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N931 Advanced Principles > Considerations for Epidural & Spinal Anesthesia > Flashcards

Considerations for Epidural & Spinal Anesthesia Flashcards

1
Q

What is an epidural anesthetic?

A

injection of a local anesthetic into the epidural
space for spread to the region of the dural cuffs

– Leaks into intravertebral foramen and paravertebral spaces
– Medication spread is diffusion dependent
– Onset is longer

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2
Q

What is the idea behind epidural/spinal anesthesia?

A

Reversible chemical blockade of neuronal transmission

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3
Q

What lasts longer, epidural or spinal?

A

epidural

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4
Q

What is interrupted with administration of an epidural or spinal?

A

autonomic, sensory and
motor nerve fiber transmission

[EPIDURAL} results are related to drug concentration & volume

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5
Q

Results of an epidural is related to?

A

drug concentration & volume

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6
Q

What are 2 major differences between a spinal and epidural?

A
  1. Spinal directly bathes spinal cord in local anesthetic
  2. Epidural is titratable & can be redosed

[spinal catheter CAN be placed but it is RARE!]

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7
Q

What are 2 other names for a spinal?

A
  1. subarachnoid block

2. intrathecal block

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8
Q

What are 6 advantages of an epidural?

A
  1. ↓ surgical stress
  2. ↓ opioid consumption
  3. ↓ overall blood loss
  4. ↓ risk of DVT
  5. provides anesthesia OR analgesia (can re-dose, or convert from pain to primary anesthetic in laboring mother)
  6. versatile
    - can use with or without adjunctive medications
    - can control extent of sensory or motor blockade based on concentration of local anesthetic used
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9
Q

What are 4 disadvantages of an epidural?

A
  1. post dural puncture headache (PDPH)
  2. sympathetic blockade occurs 100% of the time
  3. block may last longer than the procedure
  4. urinary retention
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10
Q

What is more difficult, an epidural or spinal?

A

epidural

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11
Q

What are considerations when deciding to do an epidural?

A
  1. length of surgery
  2. multimodal pain management
  3. procedure
    [involving abdomen, lower extremities]
  4. certain comorbidities
    [pulmonary disease; will keep the pt breathing, no GA necessary]
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12
Q

What are 5 absolute contraindications to an epidural?

A
  1. pt refusal
  2. increased ICP
  3. severe aortic or mitral valve stenosis
  4. severe hypovolemia
  5. infection at injection site
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13
Q

What are relative contraindications for an epidural?

7

A 
1. Uncooperative patient
       • Inability to communicate / obtain informed consent
        • Unable to assist
2. Local anesthetic allergy
3. Patient on anticoagulant or thrombolytic therapy [why are they on it? afib, DVT?] --- this might be why doing an epidural is GOOD for them... 
4. Preexisting neurologic deficit
5. Chronic headache or backache
6.  Severe spinal deformity
7.  Valvular stenosis
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14
Q

Pre-procedure medications for epidural placement?

A
  1. anxiolytic, do not over sedate!
  2. follow NPO guidelines
  3. consider IV bolus if pt is dehydrated?
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15
Q

Minimum pre-procedure monitoring for epidural placement?

A
  1. IV
  2. Suction
  3. Airway supplies
  4. ECG, BP, SpO2,
  5. oxygen
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16
Q

What should be available when performing an epidural?

A
  • suction
  • airway supplies
  • supportive medications [induction agent, paralytic, atropine, vasoactive meds, zofran]
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17
Q

What type of regional anesthesia is high volume?

A

epidural

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18
Q

What are the 2 needle approaches for spinal/epidurals?

A
  1. midline

2. paramedian

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19
Q

What vertebral body aligns with the lower scapula tip?

A

T7

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20
Q

What vertebral body aligns with the end of an adult spinal cord?

A

L1

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21
Q

What vertebral body aligns with superior iliac crests?

A

L4

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22
Q

What vertebral body aligns with the posterior superior iliac spines? (dimples)

A

S2

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23
Q

What movement of the spine will create larger interspinous spaces?

