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Epidural Anesthesia ( Newby's Take) Flashcards

The objective for today's lesson is to become so badass in epidurals that when you walk into a room there is a crowd of midget clowns cheering and doing the wave

1
Q

An epidural block can be performed at what levels?

A
  1. Lumbar
  2. thoracic
  3. Cervical
  4. Caudal
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2
Q

Epidurals have a wide rage of uses what are some areas of heathcare where the application of epidurals can be helpful

A
  • operative anesthesia
  • odstetric anesthesia and Analgesia
  • Postop pain control
  • chronic pain management
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3
Q

In the overall scheme of things an epidural can be used in different ways (think way to administer it)

A
  1. “Single shot”
  2. catheter that allows intermittent boluses or continuous infusion
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4
Q

Epidural Anesthesia:

a big advantage of epidural is that muscle blockade can range from _______ to ________

A

None to complete

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5
Q

Epidural Anesthesia:

everything (related to muscle blockade, pain control, etc) can be regulated and changed by what 4 factors?

A
  1. Drug Choice
  2. LA concentration
  3. Dosage
  4. Level of injection
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6
Q

Epidural Anesthesia:

the epidural space surrounds the Dura Mater in what directions?

A
  • posterior
  • laterally
  • Anteriorly
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7
Q

Epidural Anesthesia:

the nerve roots travel in the dura mater and exit the spinal cord where (position not location)

A

Laterally

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8
Q

Epidural Anesthesia:

So we learned that the epidural space surrounds the Dura matter posteriorly, laterally, and anteriorly. The nerve roots travel iin this space and exit the spinal cord laterally. n the nerve roots then exit the ___1___ and travel peripherally to become peripheral nerves carrying both ___2__ and __3___ pathways

A
  1. Foraman
  2. Afferent
  3. Efferent
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9
Q

Epidural Anesthesia: Anatomy

What other 4 things (besides nerve roots) does the epidural space include

A
  1. Fatty connective tissue
  2. Lymohatics
  3. Venous plexus (Batson’s)
  4. Septa and Connective tissue bands
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10
Q

what is segmental blocks?

epidural or spinal?

A

epidurals are segmental blocks

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11
Q

why are spinals not considered segental blocks?

A

bc they block above and below

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12
Q

what is one of the most important aspects of placing an epidural?

A

getting the right spot! Remember epidurals are segmental blocks

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13
Q

Label this

A
  1. Meninges
  2. Spinal Cord
  3. Spinal Nerve
  4. Epidural Space
  5. Vertebra
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14
Q

Epidural Anatomy: Name the structures found in the locations:

  • Superior
  • Inferior
  • Lateral
  • Anterior
  • Posterior
A
  • Fusion of the dura with the foramen magna
  • Sacro-coccygeal membrane
  • Vertebral pedicles and intervertebral foraminae
  • Posterior longitudinal ligament and vertebral bodies
  • Vertebral laminae and ligamentum flavum
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15
Q

Label this

A
  1. Dural sac
  2. Epidural vein
  3. Interlaminar space
  4. Lamina
  5. Ligamentum Flavum
  6. Supraspinous Ligament
  7. Intraspinous Ligament
  8. Spinous Process
  9. Transverse Process
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16
Q

LA or other solutions injected into the epidural space (steroids, Narcs) spread Anatomically.

So how is horozontal spread?

A
  • is to the region of the dural cuffs with diffusion into the CSF and Leakage through the intervertebral foramen into paravetebral spaces
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17
Q

LA or other solutions injected into the epidural space (steroids, Narcs) spread Anatomically.

how is longitudinal spread?

A

preferentially cephalad in direction

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18
Q

odd fact he stated!

Clinidine binds where in r/t the synaptic cleft?

A

Presynaptically

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19
Q

What are 6 possiable sites of anesthetic action?

A
  1. Paravertebral Nerve roots
  2. intradural spinal roots
  3. Dorsal and Ventral Spinal roots
  4. Dorsal Ganglia
  5. spinal cord
  6. Brain (by diffusion)
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20
Q

Epidural physiology:

What facilitates the rapid diffusion of LA from the Epidural Space, throught the dura and into the CSF surrounding the nerve roots?

