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Sacral block anesthesia in proctologic operations
SACRAL BLOCK ANESTHESIA IN PROCTOLOGIC OPERATIONS* JOHN
S.
LUNDY,
Rochester,
,llinnesota
Y experience with sacra1 bIock anesthesia for proctologic operations extends a IittIe over the Iast twenty-five years. In this period I have had the opportunity to use sacrat bIock for other types of operations. In addition to using this type of anesthesia for surgica1 operations I have used it for obstetric procedures and also for the diagnosis of pain paths in an attempt to bIock sacra1 nerves therapeuticaIIy. I have had an opportunity to compare a number of methods of anesthesia for proctoIogic operations and I know of no one method that offers so much satisfaction to the surgeon and the anesthesiologist, and usuaIIy to the patient, in terms of reIaxation of the operative fieId and freedom from pain, as bIocking the sacral nerves. In order to substantiate the basis of my assertion I shall summarize the annua1 reports of the Section on AnesthesioIogy of the Mayo Clinic since I was asked to head it early in 1924. (Table I.) In the majority of a reIativeIy Iarge number of cases in which sacra1 block has been used a proctoIogic operation has been performed. In other words, the fieId in which this type of anesthesia has been used most frequently during this period has been proctoIogic surgery. From time to time I have been asked, “Why not use spinal anesthesia, because it is much easier to empIoy?” It is my opinion that spinal anesthesia is folIowed by postIumbar puncture headache often enough to make its use Iess desirable than sacra1 bIock. In a great many of the cases in which this type of anesthesia has been used the bIock was produced by using a I per cent solution of procaine hydrochIoride with epinephrine in water or isotonic sodium chIoride soIution. In the second haIf of the series of cases the bIock was obtained with a I per cent soIution of metycaine which aIso contained epinephrine. In a smaI1 series of cases 250 units of penicilIin per cc. were added to the I per cent soIution of metycaine for the purpose of making avaiIabIe a solution
M
that might be needed in certain circumstances. This series was smaI1 but served to show that such a combination may be used in most cases without untoward results. In most cases in which patients are sensitive to penicillin skin manifestations may be seen at the site of the TABLE ANESTHESIA r+q
1950
AT TO
THE
1948
I MAYO
CLINIC,
INCLUSIVE
Cases TotaI number of cases in which an anesthetic was administered. . . 555,246 Regional bIock. I 25,702 SpinaI anesthesia. . 59,047 Sacral and caudaI block.. . ... 22,895 Intravenous anesthesia (1935 to 1948 incIusive) 94,774 PentothaI sodium administered intravenousIy (1935 to 1948 inclusive).. _. _. 92,620
wheaIs in the skin. These manifestations may appear earIy in the postoperative period and may be expected to recur even months later if more penicillin shouId be taken by the patient. Dangers to be faced in the use of sacra1 block anesthesia are few but must be kept in mind. The soIution may accidentaIIy be injected into a vein and cause an untoward systemic effect. This may produce convulsions which can bc controIIed by the intravenous administration of small doses of pentotha1 sodium and by the administration of oxygen. If a smaI1 dose of the anesthetic agent is administered and if the anesthetic soIution is injected sIowIy, the accidenta injection of the solution into a vein is not IikeIy to produce a severe reaction. If it is beIieved that the soIution might have been injected into a vein, the patient shouId be watched carefully for evidence of an untoward systemic reaction. Perforation of the arachnoid and injection of the soIution into the spina fluid may produce anesthesia which extends high enough to anesthetize the spinal nerves. If a I per cent soIution of procaine hydrochIoride is inadvertentIy injected into the spina fluid, fata paralysis need not be anticipated if not more than 30 cc. of the soIution is injected.
* From the Section on AnesthesioIogy,
January,
M.D.
137
Mayo Clinic, Rochester,
Minn.
