Class 9 Spinals and Epidurals Flashcards by Charles Grant

What is the benefit of using a stylet when placing a spinal?

-Prevents introduction of dermal cells, which can lead to dermoid spinal tumor

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Name the 4 types of spinal needles?

Quinke
Sprotte
Whitacre
Greene

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Name the 3 types of epidural needles.

Hustead
Touhy
Crawford

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What are the absolute contraindications to spinal anesthesia?

Patient refusal
Lack of cooperation
Uncorrected coags
Infection at block site
Increased ICP

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How should a cutting needle be introduced?

-Longitudinal to avoid cutting nerves

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What are the relative contraindications for spinal anesthesia?

Distal infection
Unknown surgery duration
Hypovolemia
Indeterminate neurologic disease (must chart thoroughly)

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What 4 things affect uptake and spread of spinals?

Concentration of LA in CSF
Surface area of exposed nerve
Lipid content of nerve
Blood flow to nerve

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What affects the distribution of spinals?

Baricity
Position
Dose

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What are the 3 baricities and what do they do?

Isobaric = Stays
Hypobaric = Moves up
Hyperbaric = Moves Down

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What 8 things will affect the level of your spinal?

Baricity
Position
Dose
Site of injection
Speed of injection
Age
Volume
Concentration

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What does adding dextrose do to a spinal?

-Hyperbaric

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What addition will help make your spinal hypobaric?

Sterile water

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How does spinal anesthesia affect the liver?

-As long as MAP is unchanged the liver will not be affected.

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How does spinal anesthesia affect the CV system?

-Sympathectomy causing hypotension and bradycardia

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How does the spinal cause hypotension?

Venodilation and arterial dilation

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With normal lungs, at what block height will a patient experience respiratory problems?

-C3,4,5 (high spinal)

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At what block height does bradycardia become a problem?

T1-T4

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GI sympathetic innervation comes from what level?

-T6-L2

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With a normal spinal, what GI problems can occur?

Increased secretions
Sphincters relax
Bowel constricts

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What drug can be used to treat spinal associated nausea and vomiting?

Atropine

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All spinal medications must be free of what?

-Preservatives

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What can be a complication associated with lidocaine spinals?

-TNS (transient neurologic symptoms)

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What is the onset, duration and dose of lidocaine spinal?

Onset = 3-5 minutes
Duration = 60-90 minutes
Dose = 25-50mg

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What is the onset, duration and dose of Tetracaine spinal?

Onset = 3-6 minutes
Duration = 70-180 minutes
Dose = 5-20mg

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What is the onset, duration and dose of bupivicaine spinal?

- Onset = 5-8 minutes - Duration = 90-150 minutes - Dose = 5-20mg

If placing a spinal in prone position, what type of solution should be used?

-Iso or hypo baric

Where are the iliac crests located?

L4/5

What should you do if the patient has parasthesia during spinal placement?

-Stop advancing and check for CSF

When is a paramedian approach used?

-calcified intraspinous ligament or difficult positioning

What is the first resistance faced when using a paramedian approach?

-ligamentum flavum

After a spinal what must a patient do prior to discharge?

-Void

What are the 4 things that can cause a neurologic injury?

- Needle introduce to nerve or cord - Spinal cord ischemia - Bacterial contamination - Hematoma

What 2 things can cause cauda equina syndrome?

Microcatheters and repeated Lido dosing

What causes arachnoiditis?

- Betadine - Infection - Myelograms from oil based dye - Blood - Neuro irritant - Surgical intervention - Intrathecal steroids - Trauma

What are the treatments for PDPH?

- Fluids - Caffeine - Bed rest - Analgesia - Sumatriptan - Blood patch (invasive)

What increases the risk for spinal hematoma?

- Anticoags - ↑ age - Female - HX of GI bleeds - Length of therapy

What is the first indication of CV collapse r/t spinal anesthesia?

Bradycardia treat agressive

What are the absolute contraindications to epidurals?

- Patient refusal - Hypovolemia - ↑ ICP - Infection at site

What are the controversial contraindications with epidurals?

- Inability to communicate - Tattoos - Complicated surgery w/ heavy blood loss

Where is an epidural place and at what age can that level be used?

- L2-4 | - Adult levels after age 8

Where does spinal cord end in a child? Adult

- L2/L3 | - L1

An epidural block below T4 can affect what?

- Vasomotor tone (T5-L1) | - Decreased venous return = decreased CO

An epidural block above T4 will affect what?

- Sympathetic fibers (T1-T4) | - Hypotension and bradycardia

Respiratory arrest with an epidural is likely caused by what?

-sympathectomy and brain ischemia

What is segmental block epidural?

-Only blocking specific levels

How does LA concentration effect an epidural?

- Low concentration will block only sensory | - High concentration will block motor

What is the key factor in epidural spread?

- Volume | - 1-2 ml for each level to be blocked.

A lumbar epidural will spread more ______ than caudal. While thoracic gets an _______ spread.

- Cephalad | - Even

How does position effect epidurals?

-It doesn't

How does age effect epidural dosing?

Increased age = decreased dose

How does height effect epidurals?

< 5'2" = 1ml per level > 5'2" = increase by .1ml for every 2 inches

How does pregnancy and obesity effect epidural dosing?

Decreased dose needed

What will identify the epidural space? what are the 2 ways to find it?

- Loss of resisance | - Advance and tap or continous pressure

How is the sacral hiatus identified?

-Sacral cornu

When placing a caudal block you will feel a pop after going through what?

-sacrococcygeal membrane

How far do you advance a caudal block in adults? children?

- Adults no more than 1.5 cm | - Kids no more than .5 cm

What is the appropriate test dose for epidural?

-3ml of 1.5%lido w/ 15mcg ept

What should you never do with and epidural?

withdraw catheter through needle, may sheer off piece of catheter that can remain in the back

What must always be done prior to epidural injection?

-Aspiration

How are epidurals dosed in the lumbar?

- Lumbar = 1-2ml per segment - Thoracic = 0.7 ml per segment - Caudal = 3 ml per segment

What is the dose for continuous epidural infusions?

4-15 ml/hr

How would you treat a unilateral epidural block?

- Pull catheter back slightly - Unaffected side down - redose - replace

How do you treat an inadequate epidural?

- raise head and redose w/ higher concentration | - Add fentanyl

When are PDPH most common?

- With younger females | - After wet tap

A subdural injection with result in what?

- Delayed response | - High spinal

A subarachnoid injection will result in what?

-Fast high spinal

What are the symptoms of meningitis?

- Non positional headache - fever - Lethargy - confusion - Nuchal rigidity

How to treat meningitis?

- Emergent antibiotics | - Head CT, lumbar puncture, neuro consult

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