Regional Anaesthesia & Spinal/Epidural Nursing

Benefits of Regional Anaesthesia

Avoids general anaesthesia — reduced airway risk
Reduced PONV — post-operative nausea & vomiting
Superior analgesia — targeted pain relief at surgical site
Earlier mobilisation — faster rehabilitation
Reduces opioid use — fewer opioid-related side effects
Reduced blood loss in some surgeries (e.g. hip arthroplasty)
Faster discharge in day-case settings
Improved outcome in high-risk cardiorespiratory patients

Neuraxial vs Peripheral Regional Blocks

Feature	Neuraxial	Peripheral
Technique	Spinal / Epidural	Nerve/plexus blocks
Coverage	Bilateral, wide dermatomal	Unilateral/focal
Haemodynamic effect	Significant (sympathectomy)	Minimal
Motor block	Bilateral legs	Target limb only
Anticoagulant concern	High (haematoma risk)	Lower (compressible)
Guidance	Landmark/surface anatomy	Ultrasound preferred

Anatomical Landmarks — Vertebral Levels

Prominent spinous process (vertebra prominens)

Nipple line (male) / sternal angle area

Xiphisternum

T10

Umbilicus

Inguinal ligament / groin crease

Iliac crest — Tuffier's Line

S3–S5

Perineum / saddle region

Tuffier's Line: Imaginary line joining the iliac crests crosses at approximately L4 vertebral body (or L4/L5 interspace). Used to identify the safe spinal injection level (below conus at L1-L2 in adults).

Dermatome Map — Clinical Reference

Level	Landmark	Clinical Relevance
T1	Inner arm / axilla	Upper limit — causes phrenic nerve risk if blocked
T4	Nipples	Required for upper abdominal surgery
T6	Xiphisternum	Required for lower abdominal/LSCS (minimum)
T10	Umbilicus	Required for Caesarean section (cold spray test)
L1	Groin	Inguinal hernia level
L4/L5	Knee/shin	Knee surgery level
S1–S3	Perineum / foot	Perineal/foot surgery; saddle block

Absolute Contraindications

Patient refusal (informed consent not obtained)
Localised infection at injection site
Coagulopathy — INR >1.5 or platelets <80 ×10⁹/L
Anticoagulant within unsafe window (see Tab 3)
Clinically significant hypovolaemia (relative in some centres)

Relative Contraindications

Systemic sepsis / bacteraemia
Spinal deformity (severe scoliosis, previous spinal fusion)
Raised intracranial pressure (risk of coning — dural puncture)
Severe aortic stenosis (cannot compensate for vasodilation)
Fixed cardiac output states
Patient unable to cooperate / communicate
Neurological disease (document pre-existing deficits)

Patient Positioning

Sitting Position

Patient seated on table edge, feet on stool
Arms folded, chin to chest, lumbar flexion maximised
Best for obese patients — identifies midline more easily
Assistant faces patient to support and monitor
Saddle blocks: patient remains sitting 5–10 min post-injection

Lateral Decubitus Position

Patient lying on side, knees to chest, chin flexed
Preferred in sedated or anxious patients
May be preferred for hip fractures (less pain)
Ensure level position on table — affects baricity spread

CSF Identification & Technique

Identify L3/L4 or L4/L5 interspace (below conus medullaris at L1–L2)

Aseptic technique: sterile field, chlorhexidine skin preparation

Skin LA infiltration with 1% lidocaine

Insert spinal needle (25G pencil-point preferred) bevel/opening cephalad

CSF free-flow confirms intrathecal placement — clear, colourless fluid

Inject drug slowly, aspirate to confirm CSF before and after injection

Bloody tap: if blood-stained CSF — withdraw needle, attempt different level. Blood in CSF may indicate epidural vessel trauma or subarachnoid haemorrhage.

