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S3 2024 ANE 8509 Principles > Exam 1- Neuraxial Principles 5/28/24 > Flashcards

Exam 1- Neuraxial Principles 5/28/24 Flashcards

1
Q

What are the two major components of regional anesthesia?

A
  1. Central Neuraxial Blocks
  2. Peripheral Nerve Blocks
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2
Q

What are the two components of Central Neuraxial Anesthesia?

Which one is harder to perform?

A
  1. Spinal Anesthesia
  2. Epidural Anesthesia (This one is harder to perform, it takes skills.)
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3
Q

Will you expect to see CSF during epidural blocks?

A

No. CSF should not be expected in epidural blocks.
If CSF is present, you have entered into the subarachnoid space.

CSF is expected in spinal blocks.

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4
Q

What ligaments will the needle pass through to get to the epidural space?

A
  1. Supraspinous Ligament
  2. Interspinous Ligament (joins adjacent vertebra)
  3. Ligamentum Flavum (piercing this ligament indicates entry into epidural space, yellow in color)
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5
Q

Spinal Anesthesia is the injection of local anesthetic (LA) into ____________ space.

A
  • Subarachnoid
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6
Q

What are two other names for Spinal Anesthesia?

A
  • Subarachnoid Block (SAB)
  • Intrathecal Block
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7
Q

Can SAB be used both as a sole anesthetic and an adjunct agent?

A

Yes. SAB can be used for both.

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8
Q

What procedures require a SAB?

A
  • C-section
  • Lower extremity surgery
  • Abdominal Surgery
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9
Q

Describe the onset between a spinal block and an epidural block.

A

Spinal Block: Rapid Onset (5 min)
Epidural Block: Slow Onset (10-15 mins)

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10
Q

Describe the spread of LA between a spinal block and an epidural block.

A

Spinal Block: Higher than expected; may extend extracranially.

Epidural Block: As expected, can be controlled w/ volume of LA.

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11
Q

Describe the nature of the block between a spinal block and an epidural block.

A

Spinal Block: Dense
Epidural Block: Segmental

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12
Q

Describe the motor block between a spinal block and an epidural block.

A

Spinal Block: Dense motor block
Epidural Block: Minimal

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13
Q

Is hypotension more likely to occur between a spinal block or an epidural block?

A
  • Spinal Block
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14
Q

What are your phrenic nerves?

A
  • C3 nerve fiber
  • C4 nerve fiber
  • C5 nerve fiber
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15
Q

What LA discussed in class is used for a “walking” epidural.

A
  • Ropivacaine

Ropivacaine provides a very segmental block

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16
Q

What are your cardiac accelerator nerves?

A
  • T1 nerve fiber
  • T2 nerve fiber
  • T3 nerve fiber
  • T4 nerve fiber
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17
Q

What term was used in class to describe antagonized sympathetic nerve fibers secondary to local anesthetics?

A
  • Sympathectomy

This usually results in hypotension and bradycardia.

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18
Q

Differentiate the duration of action between a spinal block vs an epidural block.

A

Spinal: Limited and fixed (one-shot)
Epidural: Unlimited (Catheter in place w/ LA infusion)

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19
Q

Differentiate the level of placement between a spinal block vs an epidural block.

A

Spinal Block: L3-L4, L4-L5, L5-S1
Epidural Block: Any Level

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20
Q

How many attempts are permitted for a spinal/epidural block?

A
  • Three
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21
Q

Differentiate the dosing between a spinal block vs an epidural block.

A

Spinal Block: Dose-base
Epidural Block: Volume-base

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22
Q

What is the max amount (volume) of LA for a spinal block vs epidural?

A

Spinal Block: 3 mL
Epidural Block: 20 mL

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23
Q

Differentiate the concentration of LA between a spinal block vs an epidural block.

A

Spinal Block: Concentrated and fixed

Epidural Block: Varies

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24
Q

Differentiate the LA Toxicity between a spinal block vs an epidural block.