A

flexion

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24
Q

What do you check right before performing an epidural?

A
  1. patent IV
  2. monitoring devices
  3. oxygen attached & functioning
  4. resuscitation equipment is available
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25
Q

What are characteristics of a Tuohy needle?

A
  • pronounced curve
  • easier for novice
  • directional placement of catheter
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26
Q

What are characteristics of a crawford needle?

A
  • not curved
  • easier to insert
  • higher rate of dural puncture
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27
Q

How long is a standard epidural needle?

A

9cm

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28
Q

What are 2 factors that alter distance to the ligamentum flavum?

A
  1. body habitus

2. level of placement

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29
Q

What is the standard depth of the epidural space in the lumbar region?

A

5cm

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30
Q

What type of needle requires an introducer?

A

spinal needle

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31
Q

How is the bevel situated when doing a spinal or epidural?

A

bevel “up” towards patient’s head

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32
Q

What is the needle advanced through when placing an epidural?

A
  1. skin
  2. SQ tissue
  3. supraspinous ligament
  4. interspinous ligament
  5. ligamentum flavum
  6. epidural space!
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33
Q

How is the needle inserted/advanced when placing an epidural?

A

VERY SLOW!! mm BY mm!!

tap plunger of syringe between movements

TAP EVERY mm!!!

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34
Q

If using the “loss of resistance” technique for epidural placement, how much NS or air is in the syringe?

A

2-3mL

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35
Q

What are you waiting for when advancing an epidural needle?

A

loss of resistance

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36
Q

How does an epidural catheter compare to the epidural needle?

A

the catheter is 2 gauge sizes smaller

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37
Q

Dashed lines on an epidural catheter represent, what?

A

1cm

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38
Q

Two dashed lines on an epidural catheter represent, what?

A

10cm

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39
Q

Two thick lines on an epidural catheter represent, what?

A

12cm

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40
Q

What is the distance from the hub of the epidural needle to the tip?

A

12cm

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41
Q

How far should the epidural catheter be left in the epidural space?

A

3-5cm

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42
Q

What can happen if the epidural catheter is left inserted too deep?

A
  1. puncture of the dura
  2. passage into epidural veins
  3. migration through intervertebral foramen
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43
Q

What must be remembered when manipulating the epidural catheter and needle?

A

NEVER attempt to withdrawal the catheter through the needle

-catheter can break & shear, leaving pieces in the patient!

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44
Q

After placement of an epidural catheter, the needle is removed, then what?

A

attach adapter to free end, look for blood or CSF, gently aspirate

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45
Q

After attaching the adapter to the epidural catheter, looking for blood or CSF, and gently aspirating, what next?

A

administer test dose

1.5% lidocaine with 1:200000 epi

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46
Q

What medication is used as the test dose for an epidural?

A
  1. 5% Lidocaine
    1: 200,000 epi

total: 3mL = 45mg lidocaine with 15mcg epi

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47
Q

How will you know if the epidural is in place?

A

3mL test dose will cause profound spiral block

OR

HR/BP will ↑ more than 20% if the test dose is administered into the vasculature

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48
Q

What must be remembered before giving an epidural “test dose”?

A
  • ask patient, are you about to have/are having a contraction?
  • tell me if you hear ringing in your ears, taste metal, or feel your bottom get heavy
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49
Q

What will happen if your epidural test dose is administered as a spinal?

A

heavy SADDLE BLOCK within 30 seconds

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50
Q

When is the paramedian epidural approach useful?

A

when the patient cannot flex their spine. [Hx spinal surgery, rheumatoid arthritis, hip or upper leg trauma]

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51
Q

Where is the skin wheal placed when performing a paramedian approach?

A

1cm lateral and 1cm caudal to spinous process

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52
Q

When using a paramedian approach for epidural placement, what does the needle advance through?

A
  1. skin
  2. SQ
  3. paraspinous muscles
  4. ligamentum flavum

(does NOT pass through supraspinous or interspinous ligaments

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53
Q

What do you do if a patient reports paresthesia?