Hyperbaric Bupivacaine — Baricity & Spread

Baricity Explained

Hyperbaric: denser than CSF (bupivacaine 0.5% + 8% dextrose) — sinks with gravity
Isobaric: same density as CSF — minimal positional spread
Hypobaric: less dense — rises against gravity (rare use)

Clinical Implications

Trendelenburg: hyperbaric drug spreads cephalad
Reverse Trendelenburg: block stays low
Position CRITICAL in first 20 minutes before drug fixes
Barbotage (aspirating CSF and reinjecting): increases spread but also risk

Typical Doses — Hyperbaric Bupivacaine 0.5%

Surgery	Volume	Target Level
LSCS / lower abdominal	2.0–2.5 mL	T6
Upper abdominal	2.5–3.0 mL	T4
Hip / knee	2.0–2.5 mL	T10–L1
Perineal (saddle)	1.0–1.5 mL	S2–S5
TUR prostate	2.0 mL	T10

Block Height Assessment

Method: Ice / Cold Spray Test

Apply ice or cold spray starting at lowest dermatome

Move cephalad until patient reports reduced cold sensation

Identify highest blocked dermatome using landmarks

Confirm bilateral symmetry of block

Adequacy Criteria

T4: Upper abdominal surgery — assess sensation to nipple level
T6: Lower abdominal / LSCS minimum safe level
T10: Pelvic / TURP / knee surgery
Above T2: High block warning — respiratory risk

Onset & Duration

Drug	Onset	Duration
Bupivacaine 0.5% hyp.	5–15 min	2–3 h
Levobupivacaine	5–15 min	2–3 h
Lidocaine (spinal)	3–5 min	1–1.5 h
Tetracaine	5–10 min	2–4 h

Intrathecal Opioid Additives

Intrathecal morphine 0.1–0.2 mg — 24h analgesia
Risk: respiratory depression (delayed — 12–18h post-op)
Requires 24h respiratory monitoring (RR, SpO2)
Fentanyl 10–25 mcg: faster onset, shorter duration, less respiratory risk
Diamorphine 0.3–0.4 mg (UK centres): good post-op analgesia

Saddle Block

Used for perineal surgery: haemorrhoidectomy, cystoscopy, perineal repairs
Patient remains seated for 5–10 minutes after injection
Hyperbaric LA pools in sacral (S2–S5) and lower lumbar roots
Small volume (1.0–1.5 mL hyperbaric bupivacaine) gives restricted block
Haemodynamic stability is excellent — minimal sympathectomy
Then patient can be repositioned (lithotomy) for surgery

Loss of Resistance Technique

Air vs Saline

Method	Advantages	Disadvantages
Saline (preferred)	Identifies space reliably; reduces patchy/uneven block	May dilute LA slightly
Air	Easy to see loss of resistance	Pneumocephalus risk; patchy block; never use in obstetrics

Epidural Space Characteristics

Depth from skin: typically 4–6 cm in adults (range 3–8 cm)
Deeper in obese patients (up to 8+ cm)
Contains fat, vessels, and nerve roots; negative pressure
Hanging drop technique: drop of saline aspirated into needle on entry

Catheter Management

Threading the Catheter

Thread catheter 3–5 cm into epidural space (not more — coiling risk)

Withdraw needle while holding catheter firmly

Aspirate — blood = intravascular; CSF = dural puncture

Administer test dose before full dose

Test Dose Protocol

Lidocaine 45 mg + adrenaline 15 mcg (3 mL of 1.5% lidocaine + 1:200,000 adrenaline)
Heart rate rise >20 bpm within 1 min = intravascular placement
Dense motor block within 3 min = subarachnoid placement (total spinal risk)
Wait 5 minutes before proceeding with full epidural dose

Epidural Infusion Management

Standard Infusion

Bupivacaine 0.1% + Fentanyl 2 mcg/mL
Infusion rate: 6–14 mL/h (titrate to pain score)
PCEA (Patient Controlled): bolus 5–10 mL + background 4–8 mL/h, lockout 20–30 min
Higher concentration (0.25%) for surgical anaesthesia top-up