A

Spinal: No

Epidural: Yes (Higher risk of LA entering the bloodstream due to bilateral veins on the spine.)

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25
Q

Which LA discussed in class is the most sensitive to the heart?

A
  • Bupivacaine
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26
Q

What should be done during a Bier Block procedure if IV Bupivacaine is accidentally administered instead of Lidocaine?

A
  • Leave the tourniquet in place and let the bupivacaine be absorbed.
  • Do not deflate the cuff unless you want V-tach/ V-fib.
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27
Q

Differentiate the gravity influence between a spinal block vs an epidural block.

A

Spinal Block: Yes, there will baricity

Epidural: No, unless the needle punctures the dura (“wet tap”).

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28
Q

Differentiate the manipulation of dermatome spread after dosing between a spinal block vs an epidural block.

A

Spinal: Positional Change depending on baricity (Iso, Hyper, Hypobaric)

Epidural: Incremental dermatome spread based on volume. 1-2 mL per segment.

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29
Q

The use of neuraxial anesthesia can reduce these 6 factors.

A
  • Bleeding
  • Narcotic usage
  • Postop Illeus
  • Thromboembolic events
  • PONV
  • Respiratory complications
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30
Q

What are the other benefits of Neuraxial Anesthesia?

A
  • Great mental alertness
  • Less urinary retention
  • Quicker to eat, void, ambulate
  • Quicker PACU discharge (use Lidocaine)
  • Preemptive anesthesia
  • Blunts stress response from surgery
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31
Q

What are the indications of spinal anesthesia?

A
  • Surgical procedures involved with Lower abdomen, Perineum, and Lower extremities (Knees/Hips)
  • orthopedic surgery
  • vascular surgery on the legs
  • Cesarean Delivery (for elective and stat cases only)
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32
Q

What anesthesia would be indicated if the surgeon needs the patient to be still?

A
  • General Anesthesia

Important to communicate with surgeon about the plan of care.

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33
Q

What anesthesia would be indicated if there is an emergency Cesarean delivery?

A
  • General Anesthesia (Rapid Sequence Induction)
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34
Q

What are absolute contraindication of spinal anesthesia?

A
  • Coagulopathy (risk of epidural hematoma)
  • Sepsis
  • Patient refusal/ cooperation/ mental competency/ age/ lack of informed consent
  • Evidence of dermal site infection
  • Hypovolemia (Already prone to sympathectomy)
  • Pre-existing spinal cord disorder (intraspinal mass)
  • Valvular disease (Aortic/Mitral Stenosis)
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35
Q

What is the problem with aortic stenosis when performing spinal anesthesia?

A
  • Decrease SVR resulting in hypotension

Do not perform spinal anesthesia if the patient has severe aortic stenosis <1.0 cm2

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36
Q

Absolute contraindication coagulopathy lab values for spinal anesthesia.

INR
Platelets
nagelhout

A
  • INR > 1.5
  • Platelet < 50-100K (consider trends)
  • Nagelhout x 2 (PT, aPTT, bleeding)
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37
Q

What are relative contraindications of neuraxial anesthesia?

A
  • Deformed spinal column (ie: kyphoscoliosis, spinal stenosis, ankylosing spondylitis)
  • Pre-existing disease of the spinal cord (MS)
  • Chronic HA/ backache (take a baseline assessment)
  • Inability to perform SAB after 3 attempts
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38
Q

How many vertebrae does a human have?

A
  • 33
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39
Q

How many pairs of spinal nerves does a human have?

A
  • 31 pairs
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40
Q

The inferior angle of the Scapula is parallel to which vertebrae?

A
  • T7
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41
Q

How many cervical vertebrae are there?
How many pairs of cervical spinal nerves are there?

A
  • 7 cervical vertebrae
  • 8 cervical spinal nerve pairs
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42
Q

Is caudal anesthesia an epidural or spinal block?

A
  • Epidural block
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43
Q

Where is the insertion point for a caudal anesthesia?

