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Anaesthesia > Day 5: Local and Regional Anaesthesia > Flashcards

Day 5: Local and Regional Anaesthesia Flashcards

1
Q

what is regional anesthesia

A

Regional anaesthesia affects one part of the body only

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2
Q

which parts of the the anaesthetic triad does regional anaesthesia provide

A

Analgesia
Muscle Relaxation
No Hypnosis (additional sedation may be given

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3
Q

benefits of regional anaesthesia

A
  • pre emptive analgesia
  • post op analgesia
  • hemodynamically stable (caution: neuroaxial)
  • rapid recovery post- op
  • reduced surgical stress response
  • reduced GA complications
    *avoids airway instrumentation and its complications
  • reduced PONV
  • reduced DVT in ortho
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4
Q

types of regional anaesthesia

A

-topical
- wound infiltration
-intravenous regional anesthesia of the arm (Bier’s block)
-peripheral nerve blocks/ plexus blocks
- central neve block (neuraxial blockade)

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5
Q

topical anaesthesia

A

-aerosolised (25% lignocaine)
- topical cream
-direct application (drops)

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6
Q

division of infiltration

A

subcutaneously
intradermally

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7
Q

infiltration: subcutaneously

A

-Often given into wounds at the end of surgery, under GA
-Provides some postoperative analgesia
-Wound infusion catheters can give hours of postoperative pain relief

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8
Q

infiltration: intradermally

A

Suturing of wounds
Local before siting of large IV lines, central lines, arterial lines, spinals & epidurals

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9
Q

peripheral nerve blockade division

A

-single nerve blocks
-plexus blocks
-deep infiltration

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10
Q

single nerve blocks

A

Femoral, popliteal, radial etc

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11
Q

plexus blocks

A

Brachial plexus blocks, e.g.
-Supraclavicular (forearm surgery)
-Interscalene (shoulder surgery

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12
Q

deep infiltration

A

Transversus abdominus plane block (TAP block)

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13
Q

nerve location

A

use ultrasound

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14
Q

division of neuraxial blockades

A

spinal anesthesia
epidural anesthesia

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15
Q

What is spinal anaesthesia?

A

Spinal anaesthesia involves the injection of a local anaesthetic into the cerebrospinal fluid (CSF) within the subarachnoid space.

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16
Q

How quickly does spinal anaesthesia act?

A

Spinal anaesthesia is rapidly acting, providing relatively quick onset of anaesthesia.

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17
Q

What does spinal anaesthesia achieve in terms of sensory and motor functions?

A

Spinal anaesthesia achieves both sensory and motor block, effectively numbing the area and reducing motor function.

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18
Q

What level of anaesthesia can spinal anaesthesia provide?

A

Spinal anaesthesia can provide sufficient anaesthesia for surgery, making it suitable for various surgical procedures.

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19
Q

Where is the local anaesthetic injected in spinal anaesthesia?

A

The local anaesthetic is injected into the CSF within the subarachnoid space.

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20
Q

What are the primary effects of spinal anaesthesia?

A

Spinal anaesthesia results in both sensory and motor block, effectively numbing the area and reducing motor function.

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21
Q

What is epidural anaesthesia?

A

Epidural anaesthesia involves the injection of a local anaesthetic into the epidural space, which is more superficial compared to the subarachnoid space targeted in spinal anaesthesia.

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22
Q

How does the onset time of epidural anaesthesia compare to spinal anaesthesia?

A

Epidural anaesthesia takes longer to work compared to spinal anaesthesia due to its more superficial placement.

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23
Q

What is the primary effect of epidural anaesthesia?

A

Epidural anaesthesia primarily provides sensory blockade, numbing the area where it is administered.

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24
Q

Is epidural anaesthesia typically sufficient to provide full surgical anaesthesia?

A

No, epidural anaesthesia is usually not good enough to provide full surgical anaesthesia on its own.

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25
Q

How is epidural anaesthesia often used in combination with other forms of anaesthesia?

A

Epidural anaesthesia is usually combined with general anaesthesia to provide comprehensive pain relief and anaesthesia for surgical procedures.

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26
Q

When is a neuraxial nerve block good enough for surgery?

A

If dense enough—spinal anaesthesia and high-dose epidural
-Excellent operating conditions are achieved
**Sensory block – interrupts somatic and visceral painful stimuli
**Motor block – skeletal muscle relaxation

27
Q

Where is the local anaesthetic deposited in spinal anaesthesia?

A

Where is the local anaesthetic deposited in spinal anaesthesia?

28
Q

What is the effect of local anaesthetic deposition in the subarachnoid space?

A

It leads to the blockade of nerve roots as they pass through the subarachnoid space, resulting in sensory and motor blockade.

29
Q

What lies deep to the subarachnoid space?

A

The subarachnoid space is deep to the dura mater and arachnoid mater.

30
Q

Where does the spinal portion of the subarachnoid space extend from and to?

A

The spinal portion of the subarachnoid space extends from the foramen magnum superiorly to the sacral hiatus (S2) inferiorly.

31
Q

At what vertebral level does the spinal cord typically end?

A

The spinal cord typically ends at the level of L1/L2.

32
Q

Where is the epidural space located in relation to the dura mater?

A

The epidural space lies outside the dura mater.

