Exam 3

Question 1

Advantages of lower extremity blocks include:

• avoid _____
• avoid _____
• little effect on _____
• appropriate for patients with _____, _____, & _____
• early _____
• periop and postop _____
• reduced _____
• continuous _____

Answer 1

sympathectomy associated with spinal; GA in high risk patients; hemodynamic status; head injury, CV instability, localized infection (spine); ambulation; pain relief; N/V; infusion catheter

Question 2

Disadvantages of lower extremity blocks include:

• _____
• _____ (up to 5% in the best hands)
• _____ for block may be difficult d/t _____
• _____ compared to brachial plexus
• many providers not as comfortable with techniques due to _____

Answer 2

time consuming; failure; mobilization of patient to position, co-morbidities (obesity, arthritis, fractures); nerves not as compact; ease of blocking lower extremities with neuraxial techniques

Question 3

Contraindications to lower extremity block include:
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-
-
-
-
-

Answer 3

• patient refusal
• uncooperative patient
• block interfering with procedure
• coagulopathy
• infection at site
• neurologic disease

Question 4

Nerve supply to lower extremity is from 2 plexuses: _____ and _____ (also referred to as _____) with contribution from _____. Lumbar plexus primarily innervates _____ of LE. Lumbosacral plexus primarily innervates _____ of LE.

Answer 4

lumbar plexus; sacral plexus; lumbosacral plexus; L1-S3; ventral part; dorsal part

Question 5

Lumbar spinal nerves exit _____ to their numbered vertebrae then divide into _____. Posterior rami of L1-L5 supply _____. _____ of _____ (_____) form the lumbar plexus. It courses _____ to lumbar transverse processes in the _____. The lumbar plexus has _____ main peripheral branches (_____ and _____). Cephalad branches include: _____ nerve - __, _____ nerve - __ and _____ nerve - __ (_____). Caudal branches include: _____ nerve - __, _____ nerve - __ and _____ nerve - __. These are the branches we are concerned with for LE blocks. We can block _____ or _____.

Answer 5

caudad; anterior and posterior rami; muscles and skin of back; Anterior/ventral rami; L1-L4; and occasional T12 and/or L5 contribution; anterior; body of the psoas major muscle; 6; cephalad; caudal branches; iliohypogastric; L1; ilioinguinal; L1; gentiofemoral; L1-2; we are not concerned with these; lateral femoral cutaneous; L2-3; femoral; L2-4; obturator; L2-4; all together; individually

Question 6

The lateral femoral cutaneous nerve (__) emerges _____ to _____, passes _____. It is either _____ or _____ to _____ and descends deep to _____. This nerve is purely _____ and provides innervation to the _____. It supplies the _____ distal to _____ and _____ of _____.

Answer 6

L2-3; medial; ASIS (anterior superior iliac spine); under the lateral end of the inguinal ligament; superficial; deep; sartorius muscle; the fascia lata; sensory; lateral thigh; lateral buttock; greater trochanter; proximal 2/3; lateral thigh

Question 7

The femoral nerve (___) emerges through the _____ and descends in _____. It passes _____, _____ to the _____. It then _____ into _____ upon entering the _____. It supplies muscle and skin of the _____, _____, and _____. The vein, artery, and nerve go _____ to _____ in the femoral triangle. This is the _____ of the lumbar plexus. This block is performed primarily for _____ as you can block ___ of the knee. A bit of the _____ part is missed.

Answer 7

L2-4; psoas muscle; groove between psoas and iliacus muscles; under the inguinal ligament; lateral; femoral artery; splits; numerous branches; femoral triangle; anterior thigh; knee; hips; medial; lateral; largest terminal branch; knee replacements; 80%; lateral

Question 8

The obturator nerve (__) descends towards the _____ on the _____ of _____. It exits the _____ through the _____ (why this nerve is _____). It innervates the _____ of _____, _____, _____ and _____.