A
  • Sacral Hiatus
    *located at the base of the sacrum (S5 vertebra)
    covered by sacrococcygeal ligament
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44
Q

What are the bony prominences on either side of the hiatus and aid in identifying that landmark?

A
  • Sacral Cornu
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45
Q

Where are the high points and low points when a patient is in a supine position?

A
  • High Points (Apex): C3 and L3
  • Low Points (Trough): T6 and S2
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46
Q

If a LA that is a hyperbaric solution is administered at L3. When the patient is supine where will the LA travel in the cephalad and caudal area?

A

Cephalad: T6
Caudal: S2

47
Q

What is the orientation of the lumbar spinous process?

A
  • Relatively straight
  • Posterior/horizontal orientation
48
Q

What is the orientation of the thoracic spinous process?

A
  • Pointing caudally
  • Posterior/ oblique orientation
49
Q

Blood vessels are located at the ________ aspect of the epidural space.

A
  • Lateral

When blood is encountered during needle insertion, most likely, the needle is lateral.

epidural space is located outside the dura mater

50
Q

What is the distance from skin to ligamentum flavum for 50% of the patient population?

What is the distance from skin to ligamentum flavum for 80% of the patient population?

A
  • 4 cm (50%)
  • 4 to 6 cm (80%)
51
Q

What percentage of people have their spinal cord end at T12?

What percentage of people have their spinal cord end at L1?

What percentage of people have their spinal cord end at L3?

A
  • 30% end at T12
  • 60% end at L1
  • 10% end at L3

For board purposes, L1 is the end of your spinal cord.

52
Q

Where does the spinal cord end for children?

A
  • L3
53
Q

Where does the dural sac end in an adult?

A
  • S2

This is where your subarachnoid space ends

Contains CSF

54
Q

Name the blood supplies of the spinal cord.

A
  • One anterior spinal artery
  • Two posterior spinal arteries
  • Segmental spinal arteries
55
Q

Where does the anterior spinal artery originate from?

Where do the two posterior spinal arteries originate from?

Where do the segmental spinal arteries originate from?

A
  • Anterior spinal artery originates from the vertebral artery
  • Posterior spinal arteries originate from vertebral artery
  • Segmental spinal arteries originate from the intercostal and lumbar arteries

Posterior spinal arteries have more connections and are less prone to ischemia (protects the sensory part of the spinal cord)
Anterior spinal artery being single, is more prone to ischemia –> anterior spinal artery syndrome

56
Q

The two most common drugs used to treat hypotension in anesthesia.

A
  • Neosynephrine (use when HR is high w/ low BP)
  • Ephedrine (use with bradycardia w/ low BP)
57
Q

What is the caveat of using ephedrine?

A
  • Tachyphylaxis
58
Q

What is the outermost layer of the spinal meninges?

A
  • Dura mater (thickest)
59
Q

Where does the dura mater start and end?

A
  • Start at the foramen magnum
  • Ends in S2 (fuses with filum terminale)
60
Q

The subarachnoid space lies between the ________ mater and the _______ mater and contains the CSF.

A
  • Arachnoid mater (delicate, avascular membrane)
  • Pia mater
61
Q

Which meninges is adherent to the spinal cord and comprise a thin layer of connective tissue cells interspersed with collagen

A
  • Pia mater
62
Q

What is the amount of CSF in adult humans?

A
  • 100 to 160 mL
63
Q

What is the CSF production rate?

A
  • 20 to 25 mL/hr
64
Q

The entire CSF volume is replaced every ____ hours.

A
  • 6 hours
65
Q

A decrease in CSF is usually secondary to what factor?

What is the clinical significance of lower CSF volume?

A
  • Abdominal pressure (ascites, obesity, pregnancy)
  • The pressure will disperse the CSF volume
  • Clinical Significance: Lower CSF volume = small amount of LA
66
Q

The area of cutaneous sensation supplied by a spinal nerve is anatomically identified as it passes through an intervertebral foramen.

