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Principles II N517 > Epidural Anesthesia > Flashcards

Epidural Anesthesia Flashcards

1
Q

What is an epidural?

A

A central Neuraxial block much like a spinal anesthetic, however there is variation is the space that the medication is administered.

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2
Q

What are some of the advantages of Epidurals vs general anesthetics and spinals?

A

Patients are alert much earlier, they can be fully conscious, or sedated. A lower incidence of PONV than GA because not giving gases or heavy narcotics. Slower onset of hypotension than with a spinal (slower sympathectomy). The epidural allows us to place an epidural catheter for a one shot anesthetic or a continuous epidural (better control in the level of blockade and anatomical distribution may be precisely controlled). Sensation below and above the band. Also excellent postoperative analgesia possible.

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3
Q

Why are epidurals popular for child birth?

A

Popular for pain control during childbirth they because they create a band of anesthesia so the mom can still move her legs, but still gets analgesia. Analgesia possible without motor block (very dilute concentrations of local anesthetics.) This allows for autonomic and sensory blockade without motor blockade.

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4
Q

Why are epidurals advantageous in orthopedic cases?

A

It reduces MAP/Venous pressure so there is less blood in the surgical field and less blood loss. And lower risk of postoperative thrombosis

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5
Q

How is the afferent impulse toward the cord advantageous?

A

It reduces surgical stress response of the patient. Prevents transmission of signals from surgical site to brain.

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6
Q

Why is the stress response important during the surgical procedure?

A

The release of cortisol will cause multiple side effects - increased blood glucose, suppression of immune system, etc. An epidural blocks this response, so wound healing is improved and surgical site infection risk decreased.

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7
Q

In what ways can we reduce the endocrine response?

A

By using LA, we inhibit hormonal and metabolic consequences. We can block afferent impulses from operative site to brain, or if the block is in the area that controls the efferent autonomic pathways to liver and adrenal gland blocked.

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8
Q

Will opiates alone in the epidural control the endocrine response?

A

No, must achieve a conduction blockade with LA.

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9
Q

What are some of the disadvantages of an epidural?

A

The technique is demanding and time consuming. You need to be proficient with the technique and anatomy. There is also no defined endpoint (you do not want to see CSF), meaning you never know if you are really in the space. The onset is slower (advantage or a disadvantage)- have to wait to set up before you can do surgery. Time (10-20 min)/money/mom in labor and ready for pain relief. Sympathetic block can cause profound hypotension (nausea). Surgeons complain, say it takes to much time.

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10
Q

How can we be more efficient with epidurals?

A

Place it early and be ready ahead of time.

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11
Q

What are some indications for epidural?

A

Patient has a full stomach, so you can use it to maintain protective airway reflexes. This can be an issue if the epidural wears off, then you have to put patient to sleep.
Upper airway challenge (avoids airway manipulation) - but again you need a functional epidural. Urologic procedures TURP, Prostatectomy, Obstetrics (can give sensory blockade, +/- motor blockade if the surgery progresses to a c-section - simply dose higher for anesthesia. Lower limbs, pelvis, perineum and lower abdomen. Can use for upper abdominal and thoracic procedures as well, but it can be much more difficult. More difficult to avoid patient discomfort. Hip and knee surgery (decrease blood loss and DVT), vascular reconstruction of lower limbs, Amputation (decrease incidence of phantom limb pain), thoracic trauma (improved resp function).

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12
Q

How do we know what patients to place an epidural in?

A

Two things: 1- Surgeon skill (do they understand the implications of placing an epidural instead of GA. The patient may move a little. 2- The patient themselves (are they a candidate, are they demanding one, do they have fears (do not coerce them) do they want to be in control, fear of not waking up, +/- sedation during prodecure? Age is an issue (younger patients) is 14 year old acting mature or are they immature (judgement call), do they want to go home immediately (some may not want to wait for it to wear off)

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13
Q

What are some absolute contraindications for epidural?