Answer 8

L2-4; pelvis; medial border; the psoas muscle; pelvis; obturator foramen; tough to block by itself; adductor muscles; thigh; hip; knee joints; skin medial to thigh

Question 9

The sacral plexus is made up of the _____ of ___ and ___ (some sources say ___). It has __ major nerves: the _____ nerve (__) and the _____ nerve (__). The sacral plexus supplies _____ to _____ and also provides _____.

Answer 9

anterior rami of L4-5 and S1-3; S4; 2; sciatic; L4-S3; posterior cutaneous nerve of the thigh; S1-3; sensory and motor; posterior and lateral part of the leg; nearly entire innervation of the foot

Question 10

The posterior cutaneous nerve (S1-3) courses with the _____ through the _____ and exits via the _____. It supplies the _____ of _____ and _____.

Answer 10

sciatic nerve; pelvis; greater sciatic foramen; skin; buttock; proximal posterior thigh

Question 11

The sciatic nerve (___) is the _____. It passes out of the _____ through the _____ and lies on the _____. It descends along the _____. It provides _____ innervation to the _____ and _____ except the _____. It becomes _____ at the _____ of _____ and travels to the _____ where it divides into the _____ (_____) and _____ (_____).

Answer 11

L4-S3; largest nerve in the body; pelvis; greater sciatic foramen; sciatic notch; medial aspect of the femur; motor and sensory; posterior thigh; majority of the lower leg; medial lower leg; superficial; lower border; gluteus maximus; popliteal fossa; tibial nerve; medial; common peroneal nerve; lateral

Question 12

The tibial nerve travels down the _____ and passes _____ to supply the _____ of _____ and causes _____. The _____ (__), _____ (__) and _____ (___) are all from the tibial nerve.

Answer 12

posterior calf; under the medial malleolus; skin of the medial and plantar foot; plantar flexion; medial calcaneal branches S1-2; medial planter nerve L4-5; lateral planter nerve S1-2

Question 13

The common peroneal nerve courses _____ on the _____ of the _____ and divides into the _____ and _____. The superficial peroneal nerve is _____ and supplies the _____. It passes down the _____ and divides into terminal branches from the _____. The deep peroneal nerve has _____ innervation to _____ and _____ innervation to the _____. It enters the foot _____ to _____ between _____ and _____.

Answer 13

around the head of the fibula; lateral part; lower leg; superficial peroneal nerve; deep peroneal nerve; sensory; anterior foot; lateral calf; medial to lateral malleolus; motor; dorsiflex the foot; sensory; space between the 1st and 2nd toe; lateral; anterior tibial artery; anterior tibialis tendon; extensor hallicus longus tendon

Question 14

The sural nerve is a _____ nerve formed from _____. It passes _____ to supply the _____.

Answer 14

sensory; branches of common and peroneal tibial nerves; under the lateral malleolus; lateral foot

Question 15

Your choice of LA will depend on:
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-
-
-
-

Answer 15

• duration of procedure
• time until start of procedure
• degree of anticipated pain
• toxicity of agent
• ambulatory vs. inpatient surgery

Question 16

Onset and duration of block differ depending on the _____. For example: 0.5% Ropivacaine for BP block = _____of analgesia and 0.5% Ropivacaine for sciatic nerve block = _____ of analgesia. This difference is likely due to _____. Lower concentrations tend to block _____ which higher concentrations tend to block _____.

Answer 16

site; 10-12 hours; up to 24 hours; difference in vascularity; sensory; sensory and motor

Question 17

Adding sodium bicarb to LA:
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-
-
Adding Epi to LA:
-
-

Answer 17

• increases pH of LA
• increases amount of LA in uncharged base form
• increasing rate of diffusion across nerve membrane
• speeds onset of action
• delays vascular absorption increasing the duration of drug contact with nerve tissues thereby increasing the DOA
• marker of intravascular injection

Question 18

Lateral femoral cutaneous nerve block is used to anesthetize the _____, for _____ and to _____. It emerges from the _____ border of _____ and courses _____ and _____ towards _____ and passes _____ to provide _____ innervation. Pharmacologic choices should be of a _____ concentration of ___ ml of LA (because _____).

