Anesthesia Recommendations for Surgical Procedures

Factors Favoring Spinal Anesthesia

Spinal anesthesia may reduce the incidence of postoperative confusion in elderly patients undergoing orthopedic procedures 1, 2
Spinal anesthesia avoids the risks associated with airway manipulation and mechanical ventilation that come with general anesthesia 3

General anesthesia may be the most appropriate choice in urgent/emergent situations such as profound fetal bradycardia, ruptured uterus, severe hemorrhage, severe placental abruption, umbilical cord prolapse, and preterm footling breech 4
When rapid sequence induction is required for patients with full stomachs or those at high risk for aspiration 5
When spinal anesthesia is contraindicated due to coagulation abnormalities (e.g., INR >1.4, platelets <75,000, recent LMWH administration) 5
When patient positioning makes spinal anesthesia technically difficult or impossible 3

For elderly patients with multiple comorbidities, spinal anesthesia may reduce physiological stress compared to general anesthesia 2, 3
For patients with difficult airways or risks for failed intubation, spinal anesthesia avoids airway manipulation 6

For hip fracture repair, spinal anesthesia is recommended as first-line unless contraindicated 1, 2, 3
For cesarean delivery, neuraxial techniques are preferred over general anesthesia in most cases 4

Use pencil-point spinal needles instead of cutting-bevel needles to minimize the risk of post-dural puncture headache 4
Lower doses of intrathecal bupivacaine (<10 mg) can reduce associated hypotension in elderly patients 2, 3
When using spinal anesthesia for hip fracture patients, fentanyl is preferred over morphine or diamorphine as an intrathecal opioid to reduce respiratory and cognitive depression 3
Supplemental oxygen should always be provided during spinal anesthesia 3
For postoperative analgesia after neuraxial anesthesia, consider selecting neuraxial opioids rather than intermittent injections of parenteral opioids 4

Avoid simultaneous administration of spinal and general anesthesia as this is associated with precipitous falls in intra-operative blood pressure 2
Be cautious with sedation during spinal anesthesia in elderly patients, as it may increase the risk of postoperative confusion 3
When using spinal anesthesia for cesarean delivery, IV fluid preloading or co-loading may reduce the frequency of maternal hypotension 4
Consider peripheral nerve blockade as an adjunct to either spinal or general anesthesia to extend the period of postoperative non-opioid analgesia 3

Neuraxial anesthesia can be used as the primary anesthetic technique, with Total Intravenous Anesthesia (TIVA) added later if conversion to general anesthesia becomes necessary, as recommended by the American College of Cardiology 7
Alternatively, a neuraxial block can be placed for postoperative analgesia before or after TIVA-based general anesthesia, according to the American College of Cardiology 7

The American Society of Anesthesiologists recommends using ultrasound guidance when performing any regional technique to reduce complications and local anesthetic systemic toxicity, with a strength of evidence level of high 8
Active infection or sepsis at the proposed injection site is a contraindication to neuraxial blocks, as stated by the Anaesthesia journal 8
Patient refusal or inability to cooperate is a contraindication to neuraxial blocks, as stated by the American Society of Anesthesiologists (ASA) 9
Hemodynamic instability that would be worsened by sympathetic blockade is a contraindication to neuraxial blocks, as stated by the American Society of Anesthesiologists (ASA) 9

Peripheral nerve blocks are safer than neuraxial blocks when combined with general anesthesia because they do not cause sympathectomy or widespread hemodynamic effects, as reported in the Anaesthesia journal 8
The Anaesthesia journal recommends using peripheral nerve blocks as an alternative to neuraxial blocks in patients with contraindications to neuraxial blocks 8