Surgical Top-Up

For surgical anaesthesia: bupivacaine 0.5% in 3–5 mL aliquots
Always aspirate before each top-up
Allow 5 min between increments — monitor BP and block height
Typical surgical dose: 15–25 mL total

Nursing Monitoring Checklist

BP every 5 min for 20 min after top-up, then every 30 min
Block height (cold spray) — ensure adequate and not rising
Bromage motor score — mobility and safety
Catheter site — check for displacement, leaking, infection
Pain score (0–10 NRS) and side effects (nausea, pruritus)
Urinary output — catheterisation usually required
Respiratory rate and SpO2 if opioid in infusion

Catheter Removal & Anticoagulant-Free Windows

Drug	Before Insertion	Before Removal	After Procedure
LMWH (prophylactic)	12 h	12 h	4–6 h after
LMWH (therapeutic)	24 h	24 h	4–6 h after
UFH (IV)	4–6 h (check APTT)	4–6 h	1–2 h after
Warfarin	INR <1.5 (stop 5 days)	INR <1.5	Resume when haemostasis confirmed
Rivaroxaban (DOACs)	22–26 h (CrCl>30)	22–26 h	6 h after
Apixaban	26–30 h (CrCl>30)	26–30 h	6 h after
Dabigatran	72–96 h (CrCl<80)	72 h	6 h after
Aspirin alone	No restriction	No restriction	Continue
Clopidogrel	7 days	7 days	Resume after haemostasis

Based on ESRA (European Society of Regional Anaesthesia) guidelines. Always check local protocol and patient's renal function. GCC hospitals increasingly follow these guidelines. Anticoagulant bridging is common in GCC due to high AF prevalence, mechanical heart valves, and DVT history.

Wet tap: Tuohy needle accidentally enters subarachnoid space — CSF flows freely
Incidence: 0.5–2% of epidural attempts
Immediate management: Inform patient; document; consider intrathecal catheter or re-site at different level
PDT Prophylaxis: Epidural morphine (3 mg) or saline (30–60 mL) may reduce PDPH risk
PDPH develops in 50–80% of unintentional dural punctures with 16G Tuohy needle
Refer to blood patch section in Complications tab
Document size of needle, number of attempts, and inform senior anaesthetist

Hypotension (Most Common Complication)

Cause: Sympathetic blockade → vasodilation below block level
Incidence: 15–33% with spinal; higher in elderly/LSCS
Definition: Systolic BP <100 mmHg or >20% fall from baseline

Management

Crystalloid co-load: 500–1000 mL warmed saline at time of block
Vasopressors:
- Phenylephrine (pure alpha): 50–100 mcg IV bolus — preferred in obstetrics (maintains uteroplacental blood flow)
- Ephedrine (alpha + beta): 6–12 mg IV bolus — use if bradycardia present
- Noradrenaline infusion for refractory hypotension
Left lateral tilt in pregnant patients (aortocaval decompression)
Leg elevation (passive leg raise) — caution: may raise block

High Block & Total Spinal

High Block (T2 or above)

Dyspnoea, anxiety, weak arms, nausea
Nurse action: call anaesthetist immediately
Trendelenburg position — use with caution (raises block further)
Supplemental O₂, reassure patient, monitor BP/RR/SpO2
Prepare for PPV (bag-mask) if respiratory compromise develops

Total Spinal (Emergency)

Signs: unconsciousness, apnoea, cardiovascular collapse
Cause: LA reaches brainstem via CSF
Action: call crash team, RSI intubation, ACLS support
Vasopressors: adrenaline for cardiovascular collapse
Outcome: usually good with prompt management

Post-Dural Puncture Headache (PDPH)

Clinical Features of PDPH

Positional: worse on sitting/standing, better lying flat
Bilateral, occipital or frontal, severe (8–10/10)
Associated: neck stiffness, photophobia, tinnitus, diplopia
Onset: typically 12–48 h after dural puncture
Risk factors: young female, obstetric, large needle (Tuohy > spinal), cutting needle > pencil-point

Conservative Management (24–48 h trial)