A

the dural cuffs or sleeves have arachnoid villi and granulations that reduce the THICKNESS of the dura matter thus facilitating transfer

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21
Q

the dural cuffs or sleeves have arachnoid villi and granulations that reduce the THICKNESS of the dura matter thus facilitating rapid diffusion of the LA from the epidural space through the dura and into the CSF surrounding the ther roots. then the LA diffuses into the nerve root it self, producing anesthesia to where?

A

that PARTICULAR dermatome (remember again segmental)

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22
Q

B/c Epidural anesthesia is ______ dependent, relatively large volumes of LA are needed to achieve a block that spans several dermatomes.

A

DIFFUSION

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23
Q

Max spinal Volume

Epidural volume

A
  1. 2 ml
  2. up to 15 ml
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24
Q

with an epidural the Block ONLY gets as high or low as you regulate it by what?

A

VOLUME

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25
Q

With epidurals _____ affects spread, so to get more levels give more _____

A

Volume

volume

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26
Q

With Epidurals:

The #1 factor to get action of epidural at a certain site is what?

The #2 factor is How much spread or how many dermatomes this is affected by what?

A
  1. location
  2. Volume
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27
Q

an epidural is not like a spinal in which everything distal to the level of the block is affected, an epidural is a differential block dependent on the ______ and ________?

A

volume

site of injection

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28
Q

Label this motha fucker

A
  1. Spinal cord
  2. Pia mater
  3. Arachnoid mater
  4. Dura Mater
  5. Conus Medullaris
  6. Cauda equina
  7. Ligamentum flavum
  8. Epidural space
  9. Internal filum terminale
  10. Distal dural sac
  11. External filum terminale
  12. Coccyx
  13. Sacrum
  14. Aorta
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29
Q

Epidural Advantages:

the epidural tech has the advantage of better control of ____ and ____ blockade

A

level

and sympathetic blockade

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30
Q

Epidural Advantages:

the epidural tech allows for the placement of a continuous catheter which is especially useful forwhat 4 things?

A
  1. cases of unpredictable duration
  2. prolonged postop analgesia
  3. Chronic pain control
  4. Obstetric Analgesia and Anesthesia
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31
Q

What is teh spread of epidural anesthesia termed?

A

rostral spread

the distribution of an opioid within the cerebrospinal fluid during epidural administration; it is determined by fat and water solubility properties of the narcotic

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32
Q

to be able to choose the most appropriate anesthetic dose, concentration and volume of LA the anesthetist must be familiar with the variables that affect spread and duration of Epidural anesthesia.

what has more variables spinal or epidural?

A

Epidural

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33
Q

Baricity plays a very SMALL or LARGE factor in Epidurals

A

Small

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34
Q

Unlike epidurals what is the key factor in spread and distribution of the block with spinal anesthesia

A

Baracity

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35
Q

What are 9 factors that affect the level of an epidural block?

emphisise the 2 most important factors

A
  1. injection site
  2. Dose
  3. Volume
  4. concentration
  5. position
  6. Age
  7. Height and weight
  8. pregnancy
  9. Speed of injection
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36
Q

Ulinke spinal anesthesia the epidural produces a segmental block that spreads both ____ and ____

A

Caudally

Cranially (i think cephalad is a better term)

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37
Q

Based on the fact that Ulinke spinal anesthesia the epidural produces a segmental block that spreads both Caudally and Cranially what is te most important determinant of the spread of an epidural block?

A

Injection site!!

God damn I think he states this 4 million fucking times in his god damn slides it better be a fucking question of the damn fucking test

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38
Q

The injection site should be where for an epidural?

A

in the middle of the range of dermatomes that need to be anesthetized and closest to the main nerve roots involved

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39
Q

Caudal epidural blocks are largely restricted to _____ and _____ ______ dermatomes

A

Sacral

Low Lumbar

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40
Q

Thoracic levels can be reached by caudal approach only if _______ are given, and then the block is patchy at best bc of the distance that the anesthestic must travel

A

Large volumes 30mL

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41
Q

Lumbar LA injections of __mL tend to spread caudad to include all the sacral dermatomes

A

10 mL

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42
Q

Lumbar injection of __mL volumes produce much better quality sacral blocks and can also extend cranially to include the midthoracic levels

A

20mL

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43
Q

Thoracic injections tend to produce a _______ segmental band of anesthesia with minimal lumbar spread

A

symmetric

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44
Q

When using a thoracis approach, it is prudent to decrease your volume by about ____ to ____% to prevent cranially spread.

