CH10 ANATOMY, REGIONAL ANESTHESIA, and PAIN MANAGEMENT Flashcards
phenomenom associated with repeated injection of LA leading to decreased effectiveness
TACHYPHYLAXIS
Tachyphylaxis is most closely related to
DOSING INTERVAL
dosing interval is short no tachyphylaxis
if the dosing interval is longer TACHYPHYLAXIS DEVELOPS
Treatment for pruritis from neuraxial opiates
Nalbuphine 5mg iv
diphenhydramine 50mg iv
propofol 10mg iv
dexmedetomidine 30mcg iv -
will dec narcotic dose but not treat pruritus
MAXIMUM dose of lidocaine containing 1:200,000 epinephrine is
5mg/kg withou epi
7mg/kg with epi
1:200,000
5mcg/ml
1:200,000 = 1g/200,000ml
DIGITALIS TOXICITY?
loss of appetite nausea and vomiting pain in trigeminal neuralgia pain anf discomfort in the feet pain and discomfort in the extremities transient visual disturbance
earliest sign of lidocaine toxicity
5-10 Light headedness dizziness numbness tomgue perioral numbness tinnitus
10-15
seizure
unconsciousness
15-25
rspi depression
coma
> 25
cardio
site of opiates in the spinal cord
SUBSTANTIA GELATINOSA of SC
epidural mg of morphine equivalent to intrathecal
5mg epidural Mso4= 0.1-0.3mg in intrathecal dose
AMINO ESTERS LA
one I only
procaine
chloroprocaine
tetracaine
plasma clearance by pseudocholinesterase
short half lives
AMINO AMIDE LA
2 i
bupivacaine ropivacaine lidocaine mepicavaine prilocaine
hepatic clearance
longer half lives
Interscalene Block
hand and forearm surgery
C8-T1
ULNAR NERVE SPARING
PHRENIC NERVE 100%
HORNER SYNDROME blockade of stellate ganglion. 70-90%
LOW RISK OF PNEUMOTHORAX
Structures thatare transversed bu a needle placed in the midline prior to the epidural space?
skin subq supraspinous lig intserspinous lig LIGAMENTUM FLAVUM - snap
CAUDA EQUINA SYNDROME
symptoms?
secondary to?
Low back pain
bilateral lower extremity weakness
saddle anesthesia
loss of bowel and bladder control
POOLING of LA dependent area of the Subatachnoid space
CAUDA EQUINA SYNDROME
associated with
larger cathyer
lidocaine
tetracaine
lithotomy
DIFFERENTIAL NERVE BLOCK
Symphathetic berve block 2-5 higher than motor
sensory block 2-3 higher than motor block
in epidural :
sensory and symphatetic at the same area
pain persiating for more than 3 months after resolution of herpes zoster rash
PHN
POSTHERPETIC NEURALGIA
tx: TCA anticonvulsant opioids topical LA CAPSAICIN TENS
innervates the short extensors. of the toes and the skin of the web space between the great and second toes
deep peroneal nerve
block at the ankle by infiltration between the tensons of the ant tibial and extensor hallicis longus muscle
moat cardiotoxic LA
most to least
bupivacaine
ropivacaine
lidocaine
define: anesthesia dolorosa neuropathic pain dyaesthesia hyperalgesia allodynia
anesthesia dolorosa spontaneous pain in the are with anesthesia
neuropathic pain primary lesion or dysfunction in the nervous system
dyaesthesia unpleasant abnormal sensatiin
hyperalgesia increased response to normally painful stimulus
allodynia pain with stimulus that does not normally cause pain
most toxic ester LA
tetracaine
difference between CRPS TYPE 1 and 2
CPRS TYPE 1- trauma
CPRS TYPE 2 - nerve injury
the potency of local anesthetic is directly proportional to
LIPID SOLUBILITY
speed and onset is related to PKA
LOW PKA - inc about of non ionized and penetrate lipid portio fast
most important determinants of sensory level ?
BARICITY
AND POSITION of the pt
LOWEST CONC in the fetus relative to maternal serum
CHLOROPROCAINE
rapidly metabolized by paudocholinesterase
t1/2 45 seconds
HIGH SPINAL ANESTHESIA
hypotension sympathetic blockade venodilation(dec preload) arterial dilation( dec afterload) brady ( cardioaccelerator fibers T1-T4 )
PHANTOM LIMB
80% after amputation
incidence increased with PROXIMAL
few days after sx
PNB decreased incidence
treatment:
opioids
antidepressants
gabapentin
IVRA
BIER BLOCK
upper extremety
raised arm bandage tourniquet 250-300mmHg (2.5 the pt systolic) inject 40-45 mins tourniquest time deflate for 5 sec ( look for toxicity signs)
lidocaine 0.5% 1.5 to 3mg/kg
Largest intervertebral space
L5-S1
SNS originated in the thoracic and lumbar spinal cord ?