Lundy--Sacral
138
In most cases this is the maximal I per cent
soIution
of procaine
amount
Block of a
hydrochloride
that should be injected into the cauda1 canal. The injection of a I per cent soIution of metyCaine is a different matter. I know of one patient who died after 30 cc. of this solution had been injected into the spinal fluid. The anesthesiologist was not sufficiently experienced to know that he should have tested for spina anesthesia at the first manifestation of distress, especially in regard to breathing, by the patient. If the anesthetic solution is accidentally injected into the spinal subarachnoid space, IOO cc. or more of the spinal fluid should be withdrawn and replaced with isotonic sodium chIoride solution. The tip of the dura1 sac may be as Iow as the Ieve of the second sacral foramen; therefore, the caudal needIe shouId not be inserted higher than this IeveI. One may traumatize the periostea1 surface of the posterior part of the sacrum with the needle or needles empIoyed; and if the point of the needIe is passed repeatedly through the skin and into the periosteum of the sacrum, a sinus may form. I have observed one case in which such a sinus developed. If more than the average amount of solution is used and if the patient is somewhat sensitive to drugs, cardiovascular depression or even shock may occur. If the patient is an elderly or weak person, it is advisable to reduce the amount of soIution from a third to a half. If time permits, it is sometimes possible to introduce 25 cc. of soIution into the caudal canal and ahow thirty minutes for the devetopment of anesthesia and reIaxation. No further injection may be necessary. In some cases an intracaudal injection of 25 to 30 cc. of the anesthetic soIution and injection of IO cc. of the solution in each second sacra1 foramen wiIl produce adequate anesthesia and relaxation in twenty minutes. For the most part, however, the injection of 30 cc. of solution into the caudal canat, the injection of IO cc. into the second sacra1 foramen on each side, the injection of 3 cc. into the third sacra1 foramen on each side and the injection of 2 cc. into the fourth sacral foramen on each side wiII produce good anesthesia in from ten to fifteen minutes. This technic causes a more or Iess complete distribution of the soIution on a11 sides of the sacra1 nerves concerned which makes possible the quick, uniform and satisfactory anesthesia and reIaxation that one wishes to produce. NevertheIess, the patient shouId be tested for
Anesthesia
anesthesia before the signal is given for the surgeon to start the operation. As time goes on the more one becomes experienced with the method the fewer are the failures that occur. If a physician is wiIIing to Iearn the technic that wiI1 produce good resuIts and if he will follow the technic carefuIIy, it will not take him very Iong to be able to obtain uniformly good results. I should like to call your attention to the technic which I use for sacral block. There has been practicalIy no change in this technic since 1924 except that in the first three years the technic was worked out and finally was not at all like the one I first used. The patient is pIaced in the Buie position which is the most satisfactory position for producing the bIock and for performing the proctologic operation. The skin is surgicalIS prepared. The landmarks are paIpated and drops of water are pIaced over the sacral hiatus and the foramina. Wheals are raised painlessIy by putting the bevel of the needle against the skin and by forcing the anesthetic soIution through the needle as it is engaged in the more superficia1 layers of the skin. GraduaIly the needle is forced deeper and 2 or 3 cc. of the solution are then injected through the whea1 and down to the periosteum. These wheaIs are raised after the caudal needIe has been inserted. One first raises a wheal in the skin over the sacra1 hiatus which may be paIpated just above the coccyx. A small needle is inserted into the tip of the caudal canal ant1 25 cc. of the soIution injected. The needle is left in pIace. The caudal needle is inserted against the hiatus with the bevel up; then the needIe is given a half turn and inserted not higher than the IeveI of the second sacral foramen. Insertion of the needIe should not produce blood or spinal fluid. In any event one must not inject any appreciable quantity of the solution into a vein. II one cannot find a satisfactory pIace for the needle even close to the tip of the caudaI canal, it may be necessary to eliminate the cauda1 injection and make all injections from the foramina and aIso to deposit soIution outside of the sacra1 hiatus. After the caudal injection has been made, needles should be inserted into the second, third and fourth sacral foramina on each side. Wheals are raised as described and infiltration is made as the needle is inserted from skin to bone. Then one should search for the foramen by inserting the needle against the
American
Journal
of Surgery
