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DH: Principles I > Exam 1 Spinal & Epidural Neuraxial Anesthesia [6/04/24] > Flashcards

Exam 1 Spinal & Epidural Neuraxial Anesthesia [6/04/24] Flashcards

1
Q

Failure of a dura puncture site to properly “seal over” once breached by a needle can cause:

A

Postdural Puncture Headache

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2
Q

Why does the headache actually occur in the instance of a PDPH?

A

The continuous CSF leak lowers the pressure in the brain area which causes the brain to sag slightly and stretch the surrounding membranes, leading to the headache.

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3
Q

Does sitting/standing or laying down make the headache in a PDPH better?

A

Sitting/Standing = worse
Laying down = better

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4
Q

When does a PDPH typically occur post-puncture?

A

2-3 days

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5
Q

In what manner does a PDPH spread across a patients head?

A

Frontal to occipital
(Forehead to back of head)

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6
Q

3 factors that increase the risk of developing a PDPH:

A

Young
Female
Pregnant

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7
Q

Less invasive Treatments for PDPH:

A

Bed rest
NSAIDs
Caffeine

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8
Q

More invasive treatments for PDPH:

A

Epidural Blood Patch
Sphenopalatine Ganglion Block

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9
Q

Describe the process of an epidural blood patch for PDPH:
How successful is this treatment?

A

Injection of 10-20 mls of a patient’s own blood into the epidural space

About 90% success rate

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10
Q

True or False:
Epidural blood patch is not routinely recommended within 24 hrs of dural puncture.

A

TRUE

48 hours has shown to be the standard

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11
Q

Describe the process of using the SPG block as a treatment for PDPH:

A
  1. Soak a cotton swab in a LA
  2. Tilt the patients head back and insert the swab into their nose
  3. Leave the swab for about 5-10 minutes
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12
Q

Is paresthesia more common in epidurals or CSE cases?

A

CSE

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13
Q

When preparing a patient’s back for a neuraxial block, which skin prep options are used?
Which are the most effective?

A

Iodine
Chlorhexidine
Alcohol

(Combo of Chlorhexidine and alcohol are most effective)

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14
Q

Which nerves are affected in Cauda Equina Syndrome?

A

L2-S5

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15
Q

What factors may increase the risk of Cauda Equina Syndrome?

A

High concentration of LA (5% Lidocaine in SAB)
Use of Microcatheters
Whiticare 25/26 needles

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16
Q

S/S of Cauda Equina Syndrome:

A

Bowel/Bladder Dysfunction
Back Pain
Saddle Anesthesia
Paraplegia (Late sign)

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17
Q

Treatment of Cauda Equina Syndrome:

A

Supportive Care

(If compression = immediate laminectomy)

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18
Q

Improper patient positioning during neuraxial procedures can stretch nerves causing ___.

A

Transient Neurologic Symptoms

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19
Q

Factors increasing the risk of Transient Neurologic Symptoms:

A
  • Use of 5% Lidocaine
  • Lithotomy Position
  • Outpatient Knee Arthroplasty
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20
Q

Severe radicular pain in the back and buttocks that spreads down both legs is a sign of ___.

A

Transient Neurologic Symptom

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21
Q

Treatment for Transient Neurologic Symptoms

A

NSAID’s
Trigger Point Injections

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22
Q

After which neuraxial procedure are retained catheter fragments most common?

A

Epidurals

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23
Q

What is a common cause of seeing blood in the epidural needle or catheter?

A

Needle is too far lateral

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24
Q

Risk factors for epidural vein cannulation:

A

Multiple attempts
Pregnancy
Stiff Catheters
Epidural Vein trauma

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25
Q

Common causes of unilateral epidural block

A

The catheter may have been inserted too far, exiting the epidural space through intervertebral foramen.
The catheter tip might be too close to a nerve

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26
Q

Solutions to resolve unilateral epidural block

A

Adjust the Catheter
Lateral Decubitus Position
Administer More diluted Anesthetic
Catheter Replacement

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27
Q

Most common cause of L.A.S.T.

A

Inadvertant injection

28
Q

Most frequent symptom of L.A.S.T.:
What about with Bupivicaine

A

Seizures
CV Collapse

29
Q

Is L.A.S.T. more common in peripheral nerve blocks or epidurals?

A

Peripheral

30
Q

Things that increase the risk of CNS toxicity in LAST

A

Hypercarbia (Increased CPP)
Hyperkalemia (Easily excitable)
Metabolic Acidosis

31
Q

Things that decrease the risk of CNS toxicity in LAST

A

Hypocarbia
Hypokalemia
CNS depressants

32
Q

LAST Treatment

A

Airway
Treat seizures
Modified ACLS
Lipid Emulsion therapy (20%)

33
Q

Important things of note with the modified ACLS treatment for LAST

A

Be cautious with epinephrine –> lowers effectiveness of lipid emulsion therapy
Use less than 1 mcg/kg

34
Q

When treating seizures for LAST, use ___ and avoid ___.

