Epidural Anesthesia (pt 2) Flashcards
T/F: you can give Duramorph in a spinal.
False: too much volume
Describe the dose, onset, and DOA for a morphine bolus in an Epidural (Duramorph)?
-Duramorph = 5mg/10 mL
-Give 3-5 mg
-Onset: 30 min
-DOA: 12-24 hours
Describe the dose, onset, and DOA for a fentanyl bolus in an Epidural?
-50 - 100 mcg
-Onset: 5-10 min
-DOA: 2-6 hours
What is Depodur?
15 mg ER Morphine (?)
-Meant to be used alone, WITHOUT LOCAL
-Do test dose, then flush with NS before using Depodur
Why are epidural opioid doses much higher than intrathecal opioids?
-More systemic absorption due to presence of vascular plexus (similar to IV dose)
-Epidural fat causes lipophilic drugs to be sequestered here (may need higher doses to achieve analgesia)
The goal is to have opioids get into the _____ via the dural cuff, and onto the spinal cord to the ______ _______.
The goal is to have opioids get into the CSF via the dural cuff, and onto the spinal cord to the Substantia Gelatinosa.
What is the Combination Epidural/Spinal Anesthesia technique?
-Using the epidural technique, stop at the Epidural space.
-Take a spinal needle and put it through to the subarachnoid space, until you feel the pop and have the flow of CSF
-Inject a small amount of drug into the CSF. (15-25 mcg Fentanyl + 1 mL Marcaine 0.25%)
-Patient can get relief quickly while you dose your epidural.
-Use a combined spinal/epidural kit. Newer kits eliminated problems associated with metallic particles, aseptic meningitis.
What are the 2 CSE techniques?
Two techniques:
1) 2 separate insertion sites: Place epidural including the test dose & catheter, then move 1-2 interspaces lower (according to Nagelhout) and use a spinal needle to create a puncture, give medications, then remove the spinal needle.
2) Needle through Needle technique: use a small pencil point spinal needle, put it through epidural needle until in intrathecal space, inject small amount of opioid and 1 mL of bupivicaine 0.25%, then remove needle and place catheter for epidural.
How do you do a continuous spinal technique?
-Use a Tuohy needle, position it so you are splitting and not cutting the dura
-Get return of CSF
-Do slight advancement so catheter doesn’t hit Dura
-Thread catheter 2-3 cm in Subarachnoid space
-Dose catheter (catheter itself holds 0.25 mL of fluid)
-Flush with NS after dose
-LABEL CATHETER
-Use very small doses
Accidental wet tap can turn into a continuous spinal.
What was causing Cauda Equina Syndrome?
-Thought to be r/t microcatheters and hyperbaric lidocaine
-Thought that the lido stayed in one area and pooled rather than diluting and moving.
-Caused high doses of LA to sit on these nerves, causing microtoxicity.
-Microcatheters have been removed from market
-Use Bupivicaine or dilute Lidocaine
Why is Post-Dural Puncture Headache (PDPH) less with continuous spinal in place?
Appears to be r/t inflammatory reaction around the catheter, which plugs the hole in the dura, preventing the leakage of CSF.
What should you do if the Epidural catheter is not threading?
-May not be midline, evaluate location
-Try flushing with NS to potentially open up the space.
What should you do if you have a one-sided block?
-Pull back catheter 1 cm
-Put unaffected side down
-Re-dose
-Chart new position of catheter
-If this doesn’t work, start over
What should you do if you are not able to flush the Epidural catheter?
-May be a clot, or may be against tissue/bone
-Can pull back and retry
-Use a tiny syringe (increased pressure)
What should you do if you encounter fluid coming into the syringe?
-Could be NS if you used that to open up the space
-Could be CSF - use urine strip and test for BS, proteins
