Exam 1 Spinal & Epidural Neuraxial Anesthesia [5/28/24] Flashcards
1
Q
List the 3 major anesthesia techniques
A
- General Anesthesia
- MAC
- Regional Anesthesia
S1
2
Q
Regional anesthesia has 2 classifications. What are they and its subclasses?
A
Central neuraxial
1.Spinal
2.Epidural
3.Combines spinal and epidural [CSE]
4.Caudal: this is peds specific.
Peripheral blocks
1.upper extremity blocks
2.lower extremity blocks
3.trunchal: top block, interfascial block, perivertibral, pectoral nerve block 1 and 2.
S1
3
Q
What cannot be given through the spinal?
A
Reglan and Zofran `
3
4
Q
What are the clinical Indications for neuroaxial anesthesia?
A
- Surgical procedures involving the lower abdomen, perineum, and lower extremities
- Orthopaedic surgery [alot of spinals]
- Vascular surgery on the legs
- Thoracic surgery (adjunct to GETA) [usually epidurals]
VOTS
S5
5
Q
What are the 6 benefits for neuraxial anesthesia?
A
Reduces the following:
1. Postoperative ileus
2. thromboembolic events
3. PONV
4. Respiratory Complications
5. Bleeding
6. Narcotic Usage
I Take Rare Ponies, Not Babies
S6
6
Q
What causes PONV?
What are the risk factors?
A
- PONV occurs due to induction medication like anesthetic gasses & opioids.
- Factors for increased PONV:
1.Females
2.NON-Smokers
4.Age 40 and higher
S6
7
Q
List the other benefits of neuraxial anesthesia.
A
- Great mental alertness
- Less urinary retention*
- Quicker to eat, void, and ambulate
- Avoid unexpected overnight admission from complications of general anesthesia
- Quicker PACU discharge times*
- Preemptive anesthesia
- Blunts stress response from surgery
BM QUAP
S7
8
Q
If using neuraxial anesthesia, and the pt needs to be put to sleep but needs to maintain respiratory drive what can be administered?
A
- Propofol
- 100-300 mcg/kg
S7
9
Q
What are the relative contraindication for neuroaxial anesthesia
A
- Deformities of spinal column [issues w/positioning]
- Spinal stenosis, kyphoscoliosis, ankylosing spondylitis
- scoliosis, lordosis, kyphosis
- Preexisting disease of the spinal cord [residual weakness]
- Exacerbate a progressive, degenerating disease
- Multiple Sclerosis, post polio syndrome
- Chronic headache/backache
- Inability to perform SAB/Epidural after 3 attempts
S8
10
Q
Why are chronic headaches/backaches a relative CI for neuroaxial anesthesia?
A
- A complication of neuroaxial anesthesia is post-dural puncture heacache.
- if pt has backpain, and we are sticking needes in the back it might worsen the pain
S8
11
Q
What are the absolute CI for neuroaxial anesthesia?
A
- Coagulopathy
- Patient refusal
- Evidence of dermal site infection
- known coag disoder or on anticoagulants
- Severe or critical valcular heart disease
- HSS [idiopathic hypertrophic subaortic stenosis]
- Operation >duration of LA
- Increased ICP
- Severe CHF
Cool Patients Dance Very Oddly It Seems
S9-10
12
Q
What are the coagulation problems that are absoulte contraindications for neuroaxial anesthesia
A
- INR > 1.5
- PLT < 100,000*
- PT, PTT, BT x 2
13
Q
Normal PT
A
12 - 14 seconds
S9
14
Q
Normal INR
A
0.8 - 1.1
S9
15
Q
Normal aPTT
A
25 - 32 seconds
S9
16
Q
Normal Bleeding Time [BT]
A
3 - 7 minutes
S9
17
Q
Normal Platelets
A
150,000 - 300,000 mm3
S9
18
Q
List the factors involved in the coagulation cascade
* Intrinsic
* Extrinsic
* Common
A
- Intrinsic: 12, 11, 9, 8
- Extrinsic: 3, 7
- Common: 10, 5, 1, 2,13
S9
19
Q
PT/INR measures?
PTT measures?