A

stop moving, ask if it stops

if the paresthesia goes away, continue

if paresthesia does not stop, remove needle & catheter together and restart at interspinous space above

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54
Q

How do you redirect the epidural needle after hitting bone?

A

pull the needle and stylet back into SQ fat, reposition the introducer then reinsert the needle

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55
Q

What do you do if you get blood in the epidural needle?

A

withdrawal the needle & catheter and replace

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56
Q

What are 3 indications of caudal anesthesia?

A
  1. hemorrhoidectomy
  2. chronic pain patients
  3. pediatric analgesia (inguinal herniorrhaphy, circumcision, perineal procedures)
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57
Q

How is a patient positioned for a caudal block?

A
  1. prone on a flexed table or with a pillow under pelvis, legs spread and externally rotated
  2. laterally
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58
Q

What is the dose of a caudal block?

A
  1. 5-1mL/kg
    - varying LA concentrations

2.5mg/kg

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59
Q

When doing a caudal block, ensure you are not in which two spaces?

A

bone

subcutaneous

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60
Q

What is the volume for adult caudal sacral anesthesia?

A

12-15mL

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61
Q

What is the volume for adult caudal lower extremity block

A

20-30mL

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62
Q

What are 3 complications of adult caudal anesthesia?

A
  1. high failure rate (false passage)
  2. inadvertent IV injection or catheter placement
  3. dural puncture
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63
Q

What are the two types of combined spinal epidural?

A
  1. 2 level; spinal placed then epidural catheter placed 1-2 levels above
  2. 1 level; placement of epidural needle, spinal needle is passed through & small intrathecal dose injected, then epidural catheter placed through epidural needle
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64
Q

What are concerns of combined spinal epidural in the partruient?

A
  1. intrathecal opioid effects on fetus
  2. inability to ambulate after receiving narcotics
  3. maternal hypotension & itching
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65
Q

What are 6 potential complications of combined spinal epidural?

A
  1. failure to obtain either block
  2. catheter migration
  3. increased spinal level
  4. metallic particles
  5. PDPH
  6. neurologic injury
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66
Q

What 2 things does neuraxial imaging facilitate in spinal/epidural placement?

A
  1. identify interspaces

2. determine depth to epidural space

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67
Q

How much metabolism of local anesthetics occurs in the CSF?

A

little to no

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68
Q

What does added vasopressor do to local anesthetics?

A

slows absorption and prolongs block

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69
Q

What are 3 ester local anesthetics?

A
  1. procaine
  2. Chloroprocaine
  3. Tetracaine
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70
Q

What are 4 amide local anesthetics?

A
  1. lidocaine
  2. mepivacaine
  3. ropivacaine
  4. bupivacaine
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71
Q

What is the onset & duration of procaine?

A

slow / 60-90m

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72
Q

What is the onset & duration of Chloroprocaine?

A

Fast 30-60m

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73
Q

What is the onset & duration of tetracaine?

A

slow / 180-600m

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74
Q

What is the onset and duration of lidocaine?

A

fast, 90-20m

75
Q

What is the onset & duration of mepivacaine?

A

fast 120-240m

76
Q

What is the onset & duration of ropivacaine?

A

slow / 180-600m

77
Q

What is the onset & duration of bupivacaine?

A

slow / 180-600m

78
Q

Density of the block is most affected by, what?

A

concentration of the local anesthetic

79
Q

Spread of a block is most affected by, what?

A

volume of the local anesthetic used

80
Q

No more than ___ amount per injection?

A

3-5mL

81
Q

Injection of neuraxial local anesthetic occurs after what?

A

aspiration attempt

82
Q

If the needle is placed caudal, how much volume is administered per segment to raise the level of the block?

A

2mL / segment

83
Q

If the needle is placed lumbar, how much volume is administered per segment to raise the level of the block?

A

1mL / segment,

non-pregnant, non-obese pts can go up to 2mL/segment

84
Q

If the needle is placed thoracic how much volume is administered per segment to raise the level of the block?