A

Patient refusal, infection at the site (seeding infection in CNS), Coagulopathy (check coags preop, are they on anticoags), platelet count (are they functional) check history for gum bleeding when brushing teeth, spontaneous nose bleeds, bruise easily. Severely hypovolemic (trauma, dehydration), Unstable CNS disease (Elevated ICP), if you puncture the dura accidentally you can have a brain stem herniation. Severe aortic or mitral stenosis (they have obstructive cardiac outflow downstream so do not drop afterload with sympathectomy from epidural, documented allergy to local anesthetics (some will have amide allergy, esters more often) it may have been a normal epi response at dentist.

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14
Q

What are some relative contraindications?

A

Uncooperative patient/ psychiatric disease (they can get crazy during case), Septicemia/Bacteremia (risk of seeding infection in CNS), pre-existing CNS disease (MS), they might blame your anesthetic, Stenotic valvular lesions (depends on severity, take away the afterload, chronic headaches or backache (don’t want to be blamed later), morbidly obese (technical placement), spinal column deformation (scoliosis, difficult)

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15
Q

How many vertebrae are there and what is the breakdown?

A 
33 Vertebrae 
7 Cervical
12 Thoracic
5 Lumbar
5-fused Sacral
4-fused Coccyx
Size and shape vary dramatically
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16
Q

What makes epidurals unique from spinals?

A

You can perform an epidural at any level from cervical vertebrae to sacrum.

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17
Q

Where will most epidurals be placed?

A

In the lumbar region. Can do thoracic or caudal when get more expertise.

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18
Q

What are the bumps on the back that we can feel?

A

The spinous processes.

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19
Q

Why are the lamina important anatomically?

A

It is an important landmark that is commonly hit with the needle. (I’m bumping into Oss)

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20
Q

When is the Transverse process important to know about?

A

When we get into lumbar plexus anesthesia and paravertibral anesthesia

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21
Q

Where do the spinal nerves come out?

A

The intervertebral foramen. Just important to know as an anatomical landmark, it is not anything we will be aiming at.

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22
Q

What is the anatomical name of the space we are aiming for when navigating between the vertebrae?

A

The interlaminar foramen. (Largest opening, interspace, gap for needle passage)

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23
Q

What are the differences in the Lumbar and Thoracic vertebrae?

A

The lumbar have a much more horizontal spinous process vs the more vertical spinous process of the thoracic vertebrae. It is much harder to place in the thoracic area because of the angles that have to be utilized. (para median approach)

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24
Q

What is the ligament that runs on the spinous processes in your back? And where does it extend from?

A

The supraspinous ligament. C7 all the way to the sacrum (Needle through rice crispies, thick and broad in the lumbar region)