T1-Lcan cause total sympathetic block
DURAL SAC ENDS
s1 upt to s2
spinal cord ends at
adult l1-L2
infant L3
4 stages of epidural abscess
1st - localized back pain
2nd - nerve root or radicular pain
3rd- motor or sensory deficit
4th pareplegia
entrapment of lateral femoral cutaneous nerve as it courses below the inguinal ligaments
MERALGIA PAREsthesia
associated
burnjng pain over rhe lateral aspect of the thigh
not a complication of epidura
COMPLEX REGIONAL PAIN SYNDROME
burning continous pain
not anatomically distributes
cool red clammy skin HAIR LOSS associated atrophy and oateoporosis
NEUROLYTIC BLACKADE DIFFERENCE BETWEEN PHENOL AND ALCOHOL
phenol :
painless
dual action la and neurolytic agents
how luch LA SHOULD be administered by spinal segment
1-2mlsegment
(20-40 years old
elderly and preg
0.75-1.5ml/ segment
spread of LA ANESTHETICS PER EPIDURAL ___ secondary to___
2/3 spread cephalad
1/3 spread caudally
until level of T4
secondary to
INTRATHORACIC NEGATIVE PRESSURE
Artery of Adamkiewicz arises fromt he aorta at which spinal level
radicularis magna
T9-T12
ASA( anterior spinal artery ) - anterior 2/3 SC
posterior 1/3 SC - posterior Spinal artery
damage to this artery can lead to ischemia for the lower 2/3 SC. an cause paraplegia
artery of adamkiewicz
Sciatic nerve block landmarks
PSIS
GREATER TROCHANTER OF FEMUR
Sacral HIATUS
DEEP CERVICAL PLEXUS BLOCK
c234
for carotid endarterectomy
complication of DEEP CERVICAL PLEXUS
injection vertebral artey subarachnoid space epidural space phrenic nerve hornera syndrome recurrent laryngeal nerve
retro ulbar block what nerve
346
ciliqry ganglion and nerve
all of the muscle of the larynx is innervates by the _____ except
RLN
CRicothyroid muscle - external SLN
STELATE GANGLION
lies in fromt of the neck of the first rib
vertebral artery lies andyerior to the ganglion
sharp pain during insertion of epidural catheter means
its in the nerve root
pull out and reinset
because if you push LA Caude compression of the nerve»_space; ischemia
five nerve that innervate the ankle and foot
post tibial superficial peroneal deep peroneal saphenous nerve sura
innervate the medial and ateral plantar nerve
plantar surface of the foot
post tibial nerve
CVS:CNS RATIO
lowest to highest
bupivacaine 2 levobupi 2 ropi 2 prilocaine 3 procaine chlorprocaine 3-7 etidocaine 4.4 lidocaine mepivavaine 7..2
phantom limb pt acn received regional anesthesia
NO IT CAN CAUSE REACTIvation of the sendation
GA
complete bilateral transection of the RLN
Vocal cords at the kntermediate position 2-3mm away
partial bilateral paralysis of the RLN
complete airway obstruction
PDPH
loss of CSF + posture component
head is elevated - HA severe
diplopia
nausea and vomiting
ha frontala nd occipial
onset 12-24hrs
INTERcostal STRUCTURES
CEPHALAD TO CAUDAL
VAN
Greatest concentration absortion
ICE BFS
intercostal
caudal epodurala
lumbar epidural
brachial
femoral
subq
LA are base
WEAK BASE
supraclavicular block can cause
pneumothorax
phrenic nerve
ci: respiratory dse
FEMORAL NERVE
2nd to 4th lumbar
anterior divisiin:
motor : sartorius and cutaneous sensatiin ant and medial aspect of the thigh
posterior division
quafriceps muscle
cutaneous ant medi and lateral knee
Obturator nerve block needle placement
1-2 cm lateral to and 1-2 cm below the pubic tubercle
the most SERIOUS COMPLICATION OF SUPRCLAVICULAR BLOCK
pnuemothorax
the most COMMON COMPLICATION OF SUPRCLAVICULAR BLOCK
phrenic nerve block
ipsilateral ptosis
miosis
anhidrosis
HOTNERS SYNDROME
brachial plexus innervates the sensory of the arm except
shoulder - supraclavicular nerve of the cervical plexus
posterior medial aspect of the arm - intercostobrachial nerve
brachial plexus sections
roots trunk- interscalene
trunk-division- supreclabicular
cord- infraclavicular
braches - axillary
CELIAC PLEXUS
lower esophagus stomach small intestines large intestine splenic flexure pancreas liver biliary tract spleen kidneys adrenal glands omentum
HYPOGASTRIC PLEXUS -
pelvic organ uterus ovaries prostate distal colon
GREAT TOE IS INNERVATED BY
posterior tibial deep peroneal superficial peroneal post tibial saphenous
TENS produec analgesia bu
releasing endogenous endorphins
inhibitory effect at the sc
augments the inhibitory pathways
dermatome of the fingers?
