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Advanced Principles > Epidural Anesthesia > Flashcards

Epidural Anesthesia Flashcards

1
Q

What is an advantage of an epidural over a spinal?

A

Slower onset of hypotension than spinal

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2
Q

What are some advantages of leaving the catheter in the epidural space?

A

May use as single injection or continuous
Anatomical distribution may be precisely controlled
Excellent postoperative analgesia

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3
Q

Why is an epidural a popular option for those in labor?

A

It provides segmental block/band of analgesia

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4
Q

How does an epidural reduce the surgical stress response?

A

It blocks afferent impulses toward the cord

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5
Q

How does an epidural inhibit hormonal and metabolic consequences?

A

Blocks afferent impulses from the operative site to the brain and efferent autonomic pathways to the liver and adrenal gland

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6
Q

What makes an epidural more difficult than a spinal?

A

There is no end point, in a spinal you’ll see CSF

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7
Q

How long can an epidural take to establish surgical level of anesthesia?

A

10-20minutes

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8
Q

Why might an epidural be beneficial in an amputation?

A

Decreased incidence of phantom limb pain

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9
Q

How many total vertebrae are there?

A 
33
Cervical 7
Thoracic 12
Lumbar 5
Sacral 5 -fused
Coccyx 4-fused
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10
Q

What is the name of the largest opening for needle passage?

A

Interlaminar foramen “interspace”

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11
Q

What are characteristics of a thoracic vertebrae?

A

Steep angle and length of spinous process

Body is heart shaped

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12
Q

Where does the supraspinous ligament extend?

A

C7-sacrum

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13
Q

What is the thickest, broadest ligament in the lumbar region?

A

Supraspinous ligament

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14
Q

Where does the interspinous ligament extend?

A

Extends full column length

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15
Q

Where does the Ligamentum flavum extend?

A

From the base of the skull to the sacral hiatus

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16
Q

What is the average depth of the epidural space?

A

5.3cm

Range 2-9cm

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17
Q

What are the borders of the epidural space?

A

Anterior border is the dura

Posterior border is the ligamentum flavum

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18
Q

Where does the epidural space extend?

A

From the foramen magnum to the sacral hiatus

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19
Q

What is contained in the epidural space?

A

Nerves, Fat, lymphatics and veins (epidural plexus)

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20
Q

Why is more volume injected when administering an epidural?

A

You have to give enough to fill the entire space both anteriorly and posteriorly (spotty if not covered completely)

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21
Q

What are the layers to get to the epidural space?

A 
Skin
Subcutaneous tissue/fat
Supraspinous ligament
Interspinous ligament
Ligamentum flavum
Epidural space
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22
Q

What anatomical land mark is associated with C7?

A

Most prominent vertebrae above the scapula

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23
Q

What anatomical land mark is associated with T7?

A

Inferior angle of the scapula

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24
Q

What anatomical land mark is associated with L4?

A

Inferior aspect of the iliac crest

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25
Q

How many nerves innervate the dermatomes?

A

8 spinal nerves

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26
Q

Where should the epidural needle be inserted for a Mastectomy?

A

T1

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27
Q

Where should the epidural needle be inserted for a Thoracotomy?

A

T4

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28
Q

Where should the epidural needle be inserted for an Upper abdominal procedure?

A

T7-T8

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29
Q

Where should the epidural needle be inserted for a Lower abdominal procedure?

A

T10

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30
Q

Where should the epidural needle be inserted for a lower extremity above the knee procedure?

A

L1-L2

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31
Q

Where should the epidural needle be inserted for a lower extremity below the knee?

A

L3-L4

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32
Q

Where should the epidural needle be inserted for a perineal procedure?

A

L4-L5

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33
Q

Where are sensory innervation landmarks for the clavicle?

A

C4

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34
Q

Where are sensory innervation landmarks for the nipples?

A

T4

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35
Q

Where are sensory innervation landmarks for the Xiphoid?

A

T6

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36
Q

Where are sensory innervation landmarks for the umbilicus?

A

T10

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37
Q

Where are sensory innervation landmarks for the inguinal ligament?

A

L1

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38
Q

Where are sensory innervation landmarks for the iliac crest?

A

L4

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39
Q

What are the characteristics of an epidural needle?

A

16-18g, 9cm long, 11cm to the distal hub with markings at 1cm intervals

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40
Q

What is the purpose of the epidural needle having a directional tip?

A

Facilitates catheter threading in the direction of the needle tip

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41
Q

Why should the provider never remove the catheter through the needle?