A

30-50%

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45
Q

when doing a thoracic epidural you want to use less volume to minimize crainial spread b/c what don’t you want to anesthetized and where is it located????? HMMMM

A

Cardiac Accelerator C4

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46
Q

is it generally feasable to produce surgical anesthesia in the low lumbar or sacral nerve distributions when using a thoracic injection site?

A

NOPE

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47
Q

Thoracic injections are ideally suited for procedures of where?

A

chest

upper abd

postop thoracotomy

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48
Q

within the range typically used for surgical anesthesia drug CONCENTRATION is relatively unimportant in determining what?

A

block spread!

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49
Q

What is the #1 way to tell density of block?

A

Concentration

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50
Q

_____ and _____ are important variables in determining both spread and quality of the epidural block obtained

A

Dose and Volume

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51
Q

Epidural: Dose, Volume , Concentration

if the drug CONCENTRATION is held constant, increasing the volume of LA (thus increasing the dose) results in significantly greater what?

A

Spread

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52
Q

Epidural: Dose, Volume , Concentration

if the drug CONCENTRATION is held constant, increasing the volume of LA (thus increasing the dose) results in significantly greater Spread.

Dose = what

A

dose = volume x concentration

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53
Q

Epidural: Dose, Volume , Concentration

if the drug CONCENTRATION is held constant, increasing the volume of LA (thus increasing the dose) results in significantly greater Spread.

For example notice the dose increases and VOLUME increases but the concentration remains the same thus you get a greater spread without changing the concentration

give me the doses

15 ml and 20 mL of 0.25 % Lidocaine

A

15mL x 2.5 mg/mL =37.5 mg

20 mL x 2.5 mg/mL = 50 mg

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54
Q

so after everything I just went over we now know that the CONCENTRATION of the LA generally affects the _____ of the block not the ______

A

DENSITY

SPREAD

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55
Q

Epidural: Dose, Volume, and Concentrations

So continued from all the info we now know.

  1. a small volume of a more concentrated LA will produce what in a block?
  2. Now take that same DOSE and double the volume and what will happen?
A
  1. Very limited but very STRONG
  2. SPREAD increases but weaker block
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56
Q

Epidural: Dose, Volume, and Concentration

the increase in block level is NOT in direct proportion to volume increase. Thus Doubling the VOLUME will NOT double the block spread. it is a NON-linear relationship and doubling the volume will only increase the level about ___-__ the origional # of segments

A

1/3-1/2

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57
Q

Epidural: Dose, Volume, and Concentration

the same relationshiop exist with DOSE; doubling the dose will usually only increase the level block the same ___ -___ of the origional segments blocked

A

1/3-1/2

58
Q

Epidural: Dose, Volume, and Concentration

recommended amts of LA differ as to which level is being injected:

  1. Cervical/thoracic doses are ___ - __ mL per segment
  2. Lumbar level doses are ___-____mL per segment
A
  1. 0.7-1
  2. 1.25-1.5
59
Q

Epidural: Dose, Volume, and Concentration

why do the volumes get smaller the more crainial you are in the epidural space? for ex why give 0.7- 1 mL per segment in thoracic and 1.25-1.5 in the lumbar

A

due to the narrowing of the spinal canal as iot progresses cranially

60
Q

Epidural: Dose, Volume, and Concentration

****** remember this slide****

using a lower concentration anesthetc can sometimes give u a differential block! the lower the concentration means the dose is lower and there is less LA to penetrate the nerve roots so the block acts more ________ an the nerves, differentially blocking sensory and pain fibers over larger muscle fibers in the center os the nerves

A

periperally

61
Q

Epidural: Dose, Volume, and Concentration

Based off the last slide!!