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25
What is beneath the supraspinous ligament? And where does it extend?
The Interspinous ligament. The whole vertebral column. Thin and membranous, but thicker in lumbar region.
26
What is the name of the ligament that is penetrated after the Supra and Interspinous ligament? Where does it extend
The ligament of Flavum (yellow ligament latin). ***Runs from the base of the skull to the sacral hiatus***
27
Where is the posterior longitudinal ligament?
It is on the other side of the spinal column. You have advanced the needle way to far.
28
Where is the anterior longitudinal ligament? And what important structure is in close proximity to it?
On the anterior side of the vertebral body. The aorta or vena cava
29
What is the epidural space?
A potential space. Average depth is 5.3 cm but ranges 2-9 centimeters. (Epidural has markings that tell you how many cm deep you are)
30
What is contained in the epidural space?
It is highly vascular and contains a lot of epidural fat. Lymphatics, nerves
31
The epidural space is bound anteriorly by the ____ and posteriorly by the _____? It extends from the ______ to the ____ _____?
Dura, and ligament flavum. It extends from the ***foramen magnum to sacral hiatus***.
32
What is important to note about the amount of LA placed in the epidural space?
You need enough volume to fill the posterior and anterior epidural space or your block can be spotty. The dose is volume based.
33
What is a very important landmark to know in the vertebral column?
C7- the most prominent vertebrae above the scapula, the inferior angle of the scapula should be T7. Superior aspect of the illiac crest is L4
34
Why are landmarks important for epidural placement?
They help denote how we calculate dosages and how we determine where to place our epidural and what volume of LA to give to the patients.
35
What do we have to know before we place an epidural?
The operative site (skin incision), this allows us to determine a insertion point and what sensory needs to be blocked.
36
What are the landmarks we should commit to memory for sensory innervation?
``` C4 - Clavicle T4 - Nipples T6 - Xiphoid T10 - Umbilicus L1 - Inguinal ligament L4 - Illiac crest ```
37
In preparation for an epidural, what drugs are important to have?
Vasopressors to treat the induced sypothectomy Sedatives/Narcotics (maybe) not for OB, but in the OR you may use them for sedation of patient LA of choice (what is the purpose of the epidural - anesthetic or analgesic) High concentration local anesthetic are for motor blockade and anesthesia purposes. If for analgesia, you will use weaker concentrations of LA.
38
What are the supplies that are needed?
Epidural kit, tape to secure catheter, resuscitation if patient goes apneic (in case of intravascular injection), functional IV. Supplemental O2 (maybe), Monitors (Pulse Ox, NIBP, ECG
39
Epidural needles are usually what gauge and how long? What are the marking measurement intervals?
16-18 guage, 9 cm long (needle shaft), 11 cm from the distal hub of the needle to needle tip. Markings at 1 cm intervals Tip is curved 15-30 degrees. Tip is always in same direction as the hub.
40
The loss of resistance technique utilizes what?
A glass syringe
41
What should you never do once you have inserted the catheter through the epidural needle?
Never pull the catheter back through the epidural needle, the catheter can sheet off in the patient. Always pull the two out together. Look at the tip of the catheter when you pull it out. It should be blue. If not, it may be in patient. (Epidural catheter removed intact, sheer tip noted.
42
The line that connects the illiac crest will intersect which vertebrae?
L4
43
Common tray set up.
From Right side - LA, Normal Saline, Red lettering on white label vial is test dose, blue lettering 1% lidocaine for skin local (3 cc with 25 gauge needle), 20 cc syringe for LA for epidural, behind that a yeallow square sponge that attaches to patient skin between skin and catheter, 18 gauge needle, epidural needle, filter straw for drawing LA and glass viles, Glass syringe, 3 cc syringe, circular blue filter, epidural catheter inside plastic container, drapes, sponges, labels, prep sponges and betadine.
44
How do you prep the patient?
Tell patient going to paint bulls eye on back with a scratchy cat tongue. Circular fashion. Tilt sponge downward so it does not run on fingers. Throw away sponge after use.
45
What approach will we use when we are learning?
Most likely a midline approach. There is also paramedian.
46
What do you do once the patient is prepped?
Anesthetized the skin with 1% lidocaine. Wipe the skin off first so you are not getting betadine in the subQtissue. Brace the left hand (two fingers on either side), then rest dominant hand on non dominant hand to give stability. Place tip of needle under the skin and create a skin wheel. Then you can advance the needle to increasing depth and give more anesthetic. If you encounter bone, make sure you do not insert your epidural needle the exact same direction.