A

Run the risk of shearing the catheter into the patient

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42
Q

When removing an epidural catheter what feature needs to be checked and intact?

A

The tip of the catheter, it is typically marked blue

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43
Q

What two positions are typically used when positioning a patient for an epidural?

A

Sitting up and Lying on side

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44
Q

What can occur if pre solution is introduced into the epidural space?

A

Inflammation or arachnoiditis, wipe the solution after it dries with a sterile gauze

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45
Q

What percentage of lidocaine should be used to make the skin wheal?

A

1%

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46
Q

What occurs when the loss of resistance technique is used for an epidural when passing thought the ligaments?

A

The plunger of the syringe is resistant until the ligaments are passed

47
Q

How does the provider know they are in the epidural space when using the hanging drop technique?

A

The saline drop is sucked in when the epidural space is entered

48
Q

How can saline vs CSF be differentiated if fluid were to flow out of the needle in an epidural attempt?

A

Take a drop of the fluid on the back of your hand and sense the temperature:
If the fluid is warm its probably CSF
If the fluid is cold its more than likely the saline you injected

49
Q

What is an indicator that the catheter is flush withe the needle tip?

A

When the first black mark is flush with the hub

50
Q

How far do you advance the catheter past the needle tip?

A

2-4cm

51
Q

Before securing the catheter what should be completed?

A

A test dose should be given to see if the catheter is still in the correct position. May need to manipulate the catheter

52
Q

What is a typical test dose given to a patient?

A

3-5mL of local anesthetic containing epinephrine

53
Q

What can occur is the catheter is not in the correct place?

A

Spinal anesthetic may occur if in the subarachnoid space

Increased HR may indicate the catheter is intravenous

54
Q

What can be done if you are unable to thread the catheter?

A

Rotate the needle slightly to change the bevel

55
Q

What should be done if blood is present in the catheter?

A

More than likely in an epidural vein, take out the needle and catheter and try again

56
Q

What are indication for a caudal approach?

A

Hemorrhoidectomy

Pediatric –> inguinal herniorraphy, circumcision, scrotal procedures

57
Q

What is the best position for the caudal approach?

A

Prone with the legs spread and externally rotated to optimize landmarks

58
Q

What are the landmarks for the caudal approach?

A

Posterior superior iliac spines
Sacral cornua
These three points for a triangle

59
Q

What does a caudal approach have such a high failure rate?

A

The sacral anatomy varies greatly in adults

60
Q

What population is a caudal approach ideal in?

A

Pediatrics

61
Q

What are you puncturing when attempting a caudal approach?

A

Sacral hiatus and then advancing 1-2cm

62
Q

Why does the provider typically feel when injecting into the sacral hiatus?

A

To make sure they are not injecting into the subcutaneous tissues, will feel skin rise

63
Q

If the patient begins to complain of severe pain when injecting into the sacral hiatus where is the prover more than likely injecting the local anesthetic?

A

Subperiosteum, the periosteum is very sensitive

64
Q

What factors are the basis of epidural dosing?

A

Procedure
Desired segments blocked
Needle insertion

65
Q

How do you dose epidurals?

A

Based on the region at which the needle is inserted

66
Q

What is the dosing if the needle is being inserted in the thoracic region?

A

0.7mL/segment

67
Q

What is the dosing if the needle is being inserted in the lumbar region?

A

1mL/segment

68
Q

What is the dosing if the needle is being inserted in the caudal region?

A

2mL/segment

69
Q

Why does the spread of an epidural block seem to occur faster in the cephalad direction?

A

The thoracic roots are smaller in diameter than the larger lumbar and sacral

70
Q

What is the purpose of adding a vasoconstrictor to an epidural?

A

To decrease systemic absorption

71
Q

How does age affect the epidural space?

A

The older the age, the smaller the epidural space

72
Q

Why isn’t baricity a factor with epidural anesthesia?

A

Baricity refers to mixing a solution with CSF which should not occur with an epidural

73
Q

Define two-segment regression.

A

The time it takes for a sensory love to decrease by two dermatome levels

74
Q

How can you redose an epidural if two segment regression has occurred?

A

Inject 1/3 to half of the initial activation dose

75
Q

How many mug/mL is in 1:200,000 of epinephrine?

A

5mcg

76
Q

How is epinephrine dosed with local anesthetics?

A

5mcg/mL of LA

77
Q

What is the difference in muscle relaxation of an epidural compared to a spinal?

A

Epidurals don’t get significant motor blockade like spinals do

78
Q

What is the percent of motor blockade seen with 2% Lidocaine with and without epi?