  1. Bupivicaine 0.25%, 20mL tends to provide what type of block?
  2. then if Bupivicaine 0.5% 20 mL is given what type of block is provided?
A
  1. tends to provide a sensory block, but leaves the motor fibers intact so a pt can push when needed
  2. provides a sensory block as well as a a motor block paralyzing the muscles at the levels of the block so NO pushing is going to be possible
62
Q

studies on epidural anesthesia r/t positioning showed that which position is better? sitting or lateral?

A

either it’s your choice! data showed that here was little to no difference

63
Q
  • Studies in epidurals have showed what in r/t age?
  • why?
  • what effect does this have on the dermatome coverage?
A
  • showed that there is a greater spread in older pt’s
  • b/c there is thought to be less comliant epidural space and dura mater
  • at most an increase in NO more than 3-4 dermatomes
64
Q

epidural and height and weight

  • what do the studies say concerning height and weight r/t epidural spread?
  • what is teh exception?
A
  • no clinical signicicance
  • except for MAYBE in extremly tall >6’6” or very short < 4’10” or in morbidly obese
65
Q

Epidural anesthesia: Pregnancy

what do studies say about epidural spread r/t pregnancy?

A
  • some show greater spread at term and early pregnancy
  • other studies show no significant differences in spread of pregos vs non-pregos
66
Q

Epidural and spead of injection

  • what do the studies say about spread of epidural r/t speed of injection
A
  • no study has shown it to make a difference
  • infact drugs should be injected slowly into the epidural space the avoid a rapid increase in CSF pressure, H/A, and increased ICP

(spinals use spead for spread)

67
Q

Epidural anesthesia: speed of injection

All slutions should be injected in increments of ____mL every _____ min and titrated to the disired level.

A
  • 3-5 mL
  • 3 min
68
Q

Epidural anesthesia: speed of injection

if a catheter had been placed and you are injecting through it, what needs to be done prior to every injection? and why?

A
  • aspirated
  • to show no CSF is present
69
Q

Epidural anesthesia: speed of injection

what is an advantage of an epidural of spinal r/t speed of injection

A
  • gradual administration of medication slows rate of onset of level and controls development of sympathetic block
  • the spinal is all or none where epidural can be brought up slowly
70
Q

Epidural Anesthesia: Summary

Drug Volume

A
  • larger volume gives more spread than small volumes
71
Q

Epidural Anesthesia: Summary

site on injection

A
  • the epidural space increases in volume in the cervico-caudad direction
  • thus a given volume will produce greater spread in the cervical > thoracic > lumbar > sacral
  • onset is fastest and most intense in the dermatomes nearest the site of injection
72
Q

Epidural Anesthesia: Summary

raised abdominal pressures

A
  • smaller volumes may be needed inpregnancy and morbid obesiyty
73
Q

Epidural Anesthesia: Summary

patient position

A
  • prolonged sitting position may reduce upward spread
  • earlier onset of block in dependent side in lateral position
    *
74
Q

Epidural Anesthesia: Onset of Blockade

the onset of an epidural can usually be detected within ___ min in the dermatomes immediately surrounding the injection site

A

5 min

75
Q

Epidural Anesthesia: Onset of Blockade

the time to PEAK effect differs somewhat among different LAs

  • shorter acting drugs usually reach their maximum spread in ___-___ min
  • Longer acting LAs usually reach their maximum spread in ___-___ min
A
  • 15-20 min
  • 20-25 min
76
Q

Epidural Anesthesia: Onset of Blockade

increaseing the ____ of LAs speeds the onset of both motor and sensory block

A

DOSE

77
Q

Epidural Anesthesia: Duration of Blockade

the duration of the blockade depends on what 4 factors

A
  1. The LA itself
  2. Dose given
  3. Pt age
  4. Use of adrenergic agonist
78
Q

Epidural Anesthesia: Duration of Blockade

your choice of LA is the most important factor in determining the _______ of the block

A

duration

79
Q

Epidural Anesthesia: Duration of Blockade

name the LA

__1__ is the shortest, __2__ and __2__ are intermediate, and __3__ and __3__ produce the longest lasting epidural blocks

A
  1. Chlorprocaine
  2. Lidocaine & Mepivicaine
  3. Bupivacaine & Ropivacaine
80
Q

