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Anesthesia Principles II > Epidurals > Flashcards

Epidurals Flashcards

1
Q

where does epidural work?

A

ant and post nerve roots & dorsal ganglia, and to a lesser extent ant/post rootlets and the spinal cord itself

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2
Q

distance from skin to epidural space?

A

typically 4-6cm, can be 2-9 though so be careful

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3
Q

what to do if you think epidural catheter is intravascular? (blood doesnt clear)

A

must remove catheter, try again one interspace higher

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4
Q

what happens to epidural veins in preganancy?

A

become engorged, they are more lateral than midline in teh epidural space

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5
Q

what size is tuohy needle?

A

18g

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6
Q

who is more likely to get PDPH?

A

young people

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7
Q

epidural catheter size?

A

19 or 20 guague

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8
Q

how far to thread epidural catheter into epidural space?

A

3-5cm

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9
Q

typicall epidural volume vs spinal volume?

A

epidural: 10-20cc
spinal: 1-2cc

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10
Q

how much LA do you give in epidural to acheive the level you want?

A

give 1-2cc per segment blocked.

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11
Q

which direction does the LA go in the epidural space?

A

both caudad and cephalad

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12
Q

when is epidural dosing decreased?

A

elderly, obese, pregnancy

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13
Q

physically how do you administer epidural meds?

A

give 3-5cc, wait 3-5min, give 3-5cc, wiat 3-5min, repeat until full dose given

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14
Q

how long does chloroprocaine last?

A

50-70min

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15
Q

how long does prilocaine last?

A

90-130min

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16
Q

how long does lidocaine last?

A

90-150

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17
Q

how long does mepivicaine last?

A

120-160

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18
Q

how long does bupivicaine last?

A

200-260

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19
Q

very important things to prepare for when give spinal or epidural?

A

airway mgmt and hypotension

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20
Q

what is usually the largest interspace?

A

L2-L3

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21
Q

where does epidural needle feel more secure and less flimsey?

A

in the interspinous ligament / ligamentum flavum, it will also feel more anchorded at this point. This is where you take out the stylet and connect saline/air filled syringe

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22
Q

what do each of your hands do when performing an epidural?

A

non dominant: controls how much the needle is advanced

dominant hand: check syringe for loss of resistance

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23
Q

what might you hit right before the epidural space?

A

the crunchies

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24
Q

what must you do every time before you inject anything in epidural space?

A

aspirate! look for blood and CSF

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25
Q

what is a test dose?

A

used to make sure you are not in an epidural vein. looking for HR to increaes 10-20bpm. Dont do during a contraction obviously

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26
Q

if epidural is actually intrathecal, what movemement might the patient have a hard time with?

A

gas pedal

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27
Q

medication doses for a test dose?

A

3ml of 1.5% Lidocaine (45ml) with 1:200,000 epi

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28
Q

what might patieint feel if the test dose lidocaine is given in the intrathecal space?

A

may feel legs getting warm and heavy. stop injecting!

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29
Q

totoal time for dosing and set up of an epidural?

A

20-30min

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30
Q

what level is sacral hiatus?

A

S4

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31
Q

in what pt population is the caudal epidural used?

A

pediatrics

32
Q

how to do a caudal block?

A

ID sacral hiatus, and sacral cornu which is 2: above the coccyx.

use 22g short beveled needle at 45 degrees to the skin. you will feel pop or loss of resistance getting through the tough ligament. drop needle angle, adavance a couple cm and inject the drug

33
Q

how long does it take to get a good caudal block?

A

15min

34
Q

what surgeries are caudal blocks good for?

A

perineal surgeries

used in peds with GA

good for adults in perineal/rectal surgeries

35
Q

peds caudal epidural dosing?

A

0.5-1ml/segment

36
Q

what dermatome level needed for upper abd surgery?

A

T4

37
Q

what dermatome level needed for intestinal, gynecologic, and urologic?

A

T6

38
Q

what dermatome level needed for TURP?

A

T10

39
Q

what dermatome level needed for vaginal delivery or hip surgery?

