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Mar: Sem 3 - Principles I > Exam 1 Spinal & Epidural Neuraxial Anesthesia [5/28/24] > Flashcards

Exam 1 Spinal & Epidural Neuraxial Anesthesia [5/28/24] Flashcards

1
Q

List the 3 major anesthesia techniques

A
  1. General Anesthesia
  2. MAC
  3. Regional Anesthesia

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2
Q

Regional anesthesia has 2 classifications. What are they and its subclasses?

A

Central neuraxial
1.Spinal
2.Epidural
3.Combined 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.

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3
Q

What cannot be given through the spinal?

A

Reglan and Zofran `

3

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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]

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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

Reduces PIT RBN (say it like Pit rubbin’)

S6

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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

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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

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8
Q

If using neuraxial anesthesia, and the pt needs to be put to sleep but needs to maintain respiratory drive what can be administed?

A
  • Propofol
  • 100-300 mcg/kg

S7

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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

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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

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11
Q

What are the absolute CI for neuroaxial anesthesia?

A
  1. Coagulopathy
  2. Patient refusal
  3. Evidence of dermal site infection
  4. known coag disoder or on anticoagulants
  5. Severe or critical valvular heart disease
  6. HSS [idiopathic hypertrophic subaortic stenosis]
  7. Operation >duration of LA
  8. Increased ICP
  9. Severe CHF

S9-10

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12
Q

What are the coagulation problems that are absoulte contraindications for neuroaxial anesthesia

A
  • INR > 1.5
  • PLT < 100,000
  • PT: 24-28 seconds
  • PTT: 50-64 seconds
  • BT: 6-14 min
  • Known coag disorder or taking anticoags.

PT, PTT, BT 2X THE NORMAL

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13
Q

Normal PT

A

12 - 14 seconds

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14
Q

Normal INR

A

0.8 - 1.1

S9

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15
Q

Normal aPTT

A

25 - 32 seconds

S9

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16
Q

Normal Bleeding Time [BT]

A

3 - 7 minutes

S9

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17
Q

Normal Platelets

A

150,000 - 300,000 mm3

S9

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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 →2 →1←13

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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

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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.

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21
Q

What does the bleeding time look at?

A
  • Examines PLT activation and adhesion.
  • longer BT = problem with PLTs.

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22
Q

What severe valvular heart diseases are absolute CI for neuroaxia anesthesia?

A
  • Aortic stenosis <1cm2
  • Mitral stenosis <1cm2

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23
Q

List the valve area for AS for the following:
* Mild
* Moderate
* Severe
* Critical

A
  • Mild: ≥1.5
  • Moderate: 1.0 - 1.5
  • Severe: 0.7 - 1.0
  • Critical: < 0.7

cm2

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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.

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25
Q

What are the s/sx of severe or critical AS? What are its survival rates?

A
  • Angina - 5yrs
  • Syncope - 3yrs
  • Heart failure - 2 yrs, the worst [NYHF 3 or 4]

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26
Q

Why is aortic stenosis a contraindication?

A
  • 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.

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27
Q

What is the death spiral that occurs due to AS?

A
  1. hypotension causes myocardial ischemia
  2. ischemia contractile dysfunction
  3. decreases CO
  4. worsening hypotension
  5. increased ischemia

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28
Q

Compare & Contrast the following characteristics of spinals and epidural:
* Onset
* Spread
* Nature of block
* Motor block
* Hypotension

A

S11

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29
Q

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

A

S10

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30
Q

What is the placement and needle size for spinals?

A
  • Placement: L3-L4, L4-L5, L5-S1 but we as SRNAs do L4-L5
  • Smaller needle: 25-27g

S12

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31
Q

What is the placement and needle size for epidurals?

A
  • 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

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32
Q

Baracity affects epidurals or spinals?
What does hyper, hypo, and iso -baric mean?

A
  • Affects spinals
  • hyperbaric: sinks
  • hypobaric: floats
  • isobaric: stays in place

S12

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33
Q

Positioning affects epidurals or spinals?
How would you postion a pt with right hip pain?

A
  • Affects epidurals
  • pain in right buttock - turn to right side to have LA stay on that side.

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34
Q

How many total vertebras do we have?
* Total:
* Cervicle:
* Thoracic:
* Lumbar:
* Sacrum:
* Coccyxs:

A
  • Total: 33
  • Cervicle: 7
  • Thoracic: 12
  • Lumbar: 5
  • Sacrum: 5
  • Coccyx: 4

S14

35
Q

What are the 4 curvatures of the spine?

A
  1. Normal
  2. Scoliosis
  3. Kyphosis
  4. Lordosis

S14

36
Q

Each vertebra, except for ____, is divided into two main parts:
* The____ segment, known as the body.
* The ____ segment, called the vertebral arch.

A
  • C1
  • anterior
  • posterior

slide 15

37
Q

what 2 structures link the anterior [body] and posterior [vertebral arch] segments?

A

the lamina and pedicle

slide 15

38
Q

The connection of the anterior [body] and posterior [vertebral arch] segments form the ____ ____.

A
  • verterbral foramen

slide 15

39
Q

The vertebral foramen is a crucial space within the vertebra why?

A

houses the spinal cord, nerve roots, and the epidural space, which is a protective cushioning area around the spinal cord.

slide 15

40
Q

The ____ processes stick out to the sides (lateral), while the ____ processes stick out towards the back (posterior).

A
  • transverse
  • spinous

slide 16

41
Q

what attach to the spinous and transverse processes to help stabilize and support the spine?

A

muscles

slide 16

42
Q

The spionus process is used as a landmark for what?

A

to find the middle line of the back

slide 16

43
Q

How are lumbar vertebrae different from thoracic and cervical vertebrae?

