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Regional Test II > Epidural Anasthesia > Flashcards

Epidural Anasthesia Flashcards

0
Q

Important concepts to remember when administering the LA

A

Inject slowly,

in 3-5ml increments q 3 min to get desired effect

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1
Q

What is “top off dose?”

A

When 2 segment regression of the sensory block has occurred, give 1/3 to 1/2 of the initial loading dose of local anesthetic to maintain block

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2
Q
  1. Always administer a Test dose of…
A

3ml of1.5% lidocaine w/ 1:200000 epi: 5mcq/ml
Significance:
+ numbness=SAB
+ increase of HR= intravascular

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3
Q

Test dose in subarachnoid

S/S

A

Spinal anesthesia w/in 3 min
Rapid decrease in HR & B/P
May also see s/s of sensory & motor blockage.

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4
Q

Test dose in a blood vessel

A

Intravascular
20% in HR & SBP within 30 sec
Change in SBP of >20 mmHg in pt on beta blockers is more indicative of an intravascular injection

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5
Q

What 3 meds always need to be available?

A

Ephedrine
Phenylephrine
Atropine

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6
Q

What Ned “spares” motor nerves especially in lower concentration?

A

Bupivacaine

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7
Q
  1. Identify why thoracic epidural is more difficult to insert & the risks associated w/a thoracic epidural anesthesia
A
  • spinous processes are more angled
  • spinal canal is closer to the skin (shallow)
  • accidental dura puncture- risk of spinal cord injury
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8
Q
  1. S/S of local toxicity
A

Numbness lips & tongue, metallic taste, tinnitus, visual disturbances, muscle twitching, vertigo, seizures, CNS depression/coma, respiratory arrest, CV compromise.

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9
Q
  1. Why we use additives w/LA for epidural anasthesia
A

CLONIDINE: prolongs sensory but not motor block, effects occur w/long acting locals
- causes sedation, decrease in B/P & HR
EPINEPHRINE: prolong sensory & motor block of short & intermediate acting LA
- greater decrease in MAP due to beta 2 vasodilation
NARCOTICS: prolong sensory but not motor
BICARBONATE: speeds ones to epidural block

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10
Q
  1. Identify the difference in motor, sympathetic, & sensory blockade between SABs & epidurals.
A

SAB/Epidural: Sympathetic, 2 below Sensory desired, 2 below Motor
Epidural
Sympathetic: decreased SVR due to arterial & venous dilation. Less hypotension than a SAB. Bradycardia only if T5 or higher (T1-4)
Motor: variable, depends on amount & concentration of LA

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11
Q
  1. Lab values for epidural placement
A 
INR must be  100,000
heparin SQ 2hrs after the last dose 
Lovenox 12 hrs
Plavix 7 days
Ticlid 14 days
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12
Q
  1. Epidural blood patch.
    How is it done?
    What is administered?
    Where? How much?
A

10-20 ml (15 ml) of autologous blood aseptically injected into the next lower interspace, sterile procedure.
Avoiding lifting, straining and air travel for 24-48 hrs.
Can be repeated
90% effective

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13
Q
  1. Describe the characteristics of the epidural space.
A
  • extends from skull foramen magnum to sacral hiatus
  • usually has negative pressure
  • widest @ L2 (5-6mm); narrowest @ C5 (1-1.5mm)
  • contains: spinal n roots, adipose & connective tissue, lymphatic vessels & blood vessels (sm arteries & veins that form plexus - making placement of catheter more difficult )
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14
Q

8a. Describe the procedure in Administering an epidural anesthetic in midline approach

A

MIDLINE approach - lumbar or low thoracic epid in the sitting position
- attach monitors, identify levels, spine is prepped & draped sterile, infiltrate skin wheel & deep, insert epidural needle w/stylet through same skin puncture, advance needle through supra and into inters, aprox 3 cm depth, loss of resistance needle w/2-3 cc of air or saline, push needle slowly till loss of resistance, thread catheter 3-5cm into epidural space

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15
Q

8b. Describe the paramedian approach

A

PARAMEDIAN: for entry level T3-T7, the midline level is impossible to enter due to angulation of the spinous processes.

  • skin wheel 1.5-2 cm. lateral to midline
  • needle advance perpendicular to skin until the lamina is encountered
  • needle redirected & advanced @ 10-15 degree angle toward midline
  • needle is “walked off” the bone into the ligamentum flavum
  • needle penetrates para spinous muscle w/little resistance b4 entering ligamentum flavum
16
Q
  1. Recognize the significant of test dose
A

3ml of 1.5% lidocaine w/ 1:200,000 epinephrine (5mcq/ml)
-If SAB = w/in3 min, decrease of HR & B/P, sensory & motor blockade
-If intravascular = 20% increase in HR & SBP w/in 30sec. A change in SBP >20 mm Hg in pts w/beta blocing agents is more indicative of an intravascular injection
LA toxicity may be also seen.

17
Q
  1. Identify anatomical structures associated w/ epidural insertion
A

Skin–sub q tissue–supraspinous ligament–interspinous ligament–ligamentum flavum–epidural space–spinal cord
Midline: insert needle between spinal processes
Paramedian: insert 1cm lateral to the spinous process & perpendicular to skin–contact lamina & walk off the edge to ligamentum flavum

18
Q

Anasthesia of first stage of labor

A

T10-L1 dermatomes anesthetic

19
Q

Widest epidural space

A

L2 (5-6mm)

20
Q

Narrowest epidural space

A

C5 (1-1.5mm)

21
Q

Which LA can have tachyphylaxis?

A

Lidocaine 1.5-2%

22
Q

Second stage of labor

A

S2-4 segments due to vaginal distention &perineal pressure

23
Q

Initial dosing for
Thoracic
Lumbar

A 
Thoracic poke
6-8 ml:    short reduce by 1-2; tall pts increase by 1-6 ml
Lumbar poke
L3:    8-12 ml
T10:  10-14 ml
T4:    20-25 ml (ex. C-section)
24
Q
  1. Potential complications and Rx
A

Pruritis due to narcotics: Nalmene or Benadryl
Nausea & Vomiting: Nalmene or antiemetic
Urinary retention: Foley cath, straight cath or d/c urinary cath
No pain relief: catheter not in correct spot….

25
Q
  1. How hemodynamics may be effected with epidural
A
  1. Hypotension: IVF, Ephedrine, Phenylephrine
  2. Decrease SVR
  3. Bradycardia: if level T5 or higher watch with c-section
26
Q
  1. What is caudal anesthetic?
A

Common in peds: epidural cath or single injection for post op pain

Adults: used for procedures requiring blockage of the sacral & lumbar nerves & for chronic pain Rx.

Bupivicane .25 2mg/kg, onset 12min, duration 43hrs
Ropivicane .2 2mg/kg. onset 9min, duration 17hrs

27
Q
  1. How do you know if epidural is working?
A

No pain in the surgical area

28
Q

Anatomy & dermatomes

A 
Perineum s2-s4
Lateral foot s1
Knee/thigh L3-L4
Superior iliac crest L4
Umbilicus T10
Xiphoid T6-8
Nipples T4-5
C7
C4 clavicle
29
Q

Surgical procedures and recommended peak block

A

T1: upper abd, chole, expl
T4-6: lower abd, TAH, vs, hernia, appy
T6-8: TURP, vaginal delivery, total hip, fem-pop
T8-10: LE w/tourniquet, knee replacement, BKA
S4-L1-2: percirecatal, perineal (hemorrhoidectomy, transvag sling

Regional Test II (2 decks)

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