A

0.7mL / segment

85
Q

What type of medication is clonidine and why is it added to epidurals?

A

alpha 1 agonist

when mixed with lidocaine or bupivacaine, has synergistic effects for labor analgesia

86
Q

When using opioids in a spinal or epidural, what kind need to be use?

A

PRESERVATIVE FREE

87
Q

What are the two most commonly used opioids in spinal/epidurals?

A

fentanyl

morhpine

88
Q

What is the dose of Fentanyl in epidural anesthesia?

A

50-100mcg

89
Q

What is the onset of Fentanyl in spinal/epidural anesthetics?

A

10-15m

90
Q

What is the duration of Fentanyl in spinal/epidural anesthesia?

A

1-2H

91
Q

What is the dose of morphine in epidural anesthesia?

A

2-4mg

92
Q

Is morphine polar or non-polar?

A

polar

93
Q

Is morphine lipid soluble?

A

not very

94
Q

What are 2 adverse effects of using morphine in spinal/epidural anesthetics?

A
  1. itching

2. urinary retention

95
Q

The goal of neuraxial anesthesia is to block what?

A

Adelta & C fibers

96
Q

What type of nerve fibers are blocked first?

A

Type B; preganglionic autonomic vasomotor

97
Q

What are Adelta fibers?

A

pain, cold temperature, touch

heavy meylination
intermediate block onset

98
Q

What are C fibers?

A

pain, warm and cold temperature, touch

no myelination
early block onset

99
Q

At what level are cardiac accelerator fibers?

A

T4

100
Q

What is the first sign a local anesthetic block is working?

A

flushing/hypotension

101
Q

What mirrors sensory loss?

A

temperature discrimination

102
Q

How often should dermatome level of block be checked?

A

every 2-3 minutes

103
Q

Autonomic blockade is usually where compared to sensory?

A

two dermatome levels higher

104
Q

Upper limit of MOTOR block is usually where compared to sensory block?

A

two levels BELOW sensory block

105
Q

Two risk factors for PDPH?

A
  1. needle size & type

2. young, female, pregnant

106
Q

PDPH in the first 24 hours?

A

conservative

  • recumbent position
  • analgesics
  • fluid administration
  • caffeine
  • stool softeners & soft diet
107
Q

What is an epidural blood patch?

A
  • access epidural space
  • someone else sterile obtains 15-20mL of blood
  • infuse 15-20mL of blood into epidural space BELOW initial puncture site
108
Q

No more than how much LA is injecting during spinal?

A

2mL

109
Q

To anesthetize motor & sensory, local anesthetic concentration should be?

A

0.5% or higher

110
Q

What is the specific gravity of CSF?

A

1.003 - 1.009

111
Q

What additive is used to make a hyperbaric spinal local anesthetic?

A

dextrose

112
Q

What additive is used to make a hypobaric spinal local anesthetic?

A

water

113
Q

What should you call bone when you hit it with the needle?

A

Oss

114
Q

What should you call blood if you see it during a spinal or epidural?

A

Heme

115
Q

If 2 intervertebral spaces look “good”, which one should you use first?

A

the lower then move up if you need to

116
Q

What is the swirl between NS and hyperbaric local anesthetic called?

A

biferengence

117
Q

What is rechecking aspiration called?

A

barbitage

118
Q

If a patient tells you they can’t breathe after placement of a spinal or epidural, what should you have them do?

A

squeeze your hand and let go

119
Q

At what anatomical location does a spinal block occur?

A

ventral and dorsal nerve roots

120
Q

What can be controlled when using a spinal block?

A

block distribution

121
Q

What are 4 indications of using a spinal block?

A
  1. full stomach (↓ aspiration risk compared to general)
  2. difficult airway (keeps them awake & breathing)
  3. minimal metabolic impact (liver dz, kidney dz, diabetes)
  4. reduction in systemic BP leads to ↓ risk of DVT & ↓ risk of blood loss
122
Q

What is a normal aortic cross sectional area?

A

2 cm^2

123
Q

What is CSA of mild aortic valve stenosis?