Answer 18

lateral aspect of the thigh; small skin graft donor site; lessens complaints of tourniquet pain; lateral; psoas muscle; inferiorly; laterally; ASIS; under the inguinal ligament; only sensory; low; 10-15; no motor components

Question 19

For lateral femoral cutaneous nerve block the patient should be positioned _____. Palpate and mark the ____. Use a __ gauge __ inch needle inserted __cm _____ and _____ to the _____. Insert the needle _____ and advance deep into _____. Will feel _____ as _____ is penetrated. Inject ____ml in _____ _____ and _____ the _____ from _____ to _____. Injecting in a fan wise manner accounts for _____.

Answer 19

supine; ASIS; 22; 2; 2; caudal; medial; ASIS; perpendicular to the skin; the fascia lata; “pop”; fascia lata; 10-15ml; fanwise manner; above; below; fascia lata; medial; lateral; differences in anatomy

Question 20

For US technique for lateral femoral cutaneous nerve block the patient is positioned ____ with _____ in _____. Mark the _____ and _____ and place transducer _____ to _____ along _____ and scan _____ and _____. The LFCN will appear _____. Insert the needle _____ at a _____ angle to enter the skin surface. Reach the plane between the _____ and _____. The nerve may be below the _____. The nerve passes over the _____.

Answer 20

supine; leg extended; neutral position; ASIS; IL; medial to ASIS along IL; medially and inferiorly; hyperechoic; in plane; shallow; fascia lata; fascia iliaca; 2nd fascia layer; sartorius muscle

Question 21

Complications of lateral femoral cutaneous nerve block include:
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-
-
This is a pretty \_\_\_\_ block :)

Answer 21

-failure
-discomfort
-dysesthesia during injection (rare)
low risk

Question 22

Femoral nerve block is used for operations on _____, as analgesia for _____, for post op analgesia for _____, and is often _____ for _____. The femoral nerve lies in the groove between _____ and _____ and enters the ____. It is formed by ___ and is the _____. This block is frequently used for _____. At the inguinal ligament the femoral nerve lies _____ to the femoral artery. It is not in the _____. It lies deep to _____ and _____. Distally, it gives rise to the _____ which provides _____ innervation to the _____.

Answer 22

the anterior portion of the thigh; femoral fracture; knee surgery (+/- continuous catheter placement); combined with other LE PNB’s to provide anesthesia for procedures of the lower leg and foot; psoas major; iliac muscles; thigh deep to the inguinal ligament; L2-4; largest terminal branch of the lumbar plexus; knee replacements; lateral; vascular sheath; fascia lata; iliac fascia; saphenous nerve; cutaneous; medial calf

Question 23

For femoral nerve block the patient is _____. Palpate the ____ and _____ and draw a line (this is the _____). The femoral nerve passes through the _____. Palpate the _____. Use a __ga __inch needle inserted _____ to the skin __cm ____ to the femoral artery and __cm _____ to the inguinal ligament (or just adjacent to the _____) Your non-dominant hand should be placed _____. You will feel a _____ with penetration of the _____ and _____. With PNS technique you will see _____ (or _____) at ____mA. You may or may not elicit a _____ (it is usually difficult). The nerve is _____ (rarely __cm deep). Inject ___ml in a _____ from _____ to _____ because this nerve _____.

Answer 23

supine; ASIS; pubic symphysis; inguinal ligament; center of the line; femoral artery; 22; 2; perpendicular; 1; lateral; 1; caudal; artery; on the artery; pop; fascia lata; iliac fascia; contraction of the quadriceps muscle; patellar snap; 3; 20-40; fanwise manner; needle position 1; needle position 2; branches a lot

Question 24

For USG technique for femoral nerve block the patient is positioned _____ with the leg _____. Mark the _____. Identify the ____, _____, and the _____. The femoral nerve with be _____. It is often in a _____, _____. The fascia lata (_____ line) will be _____ to the femoral nerve. _____ are also hyperechoic in this region. Insert the needle in plane (only see _____) or out of plane (see _____) and inject ___ml. If you inject _____ the _____ fluid will bring out the _____.

