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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
Common causes of unilateral epidural block
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
26
Solutions to resolve unilateral epidural block
Adjust the Catheter Lateral Decubitus Position Administer More diluted Anesthetic Catheter Replacement
27
Most common cause of L.A.S.T.
Inadvertant injection
28
Most frequent symptom of L.A.S.T.: What about with Bupivicaine
Seizures CV Collapse
29
Is L.A.S.T. more common in peripheral nerve blocks or epidurals?
Peripheral
30
Things that increase the risk of CNS toxicity in LAST
Hypercarbia (Increased CPP) Hyperkalemia (Easily excitable) Metabolic Acidosis
31
Things that decrease the risk of CNS toxicity in LAST
Hypocarbia Hypokalemia CNS depressants
32
LAST Treatment
Airway Treat seizures Modified ACLS Lipid Emulsion therapy (20%)
33
Important things of note with the modified ACLS treatment for LAST
Be cautious with epinephrine --> lowers effectiveness of lipid emulsion therapy Use less than 1 mcg/kg
34
When treating seizures for LAST, use ___ and avoid ___.
Benzos Propofol
35
Dose for lipid emulsion therapy for over 70kg patient:
100 ml bolus for 2-3 min followed by 250 ml infusion over 15-20 mins (Repeat or double if unstable)
36
Dose for lipid emulsion therapy for under 70kg patient:
Start with 1.5 ml/kg bolus for 2-3 min followed by 0.25 ml/kg infusion (Repeat or double if unstable)
37
Max dose of lipid emulsion therapy
12 ml/kg
38
MOA for why lipid emulsion works:
Lipid Sink: reduces LA in plasma Inotropic: increase calcium influx Impairs LA from binding to V-G Na channels
39
Epidural and Spinal Hematoma have been shown to be associated with:
Pre-existing abnormalities in clotting hemostasis Traumatic or difficult needle placement Indwelling catheters and long-term anticoagulation
40
Cord ischemia can be reversible if laminectomy is performed in ____.
< 8 hrs
41
Arachnoiditis can be caused by: | First sign?
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
3 common reasons for Neuraxial Anesthesia failure?
1. Wrong Dose 2. Wrong Location 3. Wrong Position
43
Always be prepared to do ___ with any neuraxial case.
General Anesthesia
44
Things that could go wrong during Neuraxial anesthesia that could lead to performing GETA?
It happens in a FLASH: Failed Block LAST Anaphylaxis Severe CV Collapse "High Spinal"
45
What are the 2 Cutting Needles?
Quincke Pitkin
46
Advantage of using pencil-point tip in SAB?
Fewer Contaminants You can feel the "Pop" Less risk of PDPH
47
Common Problems when doing a SAB
Lack of free flow CSF after turning 360 degrees No Swirl Resistance Parasthesia Blood instead of CSF No Block (Look at expiration date)
48
Both of these epidural needles are 15 degrees: Which has "wings"?
Hustead Weiss (Has wings)
49
This type of epidural needle is used when catheter placement is difficult, or the angle is too steep:
Crawford (0 Degree curvature)
50
This needle has the most curvature (30 Degrees) and the blunt tip is less likely to puncture the subarachnoid space
Tuohy
51
What is the lenth of the tuohy needle from tip to hub?
9 cm
52
Do multi-orificed or single epidural catheters have a lower incidence of inadequate anesthesia? Which has a lower incidence of inadvertent intravascular placement?
Multi-orificed Single
53
Optimal Epidural space length/depth is ___?
3-5 cm
54
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?
4 cm
55
When is it best to perfrom an epidural on someone with a lumbar tattoo? What may you also need to do?
Within 5 months of the tattoo application Paramedian approach
56
What is used as the test dose for epidural?
1.5% Lidocaine with Epi (1: 200,000) (3 mls)
57
3 Important numbers to record after performing an epidural:
1. Depth to epidural space 2. Catheter marking at the skin 3. Catheter depth/length in the epidural space
58
What is the secondary/ less useful method for identifying entrance to the epidural space? (Not L.O.R.)
Hanging drop method
59
What are we watching for when giving our test dose for an epidural?
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
What is a special consideration in regard to the epidural test dose on a pregnant woman?
Give it after a contraction ends for a clearer result
61
Initial dose and increments for an epidural?
1-2 mls/segment Given in 5 ml increments
62
Do we want to give the top-up dose before or after "two-segment regression"?
Before
63
Recommended Top Up time from initial dose for Lidocaine and Mepivicaine
60 mins
64
This LA has a Top Up time of 45 mins from the initial dose?
2-Chloroprocaine
65
We can expect that after ___ mins from the initial dose, Bupivicaine and Ropivicaine will need a Top Up dose.
120 mins
66
Common problems seen with epidurals:
"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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