A
- PT/INR = extrinsic
- PTT = intrinsic
S9
PT = PLAY TENNIS OUTSIDE = EXTRINSIC
PTT = PLAY TABLE TENNIS INSIDE = INTRINSIC
20
Q
What happens when we get injured?
A
Hemostasis:
1.Vascular effect - Body has vascular constriction.
2.Primary mechanism: where PLT is activated.
* PLT activation occurs by extrinsic methods.
* VWF (Factor VIII) pulls platelets to come closer and work together. This makes the PLT sticky. This forms a PLT plug [not strong].
3.Secondary mechanism: intrinsic/extrinsic/common pathway.
S9
21
Q
What does the bleeding time look at?
A
- Examines PLT activation and adhesion.
- longer BT = problem with PLTs.
S9
22
Q
What severe valvular heart diseases are absolute CI for neuroaxia anesthesia?
A
- Aortic stenosis <1cm2
- Mitral stenosis <1cm2
S10
23
Q
List the valve area for AS for the following:
* Mild
* Moderate
* Severe
* Critical
A
- Mild: >1.5 [greater than or equal to]
- Moderate: 1.0 - 1.5
- Severe: 0.7 - 1.0
- Critical: < 0.7
cm2
24
Q
What is the average course of valvular aortic stenosis in adults
A
- Age 35-40: increasing obstuction, myocardial overload
- Age 60: onset of severe symptoms **
- Age 63: average age of death.
S10
25
What are the s/sx of severe or critical AS? What are its survival rates?
* Angina - 5yrs
* Syncope - 3yrs
* Heart failure - 2 yrs, the worst [NYHF 3 or 4]
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26
Why is aortic stenosis a contraindication?
* Main issue for anesthesia is loss of afterload, SVR, and HR.
* W/general anesthesia, SVR is dropped.
* W/regional anesthesia esp spinal = Death Spiral
DEATH SPIRAL: decrease SVR —> hypotension —> ischemia —> decrease CO —> worsened BP —> angina.
| S10
27
What is the death spiral that occurs due to AS?
1. hypotension causes myocardial ischemia
2. ischemia contractile dysfunction
3. decreases CO
4. worsening hypotension
5. increased ischemia
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28
Compare & Contrast the following characteristics of spinals and epidural:
* Onset
* Spread
* Nature of block
* Motor block
* Hypotension
| S11
29
Compare & Contrast the following characteristics of spinals and epidural:
* Onset
* Duration
* Placement level
* Difficulty of placement
* Dosing
* Concentration
* LA toxicity
* Gravity influence
* Manipulation of dermatome spread after dosing
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30
What is the placement and needle size for spinals?
* Placement: L3-L4, L4-L5, L5-S1 but we as SRNAs do L4-L5
* Smaller needle: 25-27g
| S12
31
What is the placement and needle size for epidurals?
* Placement: anywhere there is epidural space
* bigger needle: 18-19 g
* can do epidurals by thoracic but draw back is accidentally hitting the spinal cord.
| S12
32
Baracity affects epidurals or spinals?
What does hyper, hypo, and iso -baric mean?
* Affects spinals
* hyperbaric: sinks
* hypobaric: floats
* isobaric: stays in place
| S12
33
Positioning affects epidurals or spinals?
How would you postion a pt with right hip pain?
* Affects epidurals
* pain in right buttock - turn to right side to have LA stay on that side.
| S12
34
How many total vertebras do we have?
* Total:
* Cervicle:
* Thoracic:
* Lumbar:
* Sacrum:
* Coccyxs:
* Total: 33
* Cervicle: 7
* Thoracic: 12
* Lumbar: 5
* Sacrum: 5
* Coccyx: 4
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35
What are the 4 curvatures of the spine?
1. Normal
2. Scoliosis
3. Kyphosis
4. Lordosis
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36
Each vertebra, except for ____, is divided into two main parts:
* The____ segment, known as the body.
* The ____ segment, called the vertebral arch.
* C1
* anterior
* posterior
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37
what 2 structures link the anterior and posterior segments?
the lamina and pedicle
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38
The connection of the anterior and posterior segments form the ____ ____.
