
16
18
20
Table 2: Average sensory levels at 0, 2, 4, 6, 8, 10 and 20 minutes following spinal anesthetic induction

Time (min) Group I Group II Group III

Cephalad Lateral Caudad
0(baseline)
2
4
6
8
10
12
14
16
18
20

Table 3: Average motor blockade levels at 0, 2, 4, 6, 8, 10 and 20 minutes following spinal anesthetic
induction

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4 Full flexion of knees and feet
3 Just able to flex knees, full flexion of feet still possible
2 Unable to flex knees, full flexion of feet possible
1 Unable to move legs or feet

Table 4: Bromage Scale for Motor Blockade

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References

1. Kestin IG. Spinal anesthesia im obstetrics. Br J Anaesth 1991; 66: 596-607

2. Halpern S, Preston R. Postdural puncture headache and spinal needle design. Metaanalyses.
Anesthesiology 1994; 81:1376-83
3. Gupta D. Subarachnoid space needle manipulations for successful block. J Anaesthesiol Clin
Pharmacol 2014;30:444-6.
4. G. Hocking J. A. W. Wildsmith Intrathecal drug spread BJA: British Journal of Anaesthesia,
Volume 93, Issue 4, 1 October 2004, Pages 568–578
5. Edith Masse, Pierre Drolet, Michel Girard Direction of injection does not affect the spread of
spinal bupivacaine in parturients Can J ANaeth 1997;44:8 816-819
6. Wofford, Kelly The Effect of Pencan Needle Orientation on Spinal Anesthesia Outcomes AANA
Journal April 2005/Vol.73 No.2

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Research Time Table

DATE
Basic lecture and workshop on June 2017 +
Research writing
Approval of research topic/title June 2018
Research protocol 1st draft July 2018
Research protocol 2nd draft August 2018
IRB approval August 2018
Collection of data August 2018- February 2019
Consolidation and statistical March – July 2019
analysis of data
1st draft of research paper August 2019
2nd draft of research paper September 2019
Final draft December 2019
Research presentation and defense