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2-General Anesthesia Exam 2 > Epidural/Caudal Blocks > Flashcards

Epidural/Caudal Blocks Flashcards

1
Q

What can epidural anesthesia be titrated to?

A

Can be titrated to deliver either analgesia or anesthesia

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2
Q

What is one key difference of the epidural block?

A

More control over the extent of sensory and motor blockade than with SAB

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3
Q

What is nice about the catheter with epidural anesthesia?

A

Ability to place a catheter allows for more flexibility/redosing, e.g. long procedures, post-operative pain control

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4
Q

Because epidural anesthesia is diffusion dependent, ____________ must be used than in SAB

A

larger volumes of local anesthetics

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5
Q

What is the standard epidural needle?

A

Standard needle is 16-18 gauge and 3 inches long

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6
Q

Epidural needles are Blunted bevel and gentle curve of ________ at the tip

A

15-30 degrees

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7
Q

What are the most common epidural needles?

A

Touhy and Hustead

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8
Q

What is the touhy needle?

A

most pronounced curve (30 degrees) and easiest for beginners

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9
Q

What is the hustead needle?

A

15 degree curvature allows for easier passage thru skin and ligamentum flavum

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10
Q

What is the crawford needle?

A

no curve so easier to access steep angles (e.g. thoracic spine) but increased incidence of dural penetration

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11
Q

What are the layers of anatomy that need to be transversed from posterior to anterior with an epidural anesthetic?

A 
Skin
Subcutaneous fat
Supraspinous ligament
Interspinous ligament
Ligamentum flavum
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12
Q

What should the catheter diameter be size wise?

A

Catheter diameter should be 2 gauges smaller than the needle

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13
Q

Epidural catheters: Should be

__________

A

radiopaque

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14
Q

What are the most common epidural catheters?

A

are the single-holed, open-ended (uniport) and the lateral-holed, closed tip (multiport)

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15
Q

What do the markings on the catheter indicate?

A

1cm depth increments

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16
Q

How far should the epidural catheter be inserted into the epidural space?

A

3-5cm

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17
Q

What is the test dose?

A

administered to determine whether the catheter or needle has inadvertently entered the subarachnoid space or threaded into an epidural vein

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18
Q

What is the typical LA dose for epidural test?

A

Typically 3mL of rapid acting, low toxicity LA used with epi

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19
Q

Which are the two medications used often for the epidural test dose?

A
  • Lidocaine 1.5% with 1:200,000 epi

- 45mg lidocaine / 15mcg epi

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20
Q

How soon will the epidural test indicate spinal anesthetic?

A

3min

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21
Q

How soon will the epidural test indicate intravascular injection?

A

30 seconds

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22
Q

What effects the clinical success of an epidural and dermatomal blockade?

A

primarily dependent upon dose of medication and site of injection

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23
Q

What is true about the size of segmental epidural spaces?

A

increases down the spinal cord as the spinal cord occupies less and less space

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24
Q

Suggested volumes per segment at cervical and thoracic levels are ________ per segment

A

0.7-1mL

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25
Q

What is the dose for cervical and thoracic levels?

A

Dose of 10mL will achieve a 10-14 dermatomal spread

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26
Q

What are the suggested volumes per segment at the lumbar levels?

A

1.25-1.5mL per segment

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27
Q

What are the suggested dose per segment at the lumbar levels?

A

15-20mL will achieve a 12-16 dermatomal spread

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28
Q

What is the common clinical practice to insert the epidural needle?

A

at a vertebral interspace such that the catheter tip falls near the middle of the spinal dermatomes of the proposed surgical incision

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29
Q

What effect dose height and weight have on epidural blockade?

A

Likely only relevant at the extremes

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30
Q

What effect dose age have on epidural blockade?

A

Spread may be 3-4 dermatomes greater in elderly patients because of less compliant tissues and less leaky epidural space

31
Q

What effect dose pregnancy have on epidural blockade?

A
  • Epidural spread greater

- Limit dose to 0.5-1mL per segment initially

32
Q

What is the speed or mode of injection of epidural blockade?

A

Inject slowly to avoid increases in CSF pressure, headache and increased ICP

33
Q

What is the concentration of epidural?

A

The lower the concentration the lower the effect the local anesthetic will have on the degree of sensory and motor blockade (the “density” of the block)

34
Q

What can a lower concentration of epidural medications?

A

Lower concentrations of local anesthetics used to facilitate analgesia (e.g. labor) or to provide a sympathectomy

35
Q

What are higher concentration of epidural medications?

A

Higher concentrations used to provide complete surgical anesthesia

36
Q

What is a differential blockade?

A

the local anesthetics (sympathetic blockade may be a high as 2-6 dermatomes higher than the sensory)

37
Q

What analgesia can be achieved with a epidural differential blockade?