Bed rest (lying flat relieves symptoms)
Adequate hydration (oral + IV)
Paracetamol 1g QID + NSAIDs
Caffeine 300 mg oral or IV (evidence limited)
Cosyntropin (ACTH) — emerging evidence

Epidural Blood Patch (EBP)

Gold standard treatment for persistent PDPH
Timing: offer after 24–48 h if conservative measures fail
Earlier EBP has lower success rate (40–60% vs 85–95%)
Procedure: 15–20 mL autologous blood injected epidurally at same level
Stop if patient feels back pressure/pain during injection
Keep supine for 1–2 hours post-procedure
Second EBP if first fails (repeat after 48 h)

Nursing Role

Assess and document headache characteristics (positional nature)
Distinguish from other causes (meningitis — fever, rash)
Document timing and needle size at original procedure
Support during EBP — venepuncture + epidural simultaneously

Epidural Haematoma & Abscess

Rare Emergencies

Warning Signs

New severe back pain — progressive
Neurological deterioration — increasing leg weakness/sensory loss
Bladder/bowel dysfunction
Signs of infection for abscess: fever, raised CRP/WBC

Action

Urgent MRI spine (do NOT wait for symptoms to progress)
Neurosurgical review within 6 hours of symptom onset
Haematoma: emergency surgical decompression (laminectomy)
Abscess: IV antibiotics ± surgical drainage
Document neurological exam with timestamps

Nerve Damage & Backache

Nerve Damage

Incidence: <1:10,000 (rare with correct technique)
Causes: direct needle trauma, haematoma compression, ischaemia, LA neurotoxicity
Pre-operative neuro assessment is essential — document baseline
Post-operative: assess motor/sensory function before discharge from recovery
New deficits: inform anaesthetist immediately and document with time

Backache

Common — 25–40% after regional anaesthesia
Usually resolves within 2–4 weeks
Cause: ligament trauma, local haematoma, positioning during surgery
Reassure patient; NSAIDs + physiotherapy if persistent
Persistent or worsening → rule out haematoma/abscess (MRI)

Common Peripheral Nerve Blocks & Indications

Block	Indication	Key Points
Femoral Nerve Block	Hip fracture pre-op analgesia; femoral shaft fracture	IM nerve — reduces opioid need in ED; may impair quadriceps (falls risk)
Adductor Canal Block (ACB)	Total knee replacement (TKR) post-op	Spares quadriceps (motor-sparing) vs femoral block — earlier mobilisation
Interscalene Block	Shoulder surgery	Always causes ipsilateral phrenic nerve palsy — avoid in poor respiratory reserve
Supraclavicular Block	Upper limb (elbow, forearm, hand)	Pneumothorax risk (~0.5%); good for forearm/hand surgery
Infraclavicular Block	Elbow, forearm, hand surgery	Good for catheter insertion; lower phrenic/pneumothorax risk
Axillary Block	Forearm and hand surgery	Safest brachial plexus block; no pneumothorax risk; musculocutaneous nerve missed
TAP Block	Abdominal surgery analgesia (laparotomy, laparoscopy, C-section)	Transversus abdominis plane; covers T8–L1; does not cover visceral pain
PECS Block (I & II)	Breast surgery, mastectomy, implant	PECS II covers lateral chest; landmark/ultrasound guided
Ankle Block	Foot surgery (hallux, forefoot)	5 nerves blocked (superficial peroneal, deep peroneal, sural, saphenous, tibial)
Sciatic Nerve Block	Foot, ankle, lower leg surgery	Combined with femoral for complete lower limb anaesthesia

Local Anaesthetic Systemic Toxicity (LAST)

Early Warning Signs (CNS)

Tinnitus / ringing in ears
Metallic taste in mouth
Perioral tingling / numbness
Light-headedness, dizziness
Visual disturbance / circumoral paraesthesia

Severe Signs

Seizures (tonic-clonic)
Loss of consciousness
Cardiovascular collapse
Ventricular arrhythmias (VF, broad complex tachycardia)
Bradycardia → asystole

LAST can present as CNS or cardiovascular toxicity first, or both simultaneously. Bupivacaine and ropivacaine are most cardiotoxic. CNS symptoms may be absent in deeply sedated patients.