* verterbral foramen
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39
The vertebral foramen is a crucicial space within the verbra why?
houses the spinal cord, nerve roots, and the epidural space, which is a protective cushioning area around the spinal cord.
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40
The ____ processes stick out to the sides (lateral), while the ____ processes stick out towards the back (posterior).
* transverse
* spinous
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41
what attach to the spinous and transverse processes to help stabilize and support the spine?
muscles
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42
The spionus process is used as a landmark for what?
to find the middle line of the back
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43
How are lumbar vertebrae different from thoracic and cervical vertebrae?
the orientation of the spious process is different
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44
Cervical and thoracic spinous processes tilt ____, requiring a needle approach from ____.
* downward (caudal direction)
* above (cephalad approach)
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45
Lumbar spinous processes stick out directly ____, which makes it easier to reach the spaces around the spinal cord, such as the ____ & ____ spaces.
* backwards (posterior)
* epidural and intrathecal spaces.
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46
These are the soft pads between each vertebra that act as shock absorbers.
intervertebral disc
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47
These are the openings between the vertebrae where spinal nerves exit the spine.
intervertebral foamina
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48
how is the intervertebral formaina formed?
* The anterior side of the foramen is formed by the vertebral body and the intervertebral disc.
* The posterior side of each foramen is formed by the facet joints, which are part of the vertebrae.
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49
how is each facet joint made?
* Each facet joint is made by two parts:
* The inferior articular process of one vertebra connects with the superior articular process of the vertebra right below it.
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50
whati s the function of the facet joints?
They help guide and limit the spine's movement, keeping the back's motions controlled.
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51
* what happens if a fact joint gets injured?
* what are the symptoms of this?
* it can press on nearby spinal nerves
* pain and muscle spasms in the area of skin served by that nerve (dermatome).
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52
# surface landmarks
where is the superior aspect of the iliac crest?
L4
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53
where is the posterior superior iliac spine?
S2
| slide 20
54
what is tuffier's line [intercristal line]?
This horizontal line runs across the top edges of the hip bones (iliac crests) and matches the L4 vertebra
| slide 20
55
Tuffier's Line helps identify the correct spaces between vertebrae for inserting spinal anesthesia needels.
* The space above this line aligns with the ____ vertebrae.
* The space below this line aligns with the ____ vertebrae.
* L3 - L4
* L4-L5
| slide 20
56
in infants up to one year the intercristal line corresponds with the ____ intervertebral space
L5-S1
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57
The sacrum is a triangular-shape section of fused vertebra (5). The lamina of ____ is incomplete and bridged only by ligaments.
S5
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58
Sacral Hiatus
* location?
* covered by?
* purpose?
* Located at the base of the sacrum and aligns with the S5 vertebra.
* Covered by the sacrococcygeal ligament.
* Acts as an access point to caudal anesthesia
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59
Sacral Cornua
* The projections of the articular processes are known as cornu
* The sacral cornu are the “horns” or bony protuberances that guard the area of the ____
* Landmark for ____ anesthesia
* sacral hiatus
* caudal
| slide 22
60
Components of the spinal cord?
* starts at the medulla oblongata
* conus medullaris
* caurda equina
* dural sac
* filum terminale
| slide 23/24
61
the spinal cord has a ____ origin, starting in the ____.
* rostral origin
* medulla oblongata
| slide 24
62
* What is the conus medullaris?
* where does it end in adults?
* where does it end in infants?
* where the spinal cord tapers off at the end
* In adults, it ends between the L1 and L2 vertebrae. (L1 in most textbooks)
* In infants, it ends at L3.
| slide 23
63
* what is the cauda equina?
* what does it consist of?
* A bundle of spinal nerves extending from conus medullaris to the dural sac.
* Consists of nerve roots from L2 to S5 vertebrae and the coccygeal nerve.
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64
* what is the dural sac?
* where does it end in adults?
* where does it end in infants?
* The subarachnoid spaces ends at the dural sac.
* Ends at S2 in adults.
* Ends at S3 in infants.
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65
* what is the filum terminale?
* what is its main function?
* The filum terminale is a structure that continues downward from the end of the spinal cord.
* It is a continuation of the pia mater.
* It extends from the conus medullaris to the tailbone (coccyx).
