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KDH: Principles (EXAM I) > Exam 1 Spinal & Epidural Neuraxial Anesthesia [6/03/24] - Pharm/Coags > Flashcards

Exam 1 Spinal & Epidural Neuraxial Anesthesia [6/03/24] - Pharm/Coags Flashcards

1
Q

What is the preservative found in Amide LA’s?

A

Methylparaben

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2
Q

True or False:
If someone has an ester allergy, they will most likely have an amide allergy?

A

False
There is no cross-sensitivity between esters and amides.

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3
Q

What two components of a LA determine its onset of action?

A
  1. pKa
  2. Concentration
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4
Q

What component of a LA determines its potency?

A

Lipid solubility

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5
Q

The protein binding % of a LA determines its ___.

A

Duration of Action

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6
Q

Factors Influencing Vascular Uptake and Plasma Concentration of Local Anesthetics include:

STAMP

A

Site of Injection
Tissue Blood Flow
Addition of Vasoconstrictor
Metabolism
Physiochemical Properties

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7
Q

Which LA do we NOT want to use in a Bier Block?

A

Bupivicaine

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8
Q

Which type of LA baracity is good for Hip Replacements per Dr. Tubog?

A

Isobaric

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9
Q

List examples of Hyperbaric LA solutions:

A

Bupivicaine 0.75% in 8.25% Dextrose
Lidocaine 5% in 7.5% Dextrose
Tetracaine 0.5% in 5% Dextrose
Procaine 10% in water

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10
Q

What is the baracity of Bupivicaine 0.3% in water?

A

Hypobaric

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11
Q

The 4 isobaric solutions listed in class are all mixed with what additive?

A

Saline

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12
Q

What is the only LA mixture (per the powerpoint slides) that is combined with water but is not a hypobaric solution?

A

Procaine 10% in water = Hyperbaric

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13
Q

High and Low (Peak and Trough) dermatome points in a SAB?

A

High: C3 and L3
Low: T6 and S2

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14
Q

SAB Dosing Table

A
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15
Q

In an epidural, while ensuring incremental dosing of 5 mls, we should be avoiding these 3 negative outcomes.

A
  1. Accidental “High Spinal”
  2. Hypotension from Rapid autonomic blockade
  3. LAST
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16
Q

Most common concentration of 2-Chloroprocaine for surgical anesthesia?
Why is this important?

A

3%

Higher concentration = faster onset

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17
Q

Adding NaHCO3 increases these 4 things:

A
  1. pH of LA
  2. Concentration of Non-ionized form
  3. Rate of diffusion
  4. Speed of the onset of the block

Alkalinization

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18
Q

The ___ of the LA is crucial for determining how high the anesthetic block reaches.

A

Volume

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19
Q

What is the initial dose of an epidural?
What about the top-up dose?

A

Initial: 1-2 ml/segment
Top-Up: 50-75% of initial dose

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20
Q

What aspect of a LA determines how strong/dense the block is?

A

Concentration

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21
Q

What are some positive outcomes to adding adjuncts to neuraxial anesthesia?

A
  • Postoperative Analgesia
  • Extends Duration
  • Improves the density of the block
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22
Q

Which of the following drugs has been PROVEN to be the safest adjunct for neuraxial anesthesia?

A. Neostigmine
B. Ketamine
C. Versed
D. Clonidine
E. Magnesium

A

D. Clonidine

Rationale:
All of the other drugs are still listed as “Investigative agents” and need to be further studied in order to be validated.

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23
Q

True or False:
Vasopressors improve the density, duration and analgesia in neuraxial anesthesia?

A

FALSE
Vasopressors extend the duration ONLY.

Alpha-2 agonists improve the density, duration and analgesia in neuraxial anesthesia

24
Q

Neuraxial Opioids target what area?

A

Substantia Gelatinosa of the dorsal horn (Lamina 2)

25
Q

Do neuraxial opioids diffuse into the general circulation?

A

Yes: provides a more broad pain relief.

26
Q

Examples of Hydrophilic Neuraxial anesthesia opioid adjuncts:

A

Morphine
Hydromorphone
Meperidine

27
Q

Examples of Lipophilic Neuraxial anesthesia opiod adjuncts:

A

Fentanyl
Sufentanil

28
Q

When comparing hydrophilic opioids to lipophilic opioids, describe the duration and spread:

A

Duration is longer in hydrophilic and spreads more widely in a rostral manner

29
Q

Is the onset longer or shorter in Hydrophilic opioids?
What about systemic absorption?