sacrum at severa points near the first spot touched. At this point the wheal is moved in a circular position each time the needle is almost withdrawn except from skin and reinserted. The needle is inserted as around the dial of a cIock and six thrusts are made. The first one is in the center of the circle and the other five around it. If one cannot find the foramen in six thrusts, he probabIy will not find it in sixty. He should try another Soramen; and if he does not find that one, he should try to Iind the next one. He shouId start with the fourth sacra1 foramen and end with the second because in caudal block the anesthesia starts at the bottom and extends upward. Insertion of the needIe into the fourth sacral foramen is less painful than into the third and insertion into the second foramen is less painful than into the third. When the needle is inserted into the foramen which is bottomIess, one must be very certain that the point of the needle enters the foramen for as short a distance as possible. If the needIe is inserted beyond the thickness of the sacrum, all the solution wilI go into the peIvis and none wiIl enter the foramen. In the case of smah, sensitive or weak patients the total amount of soIution used seIdom exceeds 60 cc. and may be as smaI1 as 35 to 40 cc. Only once in my experience at the chnic did we perform a proctoIogic operation on a patient under nitrous oxide-oxygen and ether in the lithotomy position. This patient was a doctor’s wife whom I had anesthetized three times for delivery. I had tested her for sensitivity to
January,
1950
procaine and metycaine. She did not tolerate either one in skin wheals but I found that she reacted we11 to inhalation anesthesia. She was the one exception that spoiled what wouId have been otherwise considered a sort of record. In a case of pilonida1 disease in which considerabIe infection precludes the use of sacral bIock spinal anesthesia has been used with compIete satisfaction except for an occasional instance of headache. In a very few cases in which a minor operation was to be done such as incision of an abscess or removal of a painful pack pentothal anesthesia has been used. In a very few cases in which general anesthesia of not more than fifteen minutes duration was needed pentothal sodium has been used. The use of curare as an aid to pentothal sodium may possibly Iead to an increased use of the combination and it may be that sacral block wit1 go the way of spinal anesthesia if the possibihty of using curare pIus equa1 parts of nitrous oxide and oxygen continues to be used more generahy than rt has been. Perhaps a method will be worked out in time that can equa1 the record established by sacral block. This will take some time, however. AIthough I do not wish to predict that nothing better can be found for proctologic surgery than blocking of the sacral nerves, I hope to bc pardoned if I look upon the results obtained with this method with some degree of satisfaction. If a new and better method of anesthesia is developed for proctologic operations, I shal1 be very eager to live to see it.
S.
LUNDY,
Rochester,
,llinnesota
Y experience with sacra1 bIock anesthesia for proctologic operations extends a IittIe over the Iast twenty-five years. In this period I have had the opportunity to use sacrat bIock for other types of operations. In addition to using this type of anesthesia for surgica1 operations I have used it for obstetric procedures and also for the diagnosis of pain paths in an attempt to bIock sacra1 nerves therapeuticaIIy. I have had an opportunity to compare a number of methods of anesthesia for proctoIogic operations and I know of no one method that offers so much satisfaction to the surgeon and the anesthesiologist, and usuaIIy to the patient, in terms of reIaxation of the operative fieId and freedom from pain, as bIocking the sacral nerves. In order to substantiate the basis of my assertion I shall summarize the annua1 reports of the Section on AnesthesioIogy of the Mayo Clinic since I was asked to head it early in 1924. (Table I.) In the majority of a reIativeIy Iarge number of cases in which sacra1 block has been used a proctoIogic operation has been performed. In other words, the fieId in which this type of anesthesia has been used most frequently during this period has been proctoIogic surgery. From time to time I have been asked, “Why not use spinal anesthesia, because it is much easier to empIoy?” It is my opinion that spinal anesthesia is folIowed by postIumbar puncture headache often enough to make its use Iess desirable than sacra1 bIock. In a great many of the cases in which this type of anesthesia has been used the bIock was produced by using a I per cent solution of procaine hydrochIoride with epinephrine in water or isotonic sodium chIoride soIution. In the second haIf of the series of cases the bIock was obtained with a I per cent soIution of metycaine which aIso contained epinephrine. In a smaI1 series of cases 250 units of penicilIin per cc. were added to the I per cent soIution of metycaine for the purpose of making avaiIabIe a solution