A
  • Dermatome
67
Q

Dermatome region related to T10.

A
  • Umbilicus
68
Q

Dermatome region related to T4.

A
  • Nipple Line
69
Q

Dermatome region related C6.

A
  • Thumb
70
Q

Dermatome region related C6, C7, and C8.

A
  • Hand
71
Q

Why do hypotension and vomiting occur during a C-section?

A
  • Fundal pressure will compress the vena cava, resulting in hypotension and emesis.

Spinal anesthesia will be administered at T4 due to the fundal pressure.

72
Q

The patient’s thumb is numb after using a hyperbaric LA spinal block. To prevent respiratory depression, how should the patient be positioned?

A
  • Raise the head of the bed
  • Start O2 nasal cannula at 1-2 L/min

Numb thumb is C6; raise the HOB so that LA doesn’t travel to C5 (phrenic nerve).

73
Q

Where is the Tuffier’s (Intercristal) Line?

A
  • A horizontal line that runs across the top edges of the hip bones (iliac crests) and matches the L4 vertebra
  • space above is L3-L4
  • space below is L4-L5
74
Q

What are the purposes of using LA additives/ adjunct agents in neuraxial anesthesia?

A
  • Prolong the block
  • Intensify the block
  • Increase speed of onset
75
Q

What factors determine the type of LA to use in a SAB?

A
  • Type of surgery (consider the position of the pt)
  • Length of surgery (<150 mins)
  • Surgeon (look at hospital data)
76
Q

If surgery is going to last 3 hours, is spinal anesthesia recommended?

A
  • No, the maximum duration of spinal anesthesia is 150 mins with epinephrine

A better option is to do general anesthesia for longer cases.

77
Q

If you give 2 mL of 0.75% bupivacaine, how many mg is that?

A
  • 15 mg

0.75% Bupivacaine
% is equal to grams/ 100 mL
0.75 grams/ 100 mL
750 grams/ 100 mL
7.5 grams/ mL
15 grams/ 2 mL

Shortcut: 0.75% move decimal one place to the right to make it 7.5 mg/mL

78
Q

How much epinephrine is in 1 cc if the concentration is 1:100,000?

A
  • 10 mcg/mL

Epinephrine 1:100,000
1 g of epinephrine in 100,000 mL
1000 mg/ 100,000 mL
1 mg/ 100 mL
1000 mcg/ 100mL
10 mcg/ mL

Shortcut: Divide 1,000,000 by 100,000 to get 10 mcg/ mL

79
Q

Local Anesthetic Dosing/ Duration Chart

A
80
Q

Name the three chemical structures that make up a LA.

A
  • Aromatic Ring
  • Ester or Amide Intermediate Linkage
  • Tertiary Amine

LAs that are amides have two “i’s”

81
Q

MOA of LA.

A
  • Block Na+ channels from the inside of the cell to block transmission of an action potential.
82
Q

What adjunct agent can intensify the blockade of a spinal block?

A
  • Opioids
  • Sufentanil, Fentanyl, Morphine

Opioids do not provide an extension of duration, just an increase in density and provide analgesia

83
Q

What adjunct agent can improve a spinal block’s density, duration, and analgesia?

A
  • Alpha-2 agonist
  • Dexmedetomidine (IV/ intrathecal), Clonidine

This could be a better option than opioids.

84
Q

What adjunct agent only extends the duration of a spinal block?

A
  • Vasopressors
  • Epinephrine and Phenylephrine
85
Q

Name the dosage of the following adjunct agent for a spinal block:

Morphine
Fentanyl
Sufentanil

A
  • Morphine 100-400 mcg (24 hrs)
  • Fentanyl 10-25 mcg
  • Sufentanil 2.5-10 mcg
86
Q

Name the dosage of the following adjunct agent for an epidural block:

Morphine
Fentanyl
Sufentanil

A
  • Morphine 3-5 mg (24 hrs)
  • Fentanyl 50-100 mcg
  • Sufentanil 10-25 mcg

Higher doses required when given by the epidural route

87
Q

Which opioid used in spinal anesthesia has a long duration of action, slow clearance, and is hydrophilic?