A

Analgesia (loss to sharp pain) 2+ segments cephalad than touch- sometimes patient still feel “touch” or pulling sensations on less dense blocks- shouldn’t be painful

38
Q

Review Table 49.4

A

Nagelhaut

39
Q

What is the increments of epidural injection?

A

in increments of 3-5mL every 3 minutes and titrated to desired anesthetic level

40
Q

What should be done before any injection of an epidural?

A

Aspiration should occur before any injection, including into an epidural catheter

41
Q

Epidural medications: __________ is then maintained with either a continuous infusion or intermittent injections

A

Anesthetics

42
Q

What is important about the infusions?

A

a lower concentration of local

43
Q

What is important about the level of block for the epidural?

A

Level of block should be assessed at regular intervals (usually with cold sensation or skin ”pricking”

44
Q

Epidural: _________ can be added to infusions

A

Opioids

45
Q

What is the spread of dermatomal blocks?

A

10-25 minutes post injection

46
Q

Level of the block will ________ over time

A

regress

47
Q

When level of sensory block has decreased by 1-2 dermatomes another dose, ________ of initial dose can be given

A

30-50%

48
Q

When can tachyphylaxis?

A

can occur if regression allowed beyond 2 dermatomal segments

49
Q

When is tachyphylaxis more often to occur?

A

More often seen with shorter-acting agents than longer-acting agents

50
Q

What is an inadequate epidural block?

A

one-sided block or single-sensory dermatome segment failure

51
Q

What can be done for an inadequate block?

A
  • Reposition patient with the unblocked segment down
  • Administer additional local
  • Not using air in loss of resistance technique
52
Q

What is the steps if an intradural catheter placement suspected?

A
  • Remove catheter

- Do not replace until after resolution of side effects, (e.g. hypotension, bradycardia)

53
Q

If reattempting epidural, place catheter __________ to the interspace previously attempted

A

one dermatome level more cephalad

54
Q

What are the epidural complications?

A

Hypotension
Bradycardia
Backache
PDPH

55
Q

What is the incidence of backache?

A

30-45% incidence in the obstetric patient population

56
Q

What is the incidence of PDPH?

A
  • Incidence 1-2%

- Much lower incidence than with SAB

57
Q

What is the two level technique of CSE?

A
  • Each component of the block performed separately at two different interspaces
  • Epidural inserted first and spinal inserted second 1 or 2 interspaces below epidural
58
Q

What single level CSE technique?

A

Epidural needle placed in the epidural space. Then used as an introducer for the spinal needle. Spinal needle removed and epidural catheter threaded into place.

59
Q

What needle is used for CSE technique?

A

Small pencil point needle (25, 27 or 29 gauge) inserted through epidural needle into subarachnoid space and injection administered

60
Q

What is the specialixed CSE needles?

A
  • Needle with two channels – one for epidural catheter and one for spinal needle
  • Needle is placed, epidural catheter is threaded, then spinal needle placed
61
Q

What is the failure rate for CSE complications?

A

3.1-17%

62
Q

What is the failure rates greater with?

A

Greater failure rates with single level technique compared with the two level technique

63
Q

What is the theories behind increased spinal level after epidural administration?

A
  • Volume of fluid injected into the epidural space compresses subarachnoid space and CSF within it, increasing the spread of local
  • A leak or flow of local from the epidural space into the subarachnoid space through the dural puncture
64
Q

What is the CSE complications?

A 
Failure rate 
Catheter migration
PDPH
Infection
Neurologic injury
65
Q

What is the caudal anesthesia?

A

Distal approach to the epidural space

66
Q

Where dose caudal anesthesia act?

A

Will act on the sacral dermatomes

67
Q

When is a caudal anesthesia?

A

Perirectal surgery, urologic and orthopedic surgery of the lower extremity

68
Q

Caudal is often used with a light ________ in preadolescent pediatric patients

A

GA

69
Q

What is the age requirement for caudal anesthesia?

A

After age 12 years sacral anatomy changes and bone growth makes identification of the epidural space difficult but not impossible

70
Q

Caudal anesthesia: Can use a __________ technique

A

continuous catheter

71
Q

What is the pediatric dose of caudal medications?

A

0.5-1mL of solution per kg of body weight will reliably achieve a level of analgesia to the umbilicus

72
Q

What is the concentration for caudal medications of bupivacine or ropivacaine?

A

in concentrations of 0.125-0.5% are usually administered with 1:200,000 epi to a maximum dose of 2.5mg/kg body weight

73
Q

Caudal dose for adults?

A

Use same dosing principles as with epidurals, not typically done

74
Q

What are the complications of caudal anesthesia?

A

-Similar to epidural – intravascular or subarachnoid injection
-High failure rate – 10-15%
Infection

2-General Anesthesia Exam 2 (11 decks)

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