M
that might be needed in certain circumstances. This series was smaI1 but served to show that such a combination may be used in most cases without untoward results. In most cases in which patients are sensitive to penicillin skin manifestations may be seen at the site of the TABLE ANESTHESIA r+q
1950
AT TO
THE
1948
I MAYO
CLINIC,
INCLUSIVE
Cases TotaI number of cases in which an anesthetic was administered. . . 555,246 Regional bIock. I 25,702 SpinaI anesthesia. . 59,047 Sacral and caudaI block.. . ... 22,895 Intravenous anesthesia (1935 to 1948 incIusive) 94,774 PentothaI sodium administered intravenousIy (1935 to 1948 inclusive).. _. _. 92,620
wheaIs in the skin. These manifestations may appear earIy in the postoperative period and may be expected to recur even months later if more penicillin shouId be taken by the patient. Dangers to be faced in the use of sacra1 block anesthesia are few but must be kept in mind. The soIution may accidentaIIy be injected into a vein and cause an untoward systemic effect. This may produce convulsions which can bc controIIed by the intravenous administration of small doses of pentotha1 sodium and by the administration of oxygen. If a smaI1 dose of the anesthetic agent is administered and if the anesthetic soIution is injected sIowIy, the accidenta injection of the solution into a vein is not IikeIy to produce a severe reaction. If it is beIieved that the soIution might have been injected into a vein, the patient shouId be watched carefully for evidence of an untoward systemic reaction. Perforation of the arachnoid and injection of the soIution into the spina fluid may produce anesthesia which extends high enough to anesthetize the spinal nerves. If a I per cent soIution of procaine hydrochIoride is inadvertentIy injected into the spina fluid, fata paralysis need not be anticipated if not more than 30 cc. of the soIution is injected.
* From the Section on AnesthesioIogy,
January,
M.D.
137
Mayo Clinic, Rochester,
Minn.
Lundy--Sacral
138
In most cases this is the maximal I per cent
soIution
of procaine
amount
Block of a
hydrochloride
that should be injected into the cauda1 canal. The injection of a I per cent soIution of metyCaine is a different matter. I know of one patient who died after 30 cc. of this solution had been injected into the spinal fluid. The anesthesiologist was not sufficiently experienced to know that he should have tested for spina anesthesia at the first manifestation of distress, especially in regard to breathing, by the patient. If the anesthetic solution is accidentally injected into the spinal subarachnoid space, IOO cc. or more of the spinal fluid should be withdrawn and replaced with isotonic sodium chIoride solution. The tip of the dura1 sac may be as Iow as the Ieve of the second sacral foramen; therefore, the caudal needIe shouId not be inserted higher than this IeveI. One may traumatize the periostea1 surface of the posterior part of the sacrum with the needle or needles empIoyed; and if the point of the needIe is passed repeatedly through the skin and into the periosteum of the sacrum, a sinus may form. I have observed one case in which such a sinus developed. If more than the average amount of solution is used and if the patient is somewhat sensitive to drugs, cardiovascular depression or even shock may occur. If the patient is an elderly or weak person, it is advisable to reduce the amount of soIution from a third to a half. If time permits, it is sometimes possible to introduce 25 cc. of soIution into the caudal canal and ahow thirty minutes for the devetopment of anesthesia and reIaxation. No further injection may be necessary. In some cases an intracaudal injection of 25 to 30 cc. of the anesthetic soIution and injection of IO cc. of the solution in each second sacra1 foramen wiIl produce adequate anesthesia and relaxation in twenty minutes. For the most part, however, the injection of 30 cc. of solution into the caudal canat, the injection of IO cc. into the second sacra1 foramen on each side, the injection of 3 cc. into the third sacra1 foramen on each side and the injection of 2 cc. into the fourth sacral foramen on each side wiII produce good anesthesia in from ten to fifteen minutes. This technic causes a more or Iess complete distribution of the soIution on a11 sides of the sacra1 nerves concerned which makes possible the quick, uniform and satisfactory anesthesia and reIaxation that one wishes to produce. NevertheIess, the patient shouId be tested for
Anesthesia