47
What is important to do for the epidural needle before putting it in?
You may need to use that 18 gauge Quinkie needle on tray to cut skin an allow 16-18 gauge epidural needle to get through the skin more easily. Make sure the stylet is seated. Firm grip on epidural needle, identified the inter-space, don't take fingers off body. Should have 9 cm of working distance.
48
If you use the glass syringe how should you prep it?
Lubricate the barrel and plunger with a little saline to make sure it does not stick.
49
How do you know when you have hit the epidural space?
The ligamentous tissue is very dense and resistant to injection of anything from the epidural syringe. You apply constant pressure. When you hit the epidural space, you will be able to push air into the space. Some providers use 2-3 mL of saline with a small air bubble in it for compressibility.
50
What structure is breached when a loss of resistance is felt in the epidural syringe?
The ligament of flavum and you have entered the potential epidural space.
51
What is the hanging drop technique?
It is rare, more for thoracic. The hub of epidural is filled with saline until a drop is hanging of hub of needle, the drop of saline will be sucked into epidural space via negative pressure. Most of that negative pressure is in thoracic area.
52
If you count 5 markings on the epidural needle, how much of the needle is in the patient?
4 cm. Loss resistance at 4 cm from the skin. 5 cm is the average depth. Most will be between 4-6 cm. Make sure to utilize the markings for our benefit.
53
Why do you inject air or saline into the epidural space?
Hopefully we are pushing away epidural space structures like veins so we do not cannulate them.
54
What is a common occurance when you remove the epidural syringe, and what should you do?
The saline you instilled in the space can come out making it hard to know if it is saline or CSF. Let it drip on the back of the glove, where it is sensitive to hot cold. If it is cold, probably saline you just injected. If warm and not stopping, it is probably CSF.
55
Once you have hit the epidural space and you have removed the loss of resistance syringe, what do you do next?
You get ready to thread the epidural catheter. You use a guide from the kit (blue or pink tip), it facilitates threading of the catheter without a stylet. Note the distance from skin to epidural space by looking at the markings on needle.
56
What position should your hands be in at this time.
The dominant hand supporting the catheter with back of hand up against the patient for stability, the non dominant threading the catheter. As you thread, warn the patient that they may feel some parathesias (little shock down the right or left leg). But it should go away immediately.
57
What technique should be used to remove the epidural needle from the back?
Leave hands how they are after threading catheter, and simultaneously pull the needle out while making sure the threaded catheter does not come out with it.
58
How do we know when the tip of the catheter is flush with the needle tip?
The first black mark on the catheter will align with the hub. Once you go any further, you cannot pull the catheter back any more without removing the needle do to possiblity of shearing the catheter into the patient.
59
What do you do if the epidural catheter has a stylet in it.
Retract the stylet a few cm before pushing it any further past the tip of the needle because it may pierce the dura or a vessel more easily.
60
How far do you advance the epidural catheter?
2 to 4 cm past the needle tip. Maybe up to 6 cm but not beyond.
61
Once the epidural needle is out what is the next step to take?
Connect the syringe for a test dose of epidural. Do not secure the catheter yet. Give test dose that contains epinephrine solution (look for increase in HR and BP). If the catheter needs to be manipulated we can do so prior to taping the catheter up. Also we wait because if the catheter is compromised (manufacturing issue), you can see the LA spraying out a crack in the catheter.
62
What is the test dose?
3-5 mL of LA that contains Epi. It is usually 1.5% lidocaine with Epi 1:200,000
63
What happens if the test dose goes into the subarachnoid space? Intravascularly?
You will get spinal anesthesia because you are injecting 45-75 mg of Lidocaine. Transient increase in HR and BP, (15 mcg epi).
64
What is a method for securement of the catheter that may keep it from being pulled out?
Serpentine the catheter up the back to give it some extra give if something should pull on it.
65
If you meet bony resistance everywhere when placing the catheter, what should you do?
Check positioning. Big part of success. Or maybe a paramedian approach.
66
What if the catheter will not thread?