A

Lidocaine: 9+/-18%

Lidocaine with Epi: 37+/-20%

79
Q

What is the percent of motor blockade seen with 2% Mepivacaine with epi?

A

30%

80
Q

What is the percent of motor blockade seen with 0.5% Bupivacaine?

A

29+/-29

81
Q

How can the provider tell if a complete motor block has occurred?

A

The patient is unable to move feet or knees

82
Q

How can the provider tell if an almost complete motor block has occurred?

A

The patient is able to move the feet only

83
Q

How can the provider tell if a partial motor block has occurred?

A

The patient is able to move their knees

84
Q

How can the provider tell if no motor blockade is present?

A

The patient has full flexion of the knees and feet

85
Q

What are the benefits to using a combined spinal-epidural technique?

A

Offers effective, rapid onset analgesic with minimal risk of toxicity or impaired motor block
Provides continuous technique with epidural catheter

86
Q

Which type of nociceptive pain requires a more dense block?

A

Somatic, burning, sharp pain

87
Q

What epidural opioid has a slow onset, long duration, high CSF solubility and extensive CSF spread?

A

Morphine

88
Q

What type of opioid is never permitted in an epidural?

A

Opioid with preservatives

89
Q

What are the advantages of epidural morphine?

A

Prolonged single dose
Extensive spread
Minimal dose compared to IV administration

90
Q

What are some disadvantages of epidural morphine?

A

Delayed onset of analgesia
Unpredictable duration
Higher incidence of side effects
Delayed respiratory distress

91
Q

What two epidural opioids are known to be lipophilic?

A

Fentanyl and Sufentanil

92
Q

What epidural opioid is know to have a rapid onset, short duration, low CSF solubility and spread?

A

Fentanyl and Sufentanil

93
Q

What are some advantages of epidural fentanyl and sufentanil?

A

Rapid analgesia
Decreased side effects
Ideal for continuous infusion

94
Q

What are some disadvantages to epidural fentanyl and sufentanil?

A

Systemic absorption
Brief single dose analgesia
Limited spread

95
Q

How often should a patients BP be evaluated if receiving epidural anesthesia?

A

3-5minutes

96
Q

What are signs that the autonomic block has occurred?

A

Large drop in BP

Nausea from hypotension

97
Q

At what level would bradycardia be seen with an autonomic block?

A

T2-T5, cardio-acclerator fibers at T4

98
Q

When sympathectomy occurs from T5-L1 what happens in the GI tract?

A

Parasympathetic outflow –> contracted gut and relaxed sphincters

99
Q

What is the first line treatment for a postdural puncture headache?

A

Oral analgesics
Bed rest
Hydration
Caffeine infusion

100
Q

What intervention can be done if conventional treatments aren’t effective against a postdural puncture headache?

A

Blood patch

101
Q

What is the process for performing a blood patch?

A

Draw 10-20mL of patient’s own blood using sterile technique and inject it into the epidural space

102
Q

What is the success rate of an epidural patch after the initial attempt?

A

90%

103
Q

What are the four stages of an epidural abscess?

A

Back or vertebral pain increase with percussion
Nerve root pain
Motor sensory deficits or sphincter dysfunction
Paraplegia or paralysis

104
Q

What is the incidence of an epidural abscess?

A

1:6,500-1:50,0000

105
Q

What is typically the cause of an epidural hematoma?

A

Abnormal coagulation

106
Q

What is the incidence of an epidural hematoma?

A

1:150,000

107
Q

Where should the skin wheal be placed in a paramedian approach?

A

1-2cm lateral to midline directly opposite upper tip of spinous process below selected interspace

108
Q

What ligaments are bypassed when utilizing a paramedic approach?

A

Supraspinous ligament

Interspinous ligament

109
Q

When does the spinal cord end?

A

L1-L2

110
Q

What two regions of the spinal column have convex sections anteriorly?

A

Cervical curve

Lumbar curve

111
Q

What two regions of the spinal column have concave sections anteriorly?

A

Thoracic curve

Sacral curve

112
Q

What are the two lowest parts of the concave sections of the spinal column?

A

T5 and S2

113
Q

Where does the supraspinous ligament extend?

A

C7 to the sacrum

114
Q

What is the pneumonic used to describe the most vascular injection of LA to the least vascular?

A

BICEPSS

Blood, intercostals, (Tracheal), caudal, epidural, plexus (brachial), sciatic, subcutaneous

Advanced Principles (16 decks)

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