Answer 24

supine; neutral; inguinal crease; femoral artery; femoral vein; iliopsoas muscle; hyperechoic; triangular hyperechoic region; superficial to iliopsoas; hyperechoic; superficial; lymph nodes; needle tip; needle shaft; 20-40; a small amount of fluid; hypoechoic; hyperechoic nerve

Question 25

``` Complications of femoral nerve block include: - - - - ```

Answer 25

-failure; hematoma; dysesthesia; intravascular injection

Question 26

Obturator nerve is a _____ and _____ nerve. It provides ____ innervation to the _____ and _____. Block of this nerve decreases _____. It is also used to treat _____ and for relief of _____ associated with _____. It is also used to improve _____. It provides _____ innervation to _____. _____ blockade is often not necessary, therefore _____ concentrations are adequate. The obturator nerve descends towards the _____ from the _____ border of the _____. It then passes through the _____ (why this block is difficult) enters the _____ and divides into _____ and _____.

Answer 26

sensory; motor; sensory; medial thigh and knee; opioid requirements after knee replacement when combined with femoral and sciatic blocks; hip joint pain; adductor muscle spasm; hemi or paraplegia; tourniquet tolerance; motor; adductor muscles of the thigh, hip, and knee joints; motor; lower; pelvis; medial; psoas muscle; obturator foramen; medial thigh; anterior and posterior branches.

Question 27

For obturator nerve block the patient should be positioned _____. Identify the _____ and mark ___cm _____ and ___cm ___ (this point should lie _____). Insert a __ga, __inch needle _____. Advance until _____ (this is the _____). Withdraw the needle slightly and redirect _____ and _____ to enter the _____ and advance ___cm. Inject __ml LA as needle is withdrawn to the level of the obturator foramen. Reinsert more _____ and _____. Inject a total of ___ml in a _____. With PNS technique you will see _____.

Answer 27

supine; pubic tubercle; 1.5; lateral; 1.5; caudal; medial to the femoral artery; 22; 4; perpendicular to the skin; you hit bone; inferior ramus of the pubis; laterally; caudad; obturator foramen; 2-3; 5; laterally; repeat the process; 10-20; fan wise manner; adduction of the thigh

Question 28

For USG technique for obturator nerve block the patient is positioned _____ and the leg is _____. Place the transducer in the _____ and scan _____ (depth ___cm). Find the _____ below the _____ and move _____. The anterior brach (_____) is between the _____ and _____. The posterior branch (_____) is between _____ and _____.

Answer 28

supine; rotated externally; inguinal crease; distally; 2-4cm; femoral vein; inguinal crease; medially; hyperechoic; adductor longus; adductor brevis; hyperechoic; adductor brevis; adductor magus

Question 29

``` Complications of obturator nerve block include: - - - - ```

Answer 29

- failure - intravascular injection - hematoma - nerve damage

Question 30

Lumbar plexus is from the ____ rami of ____ (variable __ and __). It has __ peripheral nerve. It forms in the body of _____. Complete lumbar plexus block is usually blocked _____ to consistently block the _____, _____ and _____ nerves.

Answer 30

ventral; L1-4; L5; T12; 6; psoas muscle; posteriorly; femoral nerve; lateral femoral cutaneous nerve; obtuator

Question 31

For lumbar plexus block the patient is positioned _____ with the operative side _____. Identify the _____ and draw a line to _____ (usually _____). Next identify the _____ and draw a _____ line from _____ parallel to the _____ and the point where _____ is where your needle goes in. This block is done mostly for _____. The parallel lines are normally __cm from each other. Set PNS to __mA and watch for _____. Insert __ga __inch needle with _____ angle and stop when _____ (this is the _____). Bring the needle back towards the skin and walk off the process _____ and watch for nerve stimulation _____cm _____ to spinous process. You will see _____ on PNS at __mA (usually around __cm). Inject ___ml. USG technique may be used however the _____ of this block makes visualization very difficult. You may use ultrasound to confirm _____.