A

> 1.5 cm^2

124
Q

What is CSA of severe aortic valve stenosis?

A

<1 cm^2

125
Q

What vital sign needs to be considered when choosing to do neuraxial block?

A

Blood pressure…

severe chronic HTN will not tolerate the generalized vasodilation

126
Q

What is the most prominent cervical process?

A

C7

127
Q

What vertebral body lies at the inferior tip of the scapula?

A

T7

128
Q

What factors influence the local anesthetic level of a spinal block?

A
  1. baricity of the local anesthetic used
  2. position of the patient
  3. drug dose
  4. site of injection

also..
[patient’s height, pregnancy, age, CSF volume, curvature of the spine, drug volume, intra-abdominal pressure, needle direction]

129
Q

What is the most dependent area of the supine spine?

A

T4-T8

130
Q

How is a 25G or smaller spinal needle used?

A
  1. place introducer midline in lower third of the interspace

(where lidocaine wheal should have been placed)

  1. then pass spinal needle through introducer
  2. advance through 2 ligaments (which are?)
  • supraspinous
  • interspinous
  1. you may feel 2 “pops”
    - ligamentum flavum
    - dura
131
Q

How slow should local anesthetic be injected into the spinal canal?

A

doesn’t matter

132
Q

How should local anesthetic be injected into the spinal canal?

A
  1. aspirate gently (make sure you get CSF)
  2. administer 50% of medication
  3. aspirate gently again
  4. administer 2nd half of medication
133
Q

If a bilateral spinal block is desired, how should the patient be placed immediately after medication administration?

A

supine with head slightly elevated

134
Q

If a unilateral block is desired, how should the patient be positioned immediately after medication administration?

A

leave the patient in the lateral position for at least 3 minutes prior to returning supine, slightly elevate the patient’s HOB

135
Q

What are the 2 “types” of spinal needles?

A

cutting vs pencil point

136
Q

What should you do if you are using a pencil needle and feel the dural “pop” but do not get CSF?

A

ensure stylet is in needle, advance spinal needle by 1-2mm and/or spin needle

[bevel might be covered or not fully inside the dura]

137
Q

What is one benefit of using a pencil spinal needle vs a cutting spinal needle?

A

less reports of PDPH

138
Q

What should you do if you get blood when performing a spinal block?

A
  1. frank blood = pull all equipment out and start over

2. blood or pink tinged CSF. Allow CSF to flow for several seconds to see if it clears

139
Q

What do you do if the spinal needle is FAR in and you hit bone?

A

traversed dura? possibly

  1. remove stylet
  2. attach syringe to needle
  3. slowly remove needle while gently aspirating

*pt is at increased risk for PDPH

140
Q

What type of nerve block is rapid?

A

B fiber, will cause hypotension

141
Q

What sensation mirrors sensory loss?

A

temperature discrimination

142
Q

In a good sensory block, a patient is unable to discriminate what 2 sensations?

A
  1. light touch

2. temperature

143
Q

Blocking which nerve fibers leads to surgical muscle relaxation?

A

Aalpha
Abeta
Agamma

144
Q

If A alpha, beta, & gamma fibers are blocked what may the patient still feel?

A

pressure

145
Q

How often should vital signs be checked when a patient has a spinal block?

A

2-3 minutes

146
Q

What should be checked along with vital signs every 2-3 minutes when a patient has a spinal block?

A

assess the level/degree of block.

use alcohol pad = cold

147
Q

What is the easiest way to adjust the level of a patient’s spinal or epidural block?

A

reposition/change their position

148
Q

Autonomic blockade relates to sensory blockade, how?

A

autonomic block is usually 2 levels HIGHER than sensory

149
Q

Motor blockade relates to sensory blockade, how?

A

motor block is usually 2 levels LOWER than sensory

150
Q

At what location does a saddle block occur?

A

S2-S5

** little autonomic effect

151
Q

At what level does a “low spinal” block occur?

A

T10

**blocks lumbar and sacral nerve roots

152
Q

What is the most common level for a spinal block?