LAST Management — STOP Injection Immediately

STOP injection at first sign of toxicity

Call for help — declare emergency, get lipid emulsion kit

Airway/Breathing: 100% O₂, consider intubation if unconscious

Lipid Emulsion 20%: Bolus 1.5 mL/kg IV over 1 min, then infusion 0.25 mL/kg/min

If cardiac arrest: continue CPR — lipid may take several minutes to work

Repeat bolus up to 2 more times at 5 min intervals if no response (max 12 mL/kg total)

Seizure: midazolam 2–5 mg or thiopental — AVOID propofol (lipid carrier increases LA absorption)

ACLS Modifications in LAST

Adrenaline: use reduced dose (<1 mcg/kg) — high dose worsens outcome
AVOID: vasopressin, calcium channel blockers, beta-blockers, local anaesthetics
Prolonged CPR may be needed — lipid emulsion takes time
Consider ECMO if refractory cardiovascular collapse

Ultrasound Guidance for Peripheral Blocks

Advantages of US Guidance

Real-time visualisation of needle and LA spread
Reduces volume required (dose reduction 30–50%)
Reduces LAST risk — lower volumes, avoid intravascular
Faster onset, higher success rate
Avoids inadvertent vascular injection

Nursing Role in US-Guided Blocks

Prepare sterile probe cover and sterile gel
Position patient and maintain block throughout procedure
Monitor IV access, BP, SpO2 continuously during block
Have LAST kit (lipid emulsion) immediately available
Document: drug, volume, concentration, time, who performed block
Post-block: monitor for complications for 30 min minimum

Regional Anaesthesia in the GCC

Growing uptake of regional techniques across Saudi Arabia, UAE, Qatar, Kuwait, Bahrain, Oman
High Caesarean section rates in GCC driving epidural anaesthesia demand
Trauma load (road traffic accidents) increases need for peripheral nerve blocks
Ultrasound-guided blocks now standard in major tertiary GCC hospitals
Dedicated acute pain services incorporating neuraxial and PCA techniques
GCC countries adopting ESRA / ASRA guidelines for anticoagulation management

Anticoagulant Bridging in GCC Context

High prevalence of atrial fibrillation in elderly GCC populations
Mechanical heart valves common — warfarin bridging with LMWH
DVT history and pulmonary embolism prophylaxis
GCC nurses must be competent in anticoagulant timing protocols

Regulatory & Competency Framework

DHA / DOH (Dubai & Abu Dhabi)

Anaesthesia nursing competencies include neuraxial monitoring
Epidural management in post-operative ward is a licensed nursing activity
Certification required for PCEA management in many GCC facilities

SCFHS (Saudi Arabia)

Anaesthesia nursing exam content includes regional anaesthesia monitoring
Block height assessment, complication recognition in exam scope
LAST recognition and lipid emulsion protocols tested

Patient Education — Multilingual Context

Consent and education in Arabic, Urdu, English, Filipino, Hindi
Explain: block sensation, expected numbness, recovery timeline
Limb numbness safety: prevent falls, pressure injuries, burns to numb limb
Document patient education in native language

Post-Operative Ward Nursing — Regional Anaesthesia Safety

Limb Numbness Safety

Assess motor block before mobilisation (Bromage scale)
Bed rails up while numbness persists
Protect numb limb from pressure/heat/trauma
Call bell within reach — patient education
Assisted ambulation only when Bromage = 0

Bromage Motor Scale

0: Full flexion of knees/feet — mobilise with support
1: Just able to flex knees — sit out with supervision
2: Able to flex feet only — bed rest
3: Unable to move feet — bed rest, pressure care

Ward Epidural Monitoring

Hourly: BP, RR, pain score, sedation score
2-hourly: block height, Bromage score
4-hourly: catheter site inspection
Any: new back pain, leg weakness, fever → call anaesthetist
If opioid in infusion: SpO2 monitoring; naloxone at bedside

Post-Spinal Block Level & Safety Assessment Tool

Enter patient parameters to assess block status, complications, and ward readiness.