A
  • Morphine

Watch out for delayed respiratory depression, slow spread into the intrathecal space.

88
Q

If morphine was used as an adjunct agent in spinal anesthesia, what needs to be communicated with the PACU nurse?

A
  • Watch for delayed respiratory depression
  • Continuous Pulse Ox
89
Q

What is the antidote for morphine?
What needs to be considered?

A
  • Narcan
  • Narcan’s effect is shorter acting than the effects of morphine. Reversal may be short-lived.
90
Q

Thoracic Surgery use only ____ as adjunct and not ____

A

epidural, NOT spinal

91
Q

Normal Values: PT, INR, PTT, Bleeding time, platelets

A

PT = 12-14 sec
INR = 0.8 to 1.1
PTT = 24 to 32 seconds
Bleeding time = 3-7 min
platelets = 150,000 - 300,000

92
Q

Absolute Contraindications to neuroaxial in terms of valvular heart disease

A

AS = / < 1.0 cm2 or MS < 1.0 cm2
HSS (Idiopathic hypertrophic subaortic stenosis)
operation > duration of LA
Increased ICP
Severe CHF (EF < 30-40%, preload dependence)

93
Q

Know this chart

A
94
Q

Death Spiral

A
95
Q

what is the clinical triad of aortic stenosis if an echo isn’t available? what are the average survival years associated with each?

A

Angina ( 5yrs)
syncope (3 yrs)
Heart Failure (2 yrs)

96
Q

Vertebra contains 2 main parts
Which vertebra does NOT contain these parts?

A

body (anterior segment)
vertebral arch (posterior)

C1

97
Q

These connections form the vertebral foramen which houses the spinal cord, nerve roots and cushion around the spinal cord

A

lamina and pedicle

98
Q

what is the landmark that helps find the middle line of the back?

A

spinous process

99
Q

soft pads between each vertebra taht act as shock absorbers

A

intervertebral discs

100
Q

openings between the vertebrae where spinal nerves exit the spine

A

intervertebral foramina

101
Q

what is the function of facet joints?

A

guide and limit the spine’s movement

injured facet joint can press on nearby spinal nerves, can cause pain and muscle spasms

102
Q

landmark for the superior aspect of iliac crest

A

L4

103
Q

landmark for posterior superior iliac spine?

A

S2

104
Q

Intercristal Line for infants

A

L5-S1

105
Q

Spinal cord orginates? ends

A

originates –> medulla oblongata
ends –> conus medullaris

106
Q

bundle of spinal nerves extending from conus medullaris to the dural sac (L2-S5)

A

cauda equina

107
Q

its main function is to anchor the spinal cord to the coccyx

A

filum terminale
(extends from the conus medullaris to the tailbone/coccyx)

108
Q

Anterior spinal artery injury can lead to

A

motor paralysis, loss of pain and temperature sensation below affected area

109
Q

causes of anterior spinal artery syndrome (ischemia)

A

hypotension
mechanical blockage
disease of blood vessel
bleeding

110
Q

Crucial connection that supplies blood to lower 2/3 of the spinal cord

A

artery of adamkiewicz
- arises from the aorta between T8, T9 and L2

111
Q

Layers transverse during Midline

A

skin
subcutaneous fat
supraspinous ligament
interspinous ligament
ligamentum flavum
dura mater
subdural space
arachnoid mater
subarachnoid space

112
Q

Layers traverse during paramedian

A

skin
subcutaneous fat
ligamentum flavum
dura mater
subdural space
arachnoid mater
subarachnoid space

113
Q

paramedian approach is to insert the needle ____ degrees off midline
____ cm to the side and below the space between the vertebrae

A

15 degrees, 1 cm

S3 2024 ANE 8509 Principles (27 decks)

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