Rotate the needle ever so slightly one direction or the other just to change the angle of the bevel itself. Do not pull the catheter back through the needle or rotate the need a full 180 degrees.
67
What do you do if the catheter will just not pass?
Pull the catheter and the needle out together as one single unit.
68
Is a caudal type of epidural on epidural approach?
Yes, it is just a different approach to the epidural space.
69
Why would we consider Caudal anesthesia?
Hemmorhoidectomy, pediatric (inguinal herniorhaphy, cicumcision, scrotal procedures
70
What is the best position for placing a caudal on an adult? How about a child?
Adult - Prone (flex table, pillow placed under pelvic area to lift the butt in the air. Legs spread apart a bit and externally rotated. Child - Lateral position (cleaner and more well defined anatomy)
71
What are the landmarks for the caudal approach?
Posterior Superior illiac spines, Sacral cornua, They make a triangle.
72
Can you achieve a wet tap with a caudal approach?
Yes, if you put the needle to far up into the canal you can puncture the dural sac.
73
What is the problem with a caudal approach?
It is very technically difficult. Failure rate exceeds 5%. Better for children.
74
Where do you insert the needle for a caudal approach?
You locate the sacral hiatus and advance 1-2 cm. Needle must be angled then lowered when the canal is located.
75
What are some common mistakes with caudal approach?
You do not puncture the sacral ligament, you place it in subQ tissue and you will see the skin rise. You can also place needle in the subperiostium space and not in caudal canal. This is very painful for patients up to 1-2 months.
76
What type of surgery is a caudal block good for?
Hemorrhoidectomy, inject 10 cc's of LA and it become a saddle block with a slower onset.
77
The dose of an epidural is based off of what?
Volume
78
What are the different volumes for Thoracic, Lumbar, and Caudal?
Thoracic - 0.7 mL/Segment Lumbar - 1 - 1.5 mL/Segment Caudal - 2 mL/Segment
79
If we placed a caudal and we want to dose it up to L1, how much would we give?
5 Lumbar and 5 Sacral segments. 2 mL per segment = 20 mL
80
What is the formula for the epidural dose?
The volume multiplied by the concentration.
81
The concentration defines what of the block. And the volume defines what of the block?
The concentration defines density of block | The volume defines the limits of the block (which effects the spread from where the catheter tip is)
82
Clinically useful doses are based off of what?
Volumes that permit an even filling of anterior and posterior epidural space at the level of insertion.
83
Where does the spread of the block happen most quickly?
In the cephalad direction toward the head from catheter tip, possibly because the thoracic roots above that are smaller in diameter than those large lumbar and sacral nerve roots
84
What factors specifically influence LA spread?
Choice of LA you make, Mass of drug injected (dose, volume, concentration)), Site of injection, Addition of vasoconstrictors, Age of patient (older pt, smaller volume of epidural space - give less volume), pregnancy (hormonal, mechanical factors venous congestion in area, decrease volume in epidural space), Gravity to some extent (forcepts delivery, give mom some more LA and sit her up and let it take effect)
85
What does age and height have to do with dose of epidural?
It will determine the volume sufficient to achieve anesthesia. If taller give more volume. If older give less volume.
86
Where does the LA go once injected into epidural space?
Longitudinally Up and down the epidural space (volume dependent). Some into the vasculature tree (systemic effects - important for pre-eclamptic pregnant patient - don't give local containing epi). Some goes through intervertebral foramen (some spinal root block and peripheral cord block), some through dural root sleeves via arachnoid villi (subdural spread and degree of spinal block), some in epidural fat, some through the dura into CSF producing spinal anesthesia and peripheral cord block.
87
If injecting at L2, how does the effect work over time?
You may have L3 to T10 after 5 minutes, then you will have up to S5 to T5 after about 15 minutes. Point is, the onset will be faster for areas close to injection site, and take longer to get the entire desired band of blockade.
88
How does the epidural wear off?
In the exact opposite way. Recedes in a segmental fashion.
89
What does it mean when someone uses the term Two-Segment Regression?
The time it takes for a sensory level to decrease by two dermatome levels.
90
What is the two segment regression if we have a sensory level to T4 at the nipple line that is now a T6 block.
The time it would have taken for that change to occur.
91
What are the re-dosing guidelines when a two segment regression has occurred?
You can re inject 1/3 to 1/2 of initial activation volume and reattain the level of blockade. It is called a top up dose.
92
Lidocaine 2% will give what % motor block and what duration?