Time since spinal (minutes)

Highest blocked dermatome

Current systolic BP (mmHg)

Respiratory rate (breaths/min)

Motor function (Bromage score)

SpO2 (%)

Sensation in arms?

GCC Exam Practice — 5 MCQs: Regional Anaesthesia & Spinal/Epidural Nursing

Q1. A patient develops tinnitus and a metallic taste 3 minutes after starting an interscalene nerve block injection. What is the MOST appropriate IMMEDIATE action?

A. Reassure the patient and continue the injection slowly B. STOP the injection immediately and call for help C. Administer IV midazolam prophylactically D. Reduce the injection rate by 50%

These are early CNS signs of Local Anaesthetic Systemic Toxicity (LAST). The FIRST and MOST critical action is to STOP the injection immediately. Continuing or slowing the injection risks progression to seizures and cardiovascular collapse. Call for help and prepare lipid emulsion 20% (1.5 mL/kg bolus).

Q2. A post-Caesarean section patient received intrathecal morphine 0.1 mg. Which monitoring parameter is MOST critical over the next 24 hours?

A. Blood pressure every 2 hours B. Urine output hourly C. Respiratory rate and SpO2 D. Block height every 4 hours

Intrathecal morphine provides excellent 24-hour analgesia but carries the risk of DELAYED respiratory depression (12–18 hours after administration). Respiratory rate and SpO2 monitoring is mandatory for 24 hours. The spinal block will have resolved long before the morphine-related respiratory risk period ends.

Q3. When assessing a spinal block using cold spray, the patient reports normal cold sensation at the umbilicus (T10) and reduced sensation at the xiphisternum (T6). A Caesarean section is planned. What is the correct interpretation?

A. The block is too high — delay surgery B. The block is adequate for Caesarean section C. The block is too low — supplement with IV opioids D. Epidural top-up is required before proceeding

A spinal block to T6 (reduced sensation at xiphisternum) is adequate for Caesarean section. The minimum required level is T6. The patient still feels cold at T10 (umbilicus), which is expected — this means T10 is NOT blocked, but T6 IS blocked. If cold sensation is ABSENT at T6, the block has reached T6 level. This is the target level for LSCS.

Q4. A patient on therapeutic enoxaparin (1 mg/kg BD) for DVT needs an epidural catheter removed. According to ESRA guidelines, what is the minimum time to wait after the LAST dose before catheter removal?

A. 4 hours B. 8 hours C. 12 hours D. 24 hours

Therapeutic dose LMWH (e.g. enoxaparin 1 mg/kg BD) requires a 24-hour free interval before neuraxial catheter removal. Prophylactic dose LMWH requires only 12 hours. This is critical knowledge in GCC where anticoagulation for DVT, pulmonary embolism, and mechanical valves is common. Removing the catheter too early risks epidural haematoma — a potential surgical emergency.

Q5. A patient 6 hours post-spinal anaesthesia develops new severe lower back pain and is unable to move their legs. SpO2 is 98%, BP is stable. What is the MOST urgent nursing action?

A. Reassure patient — residual spinal block is normal at 6 hours B. Increase the epidural infusion rate for better analgesia C. Administer oral paracetamol and reassess in 2 hours D. Immediately inform the anaesthetist and document neurological assessment

New severe back pain with progressive neurological deterioration (paraplegia) at 6 hours post-spinal — after expected block resolution — is an EMERGENCY presentation of epidural haematoma or abscess. Do NOT reassure or delay. Call the anaesthetist IMMEDIATELY, document a full neurological assessment with timestamps, and prepare for urgent MRI. The window for surgical decompression to prevent permanent paralysis is narrow (ideally within 6–8 hours of symptom onset).