Answer 31

in lateral decubitus; up; iliac crest; midline; L4 spinous process; PSIS; cephalad; PSIS; spine; the 2 lines cross; hip pain; 5; 1.0; quadricep twitch; 22; 2; slight medial; bone is reached; L4 transverse process; caudally; <2; caudal; quadricep twitch; 0.5; 5-8; 30-40; depth; bony anatomical landmarks

Question 32

``` Complications of lumbar plexus block include: - - - - ```

Answer 32

- intrathecal injection - intravascular injection - epidural injection or diffusion (most common) - retroperitoneal bleeding (controversial block because of this)

Question 33

Sciatic nerve is from the _____ (___). It is the _____. It contains __ major nerve trunks: _____ and _____. The sciatic nerve leaves the plexus via _____. It lies keep to _____, and travels under _____. It continues distally toward the thigh between _____ and _____ and divides into _____ and _____ _____ to _____. Supplies motor to _____ and _____ and sensory to _____.

Answer 33

lumbosacral plexus; L4-S3; largest nerve in the body; 2; tibial (medial); common peroneal (lateral); greater sciatic foramen; piriformis muscle; gluteus maximus; greater trochanter; ischial tuberosity; tibial; common peroneal nerves; cephalad; popliteal fossa; posterior thigh; all muscles of the leg and foot; skin of most of leg and foot

Question 34

``` Sciatic nerve block is used for : - - - - It supplies muscle so a _____ concentration is needed. ```

Answer 34

-leg surgery with femoral nerve block -relief from sciatica -knee surgery with femoral, LFC, and obturator nerve block (last choice) -foot and ankle surgery with saphenous nerve (femoral) block higher

Question 35

For classic approach to sciatic nerve block, block at the _____. _____ is the landmark. The patient is positioned in _____ (_____). The upper knee is _____ so the heel is at _____. Landmarks are the _____ and _____. Draw a line _____ which is approximately the _____ and _____. Draw a second line from _____ to _____. Draw a line from _____ to _____. Insert the needle directed _____ (_____). Use a __ga __inch needle. Advance ___cm or until _____. Proper placement will show _____ (desirable), _____ or _____ at ___mA. If periosteum is contacted _____. Inject ___ml.

Answer 35

greater sciatic notch; piriform muscle; lateral sims position; blocked side up; flexed; about knee level of down level; greater trochanter; PSIS; connecting the 2; superior border of the piriform muscle; upper border of sciatic notch; greater trochanter; sacral hiatus; midpoint of first line; intersect the second line; towards pubis symphysis; perpendicular to skin; 22; 4; 6-10; paresthesia is reported in sciatic nerve distribution or nerve stimulation; plantar flexion; dorsiflexion; eversion; redirect medially or laterally; 20-40

Question 36

For anterior approach to sciatic nerve block the nerve is _____ and the approach is _____ so _____ is appropriate. The patient is placed in _____ position with leg ______. Identify the _____ and _____. Draw the first line over the _____ and divide it into _____. Draw a 2nd _____ line _____. Draw a 3rd line _____ to _____ from the _____ to the _____. The insertion point is the _____. Insert the needle _____. Once _____, _____ the needle and _____. Inject ____ml after _____ or _____: _____ or _____ at ___mA.

Answer 36

deep; painful; sedation; supine; neutral; ASIS; pubic tubercle; inguinal ligament; 3 parts; perpendicular; distally from junction of the medial and middle thirds; parallel; the first; cephalad portion of the greater trochanter; 2nd line; 2nd and 3rd line intersection; perpendicular to planes; periosteum is contacted; withdraw; redirect medial; 20-40; paresthesia; nerve stimulator response; plantar flexion/inversion; dorsiflexion/eversion; <0.5

Question 37

For USG approach to sciatic nerve block use the _____. The patient is positioned _____ with the _____ and the _____. Landmarks are _____. The sciatic nerve is _____. Use depth _____. Identify the _____ and locate the _____ (it is _____). Insert the needle on the _____ of the US probe. Confirm needle placement by _____ and inject ___ml.