9 +/- 18 | 46 +/- 5
93
Lidocaine 2% with Epi will give what % motor block and what duration?
37 +/- 20 | 97 +/- 19
94
Mepivacaine 2% with Epi will give what % motor block and what duration?
30 | 117
95
Bupivacaine 0.5% with Epi will give what % motor block and what duration?
29 +/- 29 | 196 +/- 31
96
True or False: Epidurals supply you with complete motor blockade?
False
97
How would you achieve the best muscle relaxation for an open abdominal case?
With a spinal or general with NMBA 0-2/4 twitches. Epidural is not the best plan. Only provides partial muscle relaxation.
98
How do you get more motor blockade and more muscle relaxation with a epidural block?
Higher concentration of local anesthetic. Likewise by adding epinephrine.
99
How do we assess motor blockade?
If they cannot move their feet or lift knees off of the bed then it is a complete block (I), If they can move feet only its almost complete (II), If they can move feet and lift knees just barely off the bed then it is a partial block (III), If they can completely raise there knees of the bed then no block (IV).
100
What are the LA's that are available to be used?
2-Chloroprocaine, Lidocaine, Mepivacaine, Bupivacaine, Etidocaine, Ropivacaine (very popular), Levobupivacaine (off market).
101
What does a combined spinal-Epidural technique offer?
An effective, rapid-onset analgesia with minimal risk of toxicity or impaired motor block.
102
What is a combined spinal-epidural
The Epidural needle is placed, the a spinal needle is threaded through, punctures the dura and gives a dose of analgesia for immediate pain relief (up to two hours). Then the spinal needle is removed and an epidural catheter is placed for later treatment of pain. "Walking epidural"
103
What narcotic can you dose for the continuous spinal-epidural? Pros/Cons?
Hydophillic and Hydrophobic opiates. Hydrophillic (Morphine- Duramorph (no preservative) - slow onset but long duration). Can give 4 mg of Duramorph, which is the equivalent of 100's of mg of IV morphine. Run the risk of delayed onset resp depression. Hydrophobic opiates (Sufenta, Fent) - rapid onset, but sacrifice duration. They have risk for resp depression as well.
104
How do you evaluate the epidural?
Take a BP every 3-5 minutes (especially right after dosing epidural), assess cognition (ringing in ears, tingling in mouth, give idea of LA toxicity), assess progress of block every 3-5 minutes (longitudinally up and down spine), Autonomic blockade happens very quick (Nausea - take BP, due to low BP), If you are up to T4 you can get some bradycardia which can produce hypotension and Nausea. Assess temp and light touch, and motor impairment in relation to level of the block.
105
What are some physiologic effects of the Epidural? | Cardiovascular, Respiratory, GI, Urinary, Endocrine?
CV: Sympathetic block, HoTN/Tachy, T2-T5 block - brady Resp: If intercostals blocked, patient relies on diaphragm GI: T5-L1 sympathectomy -> ParaSymp outflow takes over -> contracted gut and relaxed sphincters Urinary: Atonic bladder -> Urinary retention Endocrine: Adrenals blocked -> decreased catecholamines (but blocks stress - good thing)
106
What are some of the complications of Epidural
HoTN, Inadvertent high epidural block, LAST, Total spinal (remember ABC - give sedation), Dural puncture, Catheter complications (sheering, kinked, cant get it out - have patient move around and flex, slow gentle pulling on catheter.)
107
What if the patient gets a postdural puncture headache?
Bed rest, Hydration, Caffeine, Caffeine infusion 500 mg in 1 liter of isotonic crystalloid over 1 hr, Epidural blood patch if they are not improving.
108
How do you perform an epidural blood patch?
10-20 mL of autologous blood in epidural space around where the original catheter was. 90% success rate.
109
What can happen if you do not use sterile technique during epidural? What will the patient complain of?
Epidural abscess. Four stages (Back or vertebral pain increase with percussion, Nerve root pain, Motor +/- sensory deficits or sphincter dysfunction, paraplegia or paralysis. May need antibiotics or neurosurgical intervention to drain the abscess.
110
What patients are at risk for an Epidural Hematoma?
Patients with bleeding disorders, platelet issues, anticoagulated for any reason. It can compress the spinal cord or cauda equina causing pain.
111
How do we chart all of this epidural stuff?
Example: Positioned sitting with std.(standard) monitors applied. Lumbar area prepped and draped with Betadine. L3-4 ld (identified) for midline insertion. Skin wheal w/ 1.5ml 1% lidocaine. Touhy 18ga, passed easily in midline x1 w/ LOR (loss of resistance) at 5 cm, cath passed 4 cm, (-) blood, (-) parasthesias, (-) CSF. 45 mg Lidocaine 1.5% test dose, 1:200,000 epi. Tray #ED238R21. Place supine, T-10 level bilateral, VS stable as recorded.

Principles II N517 (7 decks)

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