33
Q

What structures pass through the epidural space as they leave the spinal cord?

A

Nerve roots pass through the epidural space as they exit the spinal cord.

34
Q

Describe the composition of the epidural space.

A

The epidural space is a potential space containing fatty connective tissue, lymphatics, and a venous plexus.

35
Q

What is the nature of the epidural space in terms of pressure?

A

The epidural space is a potential space with a negative pressure.

36
Q

Layers from Skin to the Spinal Cord:

A

skin
subcutaneous tissue
superficial fascia
deep fascia
muscles
vertebral column
dura mater
arachnoid mater
subarachnoid space
pia mater
spinal cord

37
Q

indication for spinal neuraxial blocks

A

Spinal—usually as sole technique for anaesthesia

38
Q

indication for epidural neuraxial blocks

A

Epidural—usually combined with GA for analgesia

39
Q

examples of applications

A

lower abdominal surgery
inguinal surgery
urology
gynaecology
obstetrics (CS- spinal; Labour- epidural)
lower extremity surgery
lower rectal/ perineal surgery

40
Q

contra- indications: absolute

A
  • patient factors (refusal/ allergy)
    -logistical issues
    -local infection of the site
    -coagulopathies
    -severe hypovolaemia
    raised ICP
41
Q

contraindications: Relative

A

-systemic sepsis
-uncooperative patient
- pre- existing neurological deficits
- regurgitant valvular deficits
- severe spinal deformity
-previous spinal surgery
-complicated surgery where block would not last long enough or be inappropriate

42
Q

advantages of regional anaesthesia

A

-pre emptive analgesia
-post op analgesia
-usually less physiologic derangements
-rapid post op recovery
-no airway instrumentation and the complications associated with it
-no GA and associated complications (aspirations, failed intubation, PONV, MH)
- decreased incidence of DVTs

43
Q

complications of regional anaesthesia

A

-hypotension: common (especially spinal)
-high spinal
-post dural puncture headache
-meningitis, epidural abscess
-epidural and spinal hematoma
-neurological sequalea
-urinary retention
- pruritis (from opioids)
-shivering
-backache

44
Q

mechanism of hypotension

A

Sympathetic blockade leads to vasodilatation

45
Q

treatment of hypotension

A

Vasopressors
-Ephedrine: 5mg bolus
-Phenylephrine: 50ug bolus
-Adrenaline if unresponsive to above measures

IV FLUIDS

46
Q
A
47
Q

the high spinal presentation

A

-Severe hypotension
-Bradycardia
**Blockade of the cardiac accelerator fibres
-Difficulty breathing
-Loss of consciousness

48
Q

the high spinal management

A

IV Fluids
Vasopressors
Atropine
Intubation and ventilation
Adrenaline

49
Q

post dural puncture headache mechanism

A

CSF leak from a hole in the dura left by the needle
Traction on dura
Meningitis-like headache

50
Q

post dural puncture headache incidence

A

Higher with epidurals (1%) (accidental dural tap)

51
Q

post dural puncture headache

A

Smaller gauge needles
Pencil point needles

52
Q

post dural puncture headache

A

Conservative
Bedrest
IV Fluids
Simple analgesia
Opiates
Laxatives

Epidural Blood Patch
High success rate of cure

53
Q

neurological sequelae: neuropraxias

A

Transient
Nerve root damage from needle

54
Q

neurological sequelae: paralysis

A

Direct damage
Epidural haematoma or abscess (compression)
-Monitor patient for return of motor function
-Emergency
-Urgent MRI
-Must be released within 6 hours
-Laminectomy / drainage

55
Q

minor complitions

A

shivering
prutitis (naloxone)
urinary rentention
backache

56
Q
A
57
Q

pre- op care

A

=Assessment same as for GA (must be suitable for GA, in the event that you need to convert to GA)
-Starved
-Premed
-Full theatre preparation

58
Q

intra -op care

A

=Monitors: ECG, NIBP, pulse oximeter, etCO2
=Supplemental oxygen
=Sedation
=Prevent hypothermia

59
Q

post op care

A

-Block should be receding
-If no return of motor function within 6 hours: be concerned re epidural haematoma
-Timing of anticoagulation

60
Q

factors influencing the height of the block

A
  • patient position or posture
  • specific gravity of solution
    -volume of drugs
  • volume of CSF
  • site (interspace)
    -force and rate of injection
    -barbotage
  • age, height, weight
61
Q

specific gravity

A

CSF has a SG of 1,004.

Solutions with a higher SG (heavier) with sink in the SAS, they are gravity-dependent

Hyperbaric: “heavy” solutions - bupivacaine with dextrose

Isobaric: plain bupivacaine or lignocaine

62
Q

opioids as additives

A

Fentanyl or morphine usually in SA

Effect:
-Extends the duration of action
-Enhances analgesia
-Can be used alone, without LA, to give analgesia (block sensory nerves only)
-Side-effect: pruritis, can be severe

63
Q

advantages of epidural anesthesia

A

-Placement of epidural catheter allows for a constant infusion or top-up doses
-PCEA: Patient-controlled epidural anaesthesia
-Opiates enhance post-operative analgesia
-Graded block – slow establishment of level avoids the rapid haemodynamic changes

64
Q
A

Anaesthesia (14 decks)

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