Epidural Anesthesia: Duration of Blockade

Bupivicaine

  • is the opposite of what drug?
  • in low doses seems to have a preferential _____ block with minimal ____ effect
  • that is why it is an ideal drug for _____ analgesia. thus eliminating pain while preserving muscle function
A
  • Etidocaine
  • sensory; motor
  • Obstetric (they can push)
81
Q

Epidural Anesthesia: Adrenergic Agonists

what is the most common adrenergic agaent added to epidural LAs

A

epinephrine

82
Q

Epidural Anesthesia: Adrenergic Agonists

epinephrine in a concntration of what is the most common adrenergic agent added to epidural LAs

A

5 mcg/mL

1:200,000

(I always have a little problem remebering the mcg conversion probally b/c I am a dumb ass but this is now how I remember it if anyone cares… 1:200,000 means in math 1,000 mg in 200,000 so if you do the math you get 0.005mg or 5 mcg/ml or you can convert it into mcgs up front and do the math as 1,000,000 mcg in 200,000 which then equals 5mcg/mL or just do it you way! I just need to show proof why I answer something)

83
Q

Epidural Anesthesia: Adrenergic Agonists

Epinephrine 5mcg/ml, has been shown to prolong blocks of lidocaine and mepivicaine by as much as __%

A

80

84
Q

Epidural Anesthesia: Adrenergic Agonists

epinephrine has been shown NOT to significantly prolong bthe duration of anesthesia when added to concentrated solutions of ______ and ______ used for surgical anesthesia

A

bupivacaine

Ropivacaine

85
Q

Epidural Anesthesia: Adrenergic Agonists

as stated epinephrine does not increase the block when added to high concentrations of bupivacine and ropivacaine in surgical anesthesia, but what about when added to more dilute concentrations of bupivacaine used for OB

A

it has beenshown to incrase the duration and quality of block

(but no one knows why?)

86
Q

Epidural Anesthesia: Adrenergic Agonists

although NEVER proven why is it thought that epinephroine prolongs the duration of a block

A

throough vasoconstriction it slows systemic absorption and elimination

87
Q

It is often easier to deal with a block that is too high or too long than to cover uo for a block that is too low or not dense enough

A

justa little tip!! enjoy it, embrase it

88
Q

tip #2

i’s always better to have a little more than a little less, especially with regional anesthesia

A

as in all great things in life

89
Q

Epidural Anesthesia: Technique

what should always be immediatly avail when doing an epidural?

A

emergency equipment and monitors

90
Q

Name the positions as extension or flexion?

A
  1. extension
  2. flexion
91
Q

label the pic as extension or flexion

A
  1. extension
  2. Flexion
92
Q

Epidural Anesthesia: Technique

Name the most commonly performed epidural in order from most common to least common

A
  • Lumbar
  • caudal
  • thoracic
  • Cervical
93
Q

Epidural Anesthesia: Technique

today most high thoracis and cervical epidurals are performed under what and by whom

A
  • flouroscopic guidance
  • pain specialist
94
Q

Epidural Anesthesia: Technique

as you can see from the diagram

  • the lumbar region is at or greater than a 90 degree angle
  • thoracic is more acute
  • and cervical is between the 2
A
95
Q

Epidural Anesthesia: Technique

WHy is the lumbar region is by far the eastiest area to perform an epidural? (4 reasons)

A
  1. angle of spinous process
  2. larger spaces b/t spinous processes
  3. easialy identifiable locations (illiac crest)
  4. epidural width the greatest
96
Q

Epidural Anesthesia: Technique

with a spinial the practicioner looks to find CSF to confirm by peircing the dura to find proper location. in an epidural where does the practicioner want to place the tip.

A

into the fat filled space DEEP to the ligamentum Flavum and SHALLOW the DURA

97
Q

Epidural Anesthesia: Technique

is performed with what gauge neddles?