Answer 37

gluteal region; semi-prone (Sims); operative side upright; hip and knee flexed; same as in the classic approach to sciatic nerve block; hyperechoic; >4cm; ischial bone; gluteus maximus; superficial and posterior to sciatic nerve; lateral end; electrical stimulation; 20-40

Question 38

``` Complications of sciatic nerve block include: - - - - - - ```

Answer 38

- sympathetic block (sciatic nerve contains some sympathetic fibers, blockade causes mild venous pooling) - hematoma (rare) - intraneural injection - residual paresthesia (can last a really long time because this site is not very vascular and LA sits here for a long time- resolves) - failure - intravascular injection

Question 39

Popliteal fossa blockade is _____ nerve blockage _____. Below the knee the only portion not covered by the sciatic nerve is the _____ (_____ coverage). For the classic/posterior approach to this block the patient is positioned _____. The operative leg should be _____ with the foot _____. Identify the _____ (draw a _____). Draw a line at the _____ and _____. Base of triangle is the _____. From _____ of base of the triangle measure __cm (realistically ___cm) _____ and __cm _____. Mark an __. Insert needle through the __ at __degree angle _____. Use a _____ approach (_____ to _____) _____ to the _____ until the _____ (_____ or _____). Nerve lies _____ between _____ and _____. Set the stimulator initially to __mA. Foot inversion- _____ and _____ nerves (_____). Foot eversion = _____. Foot plantar flexion = _____. Foot dorsiflexion = _____. Inject __ml of LA.

Answer 39

sciatic; prior to division into tibial and peroneal branches; medial portion of the leg; saphenous; prone; slightly bent; resting freely above the bed; popliteal fossa; triangle; biceps femoris; semitendinosus (medial); skin crease behind the knee; midpoint; 7; 5-10; up; 1; lateral; X; X; 45; cephalad; fanwise approach; medial to lateral; perpendicular; center line; nerve is contacted; paresthesia or muscle contraction; midway; femur; skin; 1; tibial; deep peroneal; best sensory and motor block; superficial peroneal nerve; posterior tibial nerve; deep peroneal nerve; 40

Question 40

For classic/posterior popliteal fossa blockade using USG technique position and landmarks are _____. _____ plane gives the best image of _____. Scan starting from _____. The nerve appears _____ and is _____ to the popliteal artery. Locate the sciatic _____. Insert the needle at _____. Once nerve is stimulated inject __ml.

Answer 40

the same as non USG technique; transverse; the sciatic; the popliteal crease; hyperechoic; lateral; proximal to split into tibial and peroneal nerves; lateral end of the probe; 40

Question 41

For lateral approach to popliteal fossa blockade the patient is placed _____ with _____. This position is used _____. Locate _____ between _____. Locate _____. Mark __cm (___) _____ to _____. Set stimulator to __mA. Insert needle in _____ plane until _____. Redirect __ degrees _____ (nerve usually __cm beyond _____) Observe for nerve stimulator response in _____ or _____ (_____ is optimal for complete sensory block). Inject __ml.

Answer 41

supine; slight bend in the knee; if the patient cannot be prone; groove; biceps femoris tendon and vastus lateralis muscle; lateral epicondyle of femur; 7; 7-10; cephalad; lateral femoral epicondyle; 1; horizontal; contact with femur; 30; posteriorly; 1-2; initial femur contact; foot; calf; plantar flexion; 40

Question 42

Saphenous nerve (___) is a terminal branch of _____. Supplies sensory to _____. Does not supply _____ to anything. It is the _____. For block of the saphenous nerve the patient is positioned _____. Insert the needle _____ at _____ and aim _____. Deposit a _____ of ___ml in __cm area _____. The primary landmark is the _____.

Answer 42

L3-4; femoral nerve; medial lower leg, distal to knee to medial malleolus (occasional great toe