anesthesia before the signal is given for the surgeon to start the operation. As time goes on the more one becomes experienced with the method the fewer are the failures that occur. If a physician is wiIIing to Iearn the technic that wiI1 produce good resuIts and if he will follow the technic carefuIIy, it will not take him very Iong to be able to obtain uniformly good results. I should like to call your attention to the technic which I use for sacral block. There has been practicalIy no change in this technic since 1924 except that in the first three years the technic was worked out and finally was not at all like the one I first used. The patient is pIaced in the Buie position which is the most satisfactory position for producing the bIock and for performing the proctologic operation. The skin is surgicalIS prepared. The landmarks are paIpated and drops of water are pIaced over the sacral hiatus and the foramina. Wheals are raised painlessIy by putting the bevel of the needle against the skin and by forcing the anesthetic soIution through the needle as it is engaged in the more superficia1 layers of the skin. GraduaIly the needle is forced deeper and 2 or 3 cc. of the solution are then injected through the whea1 and down to the periosteum. These wheaIs are raised after the caudal needIe has been inserted. One first raises a wheal in the skin over the sacra1 hiatus which may be paIpated just above the coccyx. A small needle is inserted into the tip of the caudal canal ant1 25 cc. of the soIution injected. The needle is left in pIace. The caudal needle is inserted against the hiatus with the bevel up; then the needIe is given a half turn and inserted not higher than the IeveI of the second sacral foramen. Insertion of the needIe should not produce blood or spinal fluid. In any event one must not inject any appreciable quantity of the solution into a vein. II one cannot find a satisfactory pIace for the needle even close to the tip of the caudaI canal, it may be necessary to eliminate the cauda1 injection and make all injections from the foramina and aIso to deposit soIution outside of the sacra1 hiatus. After the caudal injection has been made, needles should be inserted into the second, third and fourth sacral foramina on each side. Wheals are raised as described and infiltration is made as the needle is inserted from skin to bone. Then one should search for the foramen by inserting the needle against the
American
Journal
of Surgery
sacrum at severa points near the first spot touched. At this point the wheal is moved in a circular position each time the needle is almost withdrawn except from skin and reinserted. The needle is inserted as around the dial of a cIock and six thrusts are made. The first one is in the center of the circle and the other five around it. If one cannot find the foramen in six thrusts, he probabIy will not find it in sixty. He should try another Soramen; and if he does not find that one, he should try to Iind the next one. He shouId start with the fourth sacra1 foramen and end with the second because in caudal block the anesthesia starts at the bottom and extends upward. Insertion of the needIe into the fourth sacral foramen is less painful than into the third and insertion into the second foramen is less painful than into the third. When the needle is inserted into the foramen which is bottomIess, one must be very certain that the point of the needle enters the foramen for as short a distance as possible. If the needIe is inserted beyond the thickness of the sacrum, all the solution wilI go into the peIvis and none wiIl enter the foramen. In the case of smah, sensitive or weak patients the total amount of soIution used seIdom exceeds 60 cc. and may be as smaI1 as 35 to 40 cc. Only once in my experience at the chnic did we perform a proctoIogic operation on a patient under nitrous oxide-oxygen and ether in the lithotomy position. This patient was a doctor’s wife whom I had anesthetized three times for delivery. I had tested her for sensitivity to
January,
1950
procaine and metycaine. She did not tolerate either one in skin wheals but I found that she reacted we11 to inhalation anesthesia. She was the one exception that spoiled what wouId have been otherwise considered a sort of record. In a case of pilonida1 disease in which considerabIe infection precludes the use of sacral bIock spinal anesthesia has been used with compIete satisfaction except for an occasional instance of headache. In a very few cases in which a minor operation was to be done such as incision of an abscess or removal of a painful pack pentothal anesthesia has been used. In a very few cases in which general anesthesia of not more than fifteen minutes duration was needed pentothal sodium has been used. The use of curare as an aid to pentothal sodium may possibly Iead to an increased use of the combination and it may be that sacral block wit1 go the way of spinal anesthesia if the possibihty of using curare pIus equa1 parts of nitrous oxide and oxygen continues to be used more generahy than rt has been. Perhaps a method will be worked out in time that can equa1 the record established by sacral block. This will take some time, however. AIthough I do not wish to predict that nothing better can be found for proctologic surgery than blocking of the sacral nerves, I hope to bc pardoned if I look upon the results obtained with this method with some degree of satisfaction. If a new and better method of anesthesia is developed for proctologic operations, I shal1 be very eager to live to see it.