A

Benzos
Propofol

35
Q

Dose for lipid emulsion therapy for over 70kg patient:

A

100 ml bolus for 2-3 min followed by 250 ml infusion over 15-20 mins
(Repeat or double if unstable)

36
Q

Dose for lipid emulsion therapy for under 70kg patient:

A

Start with 1.5 ml/kg bolus for 2-3 min followed by 0.25 ml/kg infusion
(Repeat or double if unstable)

37
Q

Max dose of lipid emulsion therapy

A

12 ml/kg

38
Q

MOA for why lipid emulsion works:

A

Lipid Sink: reduces LA in plasma
Inotropic: increase calcium influx
Impairs LA from binding to V-G Na channels

39
Q

Epidural and Spinal Hematoma have been shown to be associated with:

A

Pre-existing abnormalities in clotting hemostasis
Traumatic or difficult needle placement
Indwelling catheters and long-term anticoagulation

40
Q

Cord ischemia can be reversible if laminectomy is performed in ____.

A

< 8 hrs

41
Q

Arachnoiditis can be caused by:

First sign?

A

Nonapproved administration of drug into intrathecal or epidural space (medical error)

Using non-preservative free solutions

Betadine contamination (wipe off)

Fever (3-4 days after)

42
Q

3 common reasons for Neuraxial Anesthesia failure?

A
  1. Wrong Dose
  2. Wrong Location
  3. Wrong Position
43
Q

Always be prepared to do ___ with any neuraxial case.

A

General Anesthesia

44
Q

Things that could go wrong during Neuraxial anesthesia that could lead to performing GETA?

A

It happens in a FLASH:

Failed Block
LAST
Anaphylaxis
Severe CV Collapse
“High Spinal”

45
Q

What are the 2 Cutting Needles?

A

Quincke
Pitkin

46
Q

Advantage of using pencil-point tip in SAB?

A

Fewer Contaminants
You can feel the “Pop”
Less risk of PDPH

47
Q

Common Problems when doing a SAB

A

Lack of free flow CSF after turning 360 degrees
No Swirl
Resistance
Parasthesia
Blood instead of CSF
No Block (Look at expiration date)

48
Q

Both of these epidural needles are 15 degrees:
Which has “wings”?

A

Hustead
Weiss (Has wings)

49
Q

This type of epidural needle is used when catheter placement is difficult, or the angle is too steep:

A

Crawford (0 Degree curvature)

50
Q

This needle has the most curvature (30 Degrees) and the blunt tip is less likely to puncture the subarachnoid space

A

Tuohy

51
Q

What is the lenth of the tuohy needle from tip to hub?

A

9 cm

52
Q

Do multi-orificed or single epidural catheters have a lower incidence of inadequate anesthesia?
Which has a lower incidence of inadvertent intravascular placement?

A

Multi-orificed
Single

53
Q

Optimal Epidural space length/depth is ___?

A

3-5 cm

54
Q

If the total length of your epidural needle is 9 cm and 5 cm is visible, what is the distance from the skin to the epidural space?

A

4 cm

55
Q

When is it best to perfrom an epidural on someone with a lumbar tattoo?
What may you also need to do?

A

Within 5 months of the tattoo application

Paramedian approach

56
Q

What is used as the test dose for epidural?

A

1.5% Lidocaine with Epi (1: 200,000)
(3 mls)

57
Q

3 Important numbers to record after performing an epidural:

A
  1. Depth to epidural space
  2. Catheter marking at the skin
  3. Catheter depth/length in the epidural space
58
Q

What is the secondary/ less useful method for identifying entrance to the epidural space? (Not L.O.R.)

A

Hanging drop method

59
Q

What are we watching for when giving our test dose for an epidural?

A

Increase in HR by 20% or more
Pt complaint of tinnitus, metallic taste, numbness around mouth
Dense motor block within 5 min (Accidental Spinal)

60
Q

What is a special consideration in regard to the epidural test dose on a pregnant woman?

A

Give it after a contraction ends for a clearer result

61
Q

Initial dose and increments for an epidural?

A

1-2 mls/segment
Given in 5 ml increments

62
Q

Do we want to give the top-up dose before or after “two-segment regression”?

A

Before

63
Q

Recommended Top Up time from initial dose for Lidocaine and Mepivicaine

A

60 mins

64
Q

This LA has a Top Up time of 45 mins from the initial dose?

A

2-Chloroprocaine

65
Q

We can expect that after ___ mins from the initial dose, Bupivicaine and Ropivicaine will need a Top Up dose.

A

120 mins

66
Q

Common problems seen with epidurals:

A

“Wet Tap” = Went into dura, seeing CSF
Paresthesia
Unable to thread catheter (Maybe Flica)
Aspirating Blood
Positive Test Dose response
“False” positive test dose

DH: Principles I (50 decks)

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