A

Longer

Less systemic absorption

30
Q

Intrathecal, Epidural, and epidural infusion doses for Sufentanil

A
  • Intrathecal: 5-10 mcg
  • Epidural: 25-50 mcg
  • Infusion: 10-20 mcg/hr
31
Q

Intrathecal, Epidural, and epidural infusion doses for Fentanyl

A
  • Intrathecal: 10-20 mcg
  • Epidural: 50-100 mcg
  • Infusion: 25-100 mcg/hr
32
Q

Intrathecal, Epidural, and epidural infusion doses for Hydromorphone

A

Intrathecal: N/A
Epidural: 0.5-1 mg
Infusion: 0.1-0.2 mg/hr

33
Q

Intrathecal, Epidural, and epidural infusion doses for Meperidine

A

Intrathecal: 10 mg
Epidural: 25-50 mg
Infusion: 10-60 mg/hr

34
Q

Intrathecal, Epidural, and epidural infusion doses for Morphine

A
  • Intrathecal: 0.25-0.3 mg
  • Epidural: 2-5 mg
  • Infusion: 0.1-1 mg/hr
35
Q

Occurrence of pruritis after giving an opioid adjunct in neuraxial anesthesia:

A

30-100% of the time

36
Q

Prophylactic measures to try and prevent pruritis.

A
  • Minimize morphine dose < 300 mcg
  • Zofran
  • Nubain
37
Q

How long does the addition of A2 agonists extend the sensory and motor blockade?

A

Approximately 1 hour

38
Q

Doses of Precedex and Clonidine as neuraxial adjuncts:

A

Precedex: 3 mcg
Clonidine: 15-45 mcg

39
Q

Which of the following LA, when a vasoconstrictor is added as an adjunct, would cause the most profound increase in duration?

Lidocaine
Tetracaine
Bupivicaine

A

Tetracaine

40
Q

What is the most worrysome risk of performing neuraxial anesthesia on a patient taking anticoagulants?

A

Epidural Hematoma

41
Q

Symptoms of an Epidural Hematoma:

A

Lower extremity weakness, numbness
Lower back pain
Bowel/Bladder dysfunction

42
Q

Treatment for Epidural Hematoma:

A

Surgical decompression **within 8 hrs **

43
Q

With which patient population (taking anticoagulants) is neuraxial anesthesia a big challenge?

A

Patients with Cardiac Stents

44
Q

What are the guidelines for holding ASA in High Risk, Intermediate Risk, Low Risk and central neuraxial cases?

A

High/Intermediate: Hold 4-6 days
Low: No hold
Central: No additional precautions

45
Q

How long should we hold NSAIDs for High risk procedures?

A

Hold for 5 half-lives

46
Q

Place these types of surgeries in either a Low, Intermediate or High cardiac risk level:

Prostate Surgery
Cataract Surgery
Breast Surgeries
Open Aortic Surgery
Orthopedic Surgery
Head and Neck Surgery
Peripheral Vascular Surgery
Endoscopic Procedures
Intra-thoracic/Intra-abdominal Surgeries

A

Prostate Surgery (Intermediate)
Cataract Surgery (Low)
Breast Surgeries (Low)
Open Aortic Surgery (High)
Orthopedic Surgery (Intermediate)
Head and Neck Surgery (Intermediate)
Peripheral Vascular Surgery (High)
Endoscopic Procedures (Low)
Intra-thoracic/abdominal (Intermediate)

47
Q

How long should we hold Tirofiban/Eptifibatide prior to performing regional anesthesia?

What about abciximab?

A

4-8 hrs

24-48 hrs

48
Q

Hold time for Plavix, Prasugrel, Ticlopidine prior to Regional Anesthesia:

A

Plavix: 5-7 days
Prasugrel: 7-10 days
Ticlopidine: 10 days

49
Q

Unfractionated Heparin will inhibit which factors?

A

2, 9, 10, 11, 12

50
Q

Hold times for Low, High and Therapeutic doses of UFH?

A

Low (< 5,000 U): 4-6 hrs
High (20,000 U): 12 hrs
Therapeutic (> 20,000 U): 24 hrs

51
Q

Why might we insist on a PLT level prior to central neuraxial block?

A

If the patient has been on UFH for > 4 days

52
Q

LMWH will inhibit which factor?

A

Xa

53
Q

Hold times of medications (for regional anesthesia) in patients on therapeutic or prophylactic doses of LMWH:

A

Prophylactic: 12 hrs
Therapeutic: 24 hrs

54
Q

How long should Warfarin be held prior to regional anesthesia?

A

Hold for 5 days, verify a normal INR
(<1.5)

55
Q

The use of which type of anticoagulants are an absolute contraindication to neuraxial anesthesia?

A

Thrombolytic Agents
(t-PA, streptokinase, urokinase)

56
Q

Hold time for direct oral anticoagulants prior to regional anesthesia:
(Apixiban, Xarelto, Pradaxa, etc…)

A

DC at least 72 hrs prior to procedure

KDH: Principles (EXAM I) (7 decks)

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