A

16

17

0r 18

98
Q

Epidural Anesthesia: Technique

what tyoe tipped needle

A

blunted

99
Q

Epidural Anesthesia: Technique

name the epidural needles

A
  1. Standard Tuohy
  2. Blunt tip
  3. Crawform needle (thin walled)
  4. Weiss winged needle
100
Q

Label

A
  1. Dura
  2. Spinal
  3. Epidural
  4. Touhy needle
101
Q

Epidural Anesthesia: Technique

lets go name the steps!!!! start from the begining you are doing this mother fucker and need to own it

A
  1. identify landmarks and plan interspace of insertion
  2. position pt
  3. sterile prep and drape with insertion site in center of drap (where hole is located)
  4. Local anesthetic (lido 1% plain) 1-2 mL wioth 25 g skin needle
  5. firmly place back of your NON-dominant hand against the patients skin below the epidural needle
  6. grasp the needle (and eventually the hub once epidural space is found b/t your thinb and index finger of NON-dominant hand) (called the Bromage grip)
  7. the epidural needle is placed bevel up and introduced into the skin
  8. passed slowly throught th esupraspinous ligament and seated in the interspinous ligament before stylet is removed (** you can tell the needle is in the interspinous ligament by letting go of the needle it should be supported in the same position, and not drop down)
  9. After stylet removed the needle is advenced using the LOR tech
  10. As the syringe/needle combo is advanced pressure is applied to the plunger of the syringe by “bouncing” or intermittently applying pressure to the plunger
  11. the pattern is move-bounce-move-bounce-move-bounce until LOR is obtained
  12. as the needle passes throught the ligamentum flavum, resistance increases and you may feel a distinct pop as you pass through it
  13. once throught the LF you will experience an immediate LOR and then the tip of the needle will be in the epidural space
  14. once the eidural space is reached pass your stylet throough the needle to make sure there is no tissue plugs possiably blicking the flow of CSF (with an inadvertent Dural punture)
  15. Once in is confirmed begin by injecting a TEST DOSE of 3 cc of LA with epi (lido 1.5 w/epi)
  16. watch monitor at look for HR increase within 30 sec (intravascular)
  17. question the pt on ringing in ears metalic taste in mouth or cirum-oral numbness or punding in chest
  18. wait 3 min to assess for numbness or weakness in LE (dural injection)
  19. is all good give meds or pass catheter
102
Q

just some pics

A
103
Q

Just a pic

A
104
Q

Just a pic

A
105
Q

Label this

A
  1. Ligamentum flavum
  2. Epidura; Space
  3. Dura
  4. Cauda quina
  5. Supraspinous ligament
  6. Intraspinous ligament
  7. Ligamentum flavum
  8. Epidural space
  9. Dura
106
Q

Epidural Anesthesia: Technique

the local for skin is usually what? b/c it usually found in the kit and alays consitant

A

1-2 cc 1% plain

107
Q

Epidural Anesthesia: Technique

what is the “grip” called when doing the epidural

A

Bromage grip

108
Q

Epidural Anesthesia: Technique

the needle goes in with the bevel in what direction?

A

up

109
Q

Epidural Anesthesia: Technique

when is the stylet removed

A

when in the intraspinous ligament

110
Q

Epidural Anesthesia: Technique

what is used to obtain LOR

A

glass syringe filled with either 3-4 cc of air or NS or mixture of both

111
Q

Epidural Anesthesia: Technique

once usuing LOR tech the needle should be advanced how much at a time and the retested for LOR

A

0.5-1cm at a time

112
Q

Epidural Anesthesia: Technique

the syringe needle combo is advanced applying pressure the needle or syringe?

A

needle

113
Q

Epidural Anesthesia: Technique

in younger pts in OB you may not notice a distinct “pop” what might you only notice

A

LOR

114
Q

Epidural Anesthesia: Technique

once in the epidural space why do you replace the stylet?

A

to remove any tissue to asses for CSF leakage

115
Q

Epidural Anesthesia: Technique

what is teh typical test dose

A

3 cc of lido 1.5% with epi

116
Q

Epidural Anesthesia: Technique

if u inject intravascular you will see an increase in HR how fast

A

30 sec

117
Q

Epidural Anesthesia: Technique

besides watching HR with test dose what might you want to ask the pt with the test dose?

