high spinal? for hemorrhoidectomy

Started by drjunc2000, January 27, 2005, 01:16:17 PM

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hello again!  i did a hemorrhoidectomy case that went awry. The patient was a 39y/o male, 190 pounds, ASA 1 for proctoscopy-hemorrhoidectomy. After preloading the patient with 700cc IV solution, i gave spinal anesthesia using Bupivacaine 0.5% heavy 10mg after which patient was placed on prone position. Just after a minute, patient complained of difficulty of breathing, O2 saturation decreased from 99 to 80 to 75, bp went down from 120/80 to 70/50. i tried ventilating but 02 sat went up to only 85. I immediately called for help and placed the patient on supine . There wwas improvement after a few seconds. Is this high spinal?


In what position did you do the spinal?  If sitting, how long did you let him remain sitting?



Injecting LA into the mid-lumbar area, the needle is at the highest point of the lumbar lordosis whent he patient lies supine. It then sinks down the lumbar and lower thoracic column until it meets the uphill thoracic kyphosis which limits how high the bupivacaine goes - usually mid-thoracic. It takes about 20 minutes to fix to tissues.

If you positioned the patient prone immediately after injecting the anesthetic, the thoracic kyphosis becomes a depression rather than a hill, and the LA would continue to flow into the higher thoracic dermatomes, paralysing the intercostals and blocking all the sympathetics.

All you need here is a saddle block - sacral dermatomes. Inject the heavy bupivacaine, sit the patient up and keep them sitting for 15-20 minutes before positioning them prone.


i did the case in a lateral decubitus position. i did not attempt to do a saddle block because in need the T10 for the proctoscopy


you can use a lat.dec.position but what if u elevate the table head or a bit anti-trend. position and manibulation of table can help in controll the level and if u will not let that lateral position for long time, so u will get unilateral block so after block if u turn patient u turn into supine and bit head up and prone when control level and fixation takes place.
Do u use spinal narcotics?


yes i did put the patient on reverse trend position...and yes i incorporated morphine in my spinal..thanks for the response guys


But how long did you keep the patient in this position after the spinal insertion? If it was less than1 5-20 minutes, the bupivacaine will still shift as per my previous post, and a high spinal will result.

Sandy Hancock

I prefer to use plain bupivacaine for these. Typically 7-8mg with 20-25mcg fentanyl. Once they roll over and stick their bum in the air the slightly hypobaric local anaesthetic has nowhere to go. No need to wait 20 minutes for it to fix.

Surgeons I work with generally do haemorrhoids in lithotomy, but I do this occasionally for pilonidal sinuses.



Hi, In Mumbai, India, some of our surgeons do preffer to do under prone position. One place, where they did not get their regular Anaesthesiologist, they had called me to do a Piles surgery in prone position. I did give a saddle block with pt sitting for 12-15 mins. The surgeon actually gives, not a prone position but a Jack Knife( Knee Chest) position. This offers them a very good view. This position is really dangerous, as the drug can so easily seep upwards in to the thoracic or even higher level.
All went well, but when I commented that this is a bad and dangerous position for a surgery, the surgeon says that he has already had two problem events and they had to make the pt supine urgently and treat the hypotension and resp arrest.
I have seen a CD called "Glass Spine", where some one has made an excellant effort to make a glass tube into a spine shaped tube , filled with Fluid of CSF density and he injects a  red dye which has a density of Bupivacain Heavy. He shows how the drug flows, in what position and after how much time. Just imagine this and then work.


sir it is not high spinal. simple prone position it self can cause sever hypotension. in jackknife position venous pooling will be much more in legs and lungs.