A

the orientation of the spious process is different

slide 17

44
Q

Cervical and thoracic spinous processes tilt ____, requiring a needle approach from ____.

A
  • downward (caudal direction)
  • above (cephalad approach)

slide 17

45
Q

Lumbar spinous processes stick out directly ____, which makes it easier to reach the spaces around the spinal cord, such as the ____ & ____ spaces.

A
  • backwards (posterior)
  • epidural and intrathecal spaces.

slide 17

46
Q

These are the soft pads between each vertebra that act as shock absorbers.

A

intervertebral disc

slide 18

47
Q

These are the openings between the vertebrae where spinal nerves exit the spine.

A

intervertebral foamina

slide 18

48
Q

how is the intervertebral formaina formed?

A
  • 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.

slide 18

49
Q

how is each facet joint made?

A
  • 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.

slide 19

50
Q

whati s the function of the facet joints?

A

They help guide and limit the spine’s movement, keeping the back’s motions controlled.

slide 19

51
Q
  • what happens if a facet joint gets injured?
  • what are the symptoms of this?
A
  • it can press on nearby spinal nerves
  • pain and muscle spasms in the area of skin served by that nerve (dermatome).

slide 19

52
Q

surface landmarks

where is the superior aspect of the iliac crest?

A

L4

slide 20

53
Q

where is the posterior superior iliac spine?

A

S2

slide 20

54
Q

what is tuffier’s line [intercristal line]?

A

This horizontal line runs across the top edges of the hip bones (iliac crests) and matches the L4 vertebra

slide 20

55
Q

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.

A
  • L3 - L4
  • L4-L5

slide 20

56
Q

in infants up to one year the intercristal line corresponds with the ____ intervertebral space

A

L5-S1

slide 20

57
Q

The sacrum is a triangular-shape section of fused vertebra (5). The lamina of ____ is incomplete and bridged only by ligaments.

A

S5

slide 22

58
Q

Sacral Hiatus
* location?
* covered by?
* purpose?

A
  • 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

slide 22

59
Q

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

A
  • sacral hiatus
  • caudal

slide 22

60
Q

Components of the spinal cord?

A
  • starts at the medulla oblongata
  • conus medullaris
  • caurda equina
  • dural sac
  • filum terminale

slide 23/24

61
Q

the spinal cord has a ____ origin, starting in the ____.

A
  • rostral origin
  • medulla oblongata

slide 24

62
Q
  • What is the conus medullaris?
  • where does it end in adults?
  • where does it end in infants?
A
  • 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
Q
  • what is the cauda equina?
  • what does it consist of?
A
  • 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.

slide 23

64
Q
  • what is the dural sac?
  • where does it end in adults?
  • where does it end in infants?
A
  • The subarachnoid spaces ends at the dural sac.
  • Ends at S2 in adults.
  • Ends at S3 in infants.

slide 24

65
Q
  • what is the filum terminale?
  • what is its main function?
A
  • 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
Q

what are the parts of the filum terminale?

A
  • 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
Q

how does the spinal cord receive blood supply?

A
  • one anterior spinal artery
  • two posterior spinal arteries

slide 25

68
Q

Anterior spinal artery
* origination?
* supplies what part of the cord?
* how much does it supply?

A
  • 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
Q

Two posterior spinal arteries
* Emerge from the ____.
* Originates from the ____ artery.
* Supply the ____ portion of the spinal cord.

A
  • cranial vault
  • vertebral
  • posterior (sensory

slide 25

70
Q

what part of the cord has better protection from ischemia the posterior or anterior?

A
  • 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
Q

what are symptoms of anterior spinal artery syndrome?

A

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
Q

what are causes of ischemia that can lead to anterior spinal artery syndrome?

A
  • Low blood pressure (profound hypotension).
  • Mechanical blockage.
  • Blood vessel disease (vasculopathy).
  • Bleeding (hemorrhage).

slide 26

73
Q

the anterior spinal artery receives additional blood slupply through what branches?

A

The anterior spinal artery receives additional branches from the intercostal and iliac arteries, though these are variable.

slide 26

74
Q

Artery of Adamkiewicz:
* what is it?
* where does it arise?
* damage to this can cause what?

A
  • 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
Q

what are the spinous ligaments [posterior to anterior]?

A
  • Supraspinous Ligament
  • Interspinous Ligament
  • Ligamentum Flavum
  • Posterior Longitudinal Ligament
  • Anterior Longitudinal Ligament

slide 27

76
Q

Runs along the back, connecting the tips of the spinous processes from the upper back down to the lower back.

A

Supraspinous Ligament

s;ode 27

77
Q

Located between the spinous processes, providing stability by joining adjacent vertebrae.

A

interspinous ligament

slide 27

78
Q
  • 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.
A

ligamentum flavum

slide 27

79
Q

Runs along the back side of the vertebral bodies inside the spinal column.

A

posterior longitudinal ligament

slide 27

80
Q
  • 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.
A

anterior longitudinal ligament

slide 27

81
Q

what layers are transvered during a midline spinal?

A
  • Skin
  • Subcutaneous fat
  • Supraspinous ligament
  • Interspinous ligament
  • Ligamentum flavum
  • Dura Mater
  • Subdural space
  • Arachnoid Mater
  • Subarachnoid space

slide 28

82
Q

what layers are transvered during a paramedian approach?

A
  • Skin
  • Subcutaneous fat
  • Ligamentum flavum
  • Dura Mater
  • Subdural space
  • Arachnoid Mater
  • Subarachnoid space

slide 28

83
Q

paramedian approach
* Used when?
* Positioning:

A
  • 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.

slide 28

84
Q

Paramedian Approach Procedure:

A
  • 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

Mar: Sem 3 - Principles I (29 decks)

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