c6- thumb
c7 - 2nd and middle
c8 - 4th and little
neurolytic nerve block
duration of action
alcohol?
phenol?
alcohol 3-6 months
phenol 2-3 months
never permanent
TNS is not affected by
baricity conc addtion of epinephrine dextrose hypotension
ULTRASOUND :
high freq
lower freq
high - lower stucture
low for - deeper stucture
PDPH INCREASED incidence
younger
women
pregnant
large needle
VISCERAL PAIN
transmitted by sympathetic nervous system
unmyelinated c fibers
dull aching and burning
PSOAS COMPARTMENT BLOCK
posterior lumbar plexus
for proximal aspect of the thigh and hips
+sciatic block = complete leg block
sensory innervation of the MEDIAL ASPECT OF THE LOWER LEG
saphenous nerve
most common complication of celiac plexus block
hypotensio
occipit receive sensory innervation from
lesser and greater ocipinal nervce (c2-c3)
from the cervical plexus
thoracic paravertebral blocks are used for
postoperative analgesia for breast, axillary or chest wall rigidity surgery
thoracic paravertebral blocks
most common complication
pneumothorax
intrathecal injection of large dose LA will cause
HYPOTENSION
symphathetic fiber
t1-L2
BRADYCARDIA
cardiac accelerator
T1-T4
RESPIRATORY ARREST
phrenic nerve
C3-C5
dilated pupils
CENTRAL PAIN
encephalization
psychogenic pain
malingering
metabolites of ester LA RESponsible for allergic reaction
PABA
MYELINATEF NERVE
suscrptible to LA
Complete anesthesia for shoulder arthroscopy
interscalene and SUPERFICIAL CERVICAL BLOCK
when to stop LMWH prior ti PNB
low doses at 10-12 hrs
hig doses 24 hrs
NA BICARBONATE + LA
hasten onset
decrease pain with infiltration
dec durationof PNB
DURATION OF LA
SHORT
procain an dchloroprocaine
INTErMEDIATE
lidocaine
mepivacaine
prilocaine
LONG etidocaine bupivacaine levo bupi tetracaune rooivacaine
TAP BLOCK
abdominal wall analgesia
subcostal T12
illioinguinal L1
hypogastruc L1
injection is between the internal oblique and TA MUSCLE
POSTERIOR TIBIAL NERVE
flexion of the toes
sensory of the plantar foot
S FORM OF ROPIVACAINE
reduced cardiac and nephro toxicity
LUMBAR PLEXUS
L1-2 genitofemoral
L2-3 femoral cutaneous
L2-4 obturator, femoral
sciatic
L4 ( lumbar plexus)+ L4-s3 ( scral plexus)
LAST AVOID THE USE OF
vasopressin
Cachannel blocker
b blocker
LA
EPI REDUCED TO < 1mcg/kg
LIPID EMULSION 1.5mg/kg c 1 min
0.25ml/kg/min
continue until 10 mins after CV STABILITY
upper limit 12ml/kg
Pain nerve fiber
Aa skeletal muscle
Ab touch and proprioceptio
Ay muscle tone
Ad sharp pain temp and touc
B sympathetic
C nolocalized pain touch and tem
prilocaine causes formation of
Methemoglobin
PDPH
ETIOLOGY
dec csf pressure»_space; tension meningeal vessels and nerves
treatment for neuropathic pain
selective inhibitionof serotonin and NE REUPTAKE
DULOXETINE
pudendal nerve
s2-s4
greater splanic
T5-T90
lesser splanchnic
T10-T12