A
  • Ringing/buzzing in ears
  • metallic taste
  • circum-oral numbness
  • punding in chest
    *
118
Q

Epidural Anesthesia: Technique

if you happen to inject the test dose in the dural space what might the pt have that you want to assess for? and how long does it take to show up?

A
  • numbness or weakness or pins and needle sensation in LE
  • 3 minutes
119
Q

Epidural Anesthesia: Technique

pros to advancing catheter first

A
  • you can slowly raise the level of anesthesia and have better control and less incidence of sympathetic block
120
Q

Epidural Anesthesia: Technique

cons of catheter placement first

A
  • cath may not go into correct space
  • may come out on nerve root
  • may kink or coil
  • thus giving a useless epidural or patchy at best
121
Q

Epidural Anesthesia: Technique

pros of injection first

A
  • LA opens up and distends epidural space makiing it easier to pass catheter
  • if catheter fails you still have a complete block for a while
122
Q

Epidural Anesthesia: Technique

regardless what tech is used as you pas the catheter the patient should be warned that while movement of catheter they may feel what?

and why?

A
  • electrical shock or funny bone feeling
  • b/c cath tip brushing up against nerve root or two as it is passed in epidural space
123
Q

Epidural Anesthesia: Technique

as the cath is passes you may feel initially some rersistance at the tip, what should you do?

A

give a slightly stringer push

124
Q

Epidural Anesthesia: Technique

the catheter should be inserted between what depths

A

3-5 cm

no more than 3-5 black lines

125
Q

Epidural Anesthesia: Technique

NEVER do what with the catheter?

A

pull back throught the needle once it has been inserted

126
Q

Epidural Anesthesia: Technique

whay do you never want to pull the catheter back throught the needle?

A
  • there is a possibility to catch the catheter on the needle tip and shear or cut the tip off
  • then it becomes a permanent new addition to the epidural space and will be there for the rest of the patients life!!! way to fuck that up
127
Q

what are the 2 most dreadful words by an SRNA performing an epidural?

A

WET TAP

128
Q

PDPH occurs in up to __% of pts who have a dural puncture with a touhy needle?

A

75%

129
Q

WET TAP:Treatment

how do you treat it with consevation tech

A
  • IV fluids
  • analgesics
  • IV/PO caffine
  • lying flat in dark room
130
Q

WET TAP:Treatment

what are invasive treatment tech

A
  • epidural blood patch
  • although invasive it is effective 90% of the time
131
Q

Caudal anesthesia:

used for what sx’s

A
  • anorectal sx in adults
  • pediactrics
132
Q

Caudal anesthesia:

Caudal anesthesia involves needle ot catheter penetration of the ______ ________ covering the sacral hiatis

A

Sacrococcygeal ligament

133
Q

Caudal anesthesia:

the sacral hiatus is created by the unfused __ and ___ lamina

A

S4 and S5

134
Q

Caudal anesthesia:

the sacral hiatus can be felt as a grove or notch where?

A

aboove the coccyx and b/t 2 bony prominences, “the sacral Cornua

135
Q

Caudal anesthesia:

pic of sacral hiatus

A
136
Q

Caudal anesthesia:

how is the block performed?

A
  • The posterior Superior Illiac Spines and the sacral Hiatus form a triange
  • pt placed prone or lateral decubitus
  • sterile prep
  • needle or cath is inserted at 45 degree angle to the skin until a “pop” is felt
  • then the angle is droped and advanced aspirating for blood or CSF Q 1-2 cm
137
Q

LAbel this pic

A
  1. Sacrococcygeal ligament
  2. Sacral hiatus
  3. Sacral canal
  4. Dural sac
138
Q

Label this

A
  1. PSIS
  2. PSIS
  3. Sacral hiatus
139
Q

Caudal anesthesia:

advantage for adults with anorectal procedures

A

can provide dense sacral sensory blockade with limited cephalad spread

140
Q

Caudal anesthesia:

usual dose of anesthetic

A

15-20cc of 1.5-2% lidocaine with or w/o epi

141
Q

Caudal anesthesia:

shuld be avoided in pt’s with what

A

pilionidal cyst

Regional (24 decks)

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