A

T10

40
Q

what dermatome level needed for thigh surgery or lower leg amputation?

A

L1

41
Q

dermatome needed for foot and ankle surgery?

A

L2

42
Q

dermatome needed for perineal or anal surgery?

A

S2-S5 (saddle block)

43
Q

bupivicane concentration?

A

0.0625%-0.5%

44
Q

bupivicaine onset?

A

15-20min

45
Q

onset of 2 cholorprocaine?

A

5-15min

46
Q

onset of lidocaine?

A

10-20min

47
Q

onset of ropivicane, bupivicane, and levobupivicane?

A

15-20min

48
Q

what must you do if using depodur 15mg ER?

A

must do a test dose and flush with NS before using depodur.

also meant to be used alone without LA

49
Q

Fentanly dose onset and doa?

A

50-100mcg
onset 5-10min
doa 2-6hr

50
Q

morphine dose onset and doa?

A

3-5mg (duramorph 5mg-10cc)
onset 30min
doa 12-24hr

51
Q

where do we want epidural opioids to end up?

A

get to the substania gelatinosa on spinal cord after getting through the dural cuff

52
Q

why might you need higher opiod doses in epidurals?

A

because of the epidural fat, lipphilic drugs may be sequestered there

53
Q

2 techniques for combined spinal/epdiural?

A

dural puncture epdidural technique

needle through needle technique

54
Q

how far would you advance catheter into intrathecal space?

A

2-3cm

55
Q

how much fluid does spinal catheter hold?

A

0.25ml

56
Q

what was cauda equina syndrome related to?

A

microcatheters and hyperbaric lidocaine

57
Q

why is PDPH less with spinal catheter?

A

creates inflammation thought to plug the hole

58
Q

how to trouble shoot one sided block?

A

withdraw catheter one cm, put unaffected side in down position and re-dose

59
Q

what may be happening if getting parathesia with epidural placement?

A

could be in a root and not midline. if consistent parathesia pull out and start again

60
Q

where is an open ligamentum flavum most often seen?

A

between L1-L2

61
Q

what body response can make PDPH worse?

A

dilation of intracranila vessels to compensate for lost space

62
Q

S/S PDPH?

A

N/V, headache, feeling miserable, diplopia, photosensitive, extreme headache when sitting up

63
Q

when does PDPH prsent?

A

within 1-2 days, but can take up to 5 days

64
Q

how quickly will PDPH resolve without any tx?

A

usually 5-7days

65
Q

how to treat PDPH?

A

conservative first, bedrest, prone position, abd binder, IV fluids 3L/day

caffeine sodium benzoate IV vasoconstrictor

66
Q

how does international calssification of headache disorders define PDPH?

A

onset within 15min of moving to the supine position with at least 1 of the following symptoms:
headache, neck stiffness, tinnitus, photophobia or nausea

67
Q

differential dx for PDPH?

A

migraine, HTN, subarachnoid hemorrhage, meningitis, lactation headache, pneumocephalus (has postural component), brain tumor, sinusitis

68
Q

If caffeine and conservative measures for PDPH fail what do you do?

A

epidural blood patch

69
Q

how do you do an epidural blood patch?

A

aseptically draw up 10-20ml pt blood

inject blood into epidural space 1 level lower than original puncture.

need to inject 10-20cc, but 15 is optimum.

70
Q

common complaints with epidural blood patch?

A

pressure, back ache, hip fullness

71
Q

how effective our epidural blood patches?

A

get rid of 85-90% of PDPH on first try

72
Q

when can you repeat epidural blood patch?

A

in 24hours

73
Q

another symptom you may see with epidural blood patch?

A

bradycardia

74
Q

relative contraindications for epidural?

A

spinal pathology
chronic headahce/backaches
atempts failed after 3x

75
Q

epidural contraindications?

A

1 pt refusall, or uncooperative pt

infection or derm issues
spetic shock
high rapid blood loss case
severe hypotension/hypvolemia
increase ICP
clotting issue
severe AS or mitral stenosis (cant tolerate drop in BP)

Anesthesia Principles II (14 decks)

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