* Its main function is to anchor the spinal cord to the coccyx.
| slide 24
66
what are the parts of the filum terminale?
* Internal Filum Terminale:
* Begins at the conus medullaris, extending to the dural sac.
* L1-S2
* External Filum Terminale:
* Starts from the dural sac and extends into the sacrum.
* S2-S5
| slide 24
67
how does the spinal cord receive blood supply?
* one anterior spinal artery
* two posterior spinal arteries
| slide 25
68
Anterior spinal artery
* origination?
* supplies what part of the cord?
* how much does it supply?
* Originates from the vertebral artery.
* Supplies the front (motor) portion of the spinal cord.
* Supplies the anterior 2/3 of the spinal cord
| slide 25
69
Two posterior spinal arteries
* Emerge from the ____.
* Originates from the ____ artery.
* Supply the ____ portion of the spinal cord.
* cranial vault
* vertebral
* posterior (sensory
| slide 25
70
what part of the cord has better protection from ischemia the posterior or anterior?
* The posterior spinal arteries are paired and have many connections (collateral anastomotic links) from the subclavian and intercostal arteries.
* These connections help protect the sensory part of the spinal cord from ischemia.
* The anterior spinal artery, being a single artery, does not have as many protective links, making the motor part more vulnerable to ischemia.
| slide 25
71
what are symptoms of anterior spinal artery syndrome?
If the anterior spinal artery is affected by ischemia, it can lead to:
* Motor paralysis.
* Loss of pain and temperature sensation below the affected area.
| slide 26
72
what are causes of ischemia that can lead to anterior spinal artery syndrome?
* Low blood pressure (profound hypotension).
* Mechanical blockage.
* Blood vessel disease (vasculopathy).
* Bleeding (hemorrhage).
| slide 26
73
the anterior spinal artery receives additional blood slupply through what branches?
The anterior spinal artery receives additional branches from the intercostal and iliac arteries, though these are variable.
| slide 26
74
Artery of Adamkiewicz:
* what is it?
* where does it arise?
* damage to this can cause what?
* A crucial connection that supplies blood to the lower two-thirds of the spinal cord.
* It usually arises from the aorta between the T9and L2 regions
* Damage to this artery can also lead to anterior spinal artery syndrome.
| slide 26
75
what are the spinous lingaments posterior to anterior?
* Supraspinous Ligament
* Interspinous Ligament
* Ligamentum Flavum
* Posterior Longitudinal Ligament
* Anterior Longitudinal Ligament
| slide 27
76
Runs along the back, connecting the tips of the spinous processes from the upper back down to the lower back.
Supraspinous Ligament
| s;ode 27
77
Located between the spinous processes, providing stability by joining adjacent vertebrae.
interspinous ligament
| slide 27
78
* They are particularly thick in the lower back and form the sidewalls of the space outside the spinal cord (epidural space).
* Piercing this ligament indicates entry into the epidural space during procedures.
ligamentum flavum
| slide 27
79
Runs along the back side of the vertebral bodies inside the spinal column.
posterior longitudinal ligament
| slide 27
80
* Attached to the front of the vertebral bodies, running the length of the spinal column.
* Also connects to the outer fibers of the intervertebral discs, helping to bind the vertebrae together.
anterior longitudinal ligament
| slide 27
81
what layers are transvered during a midline spinal?
* Skin
* Subcutaneous fat
* Supraspinous ligament
* Interspinous ligament
* Ligamentum flavum
* Dura Mater
* Subdural space
* Arachnoid Mater
* Subarachnoid space
| slide 28
82
what layers are transvered during a paramedian approach?
* Skin
* Subcutaneous fat
* Ligamentum flavum
* Dura Mater
* Subdural space
* Arachnoid Mater
* Subarachnoid space
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83
paramedian approach
* use:
* Positioning:
* Use: When the interspinous ligament is calcified or the patient cannot flex their spine.
* Positioning: Can be performed while the patient is sitting, lying on their side, or face down.
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84
Paramedian Approach Procedure:
* Insert the needle 15 degrees off the spine’s midline.
* Position the needle 1 cm to the side (lateral) and 1 cm below (inferior) the space between the vertebrae (interspace).
| slide 28