A

T4

153
Q

What procedures can be done with a spinal block at T4?

A

abdominal and lower extremity procedures

154
Q

What procedures can be done with a spinal block at T10?

A

low abdominal & lower extremity vascular & ortho procedures

155
Q

At what level does a “high spinal” block occur?

A

C8

156
Q

What is the onset of morphine when used in an epidural?

A

10-15 minutes

157
Q

What is the duration of action of morphine when used in an epidural?

A

8-10 hours

158
Q

What is the lumbosacral “Taylor” approach for a spinal block?

A

modified paramedian approach

uses L5-S1 interspace

159
Q

How is the “Taylor” lumbosacral approach completed?

A
  1. identify posterior superior iliac spine
  2. make skin wheal 1cm medial and 1mc caudal to the spine
  3. insert needle at 45-55d angle medial and cephalad to the dorsal surface of the sacrum toward the midline of the lumbosacral foramen
160
Q

What size epidural needle is used for placement of a SPINAL catheter?

A

17G

161
Q

How is medication given through a SPINAL catheter?

A

small, slow doses

slow onset of hypotension

162
Q

What is one situation in which a spinal catheter could be placed?

A

if a “wet tap” occurs when attempting placement of an epidural catheter

163
Q

What are 3 additive medications to a spinal block?

A
  1. epinephrine
  2. phenylephrine
  3. clonidine
164
Q

What is the dose of epinephrine in a spinal or epidural?

A

0.1 - 0.2 mL of 1:1000 = 100-200mcg of epinephrine

165
Q

Epinephrine has the greatest effect when added to what local anesthetic?

A

tetracaine

166
Q

How much phenylephrine is added to local anesthetic?

A

0.05-0.2mL of 1% phenylephrine

^^
10mg/mL = 0.5-2mg of phenylephrine

167
Q

Phenylephrine has the greatest effect when added to what local anesthetic?

A

tetracaine

168
Q

Is clonidine a vasoconstrictor?

A

no

169
Q

What is the MOA of clonidine?

A

selective alpha 2 agonist

170
Q

When is clonidine used in local anesthetics?

A

when epinephrine is contraindicated

171
Q

Clonidine has synergistic effects with what local anesthetics?

A

lidocaine

bupivacaine

172
Q

The central action of clonidine helps with what?

A

tourniquet pain

173
Q

What are 2 benefits of Fentanyl’s high lipid solubility when used in spinal/epidurals?

A
  1. binds directly to lipid elements of the spinal cord

2. less drug available to diffuse systemically

174
Q

When administered in a spinal anesthetic, when will morphine reach the respiratory center?

A

6-8 hours

175
Q

How does morphine act in the spinal column?

A

drifts freely in the CSF

176
Q

What is the dose of Fentanyl in spinal anesthesia?

A

12.5-25mcg mixed with local anesthetic

177
Q

What is the onset of Fentanyl in spinal anesthesia?

A

5-10 minutes

178
Q

What is the duration of action of Fentanyl in spinal anesthesia?

A

2-4H

179
Q

What is the dose of morphine in spinal anesthesia?

A

0.1-0.25mg mixed with local anesthetic

180
Q

What is the onset of morphine when used in spinal anesthesia?

A

60-90 minutes

181
Q

What is the duration of action of morphine when used in spinal anesthesia?

A

~24 hours

182
Q

What is one adverse effect of morphine that is specific to SPINAL anesthesia?

A

DELAYED RESPIRATORY DEPRESSION

183
Q

What are some complications of spinal anesthesia?

A
  • hypotension
  • intercostal muscle paralysis
  • apnea/phrenic nerve paralysis
  • paresthesia
  • subarachnoid or epidural hematoma
  • meningitis/epidural abcess
  • chemical meningitis
  • cauda equina syndrome
  • transient neurologic symptoms
  • new nervous system lesion
  • exacerbation of preexisting neurologic disease
  • N/V
  • urinary retention
  • PDPH

N931 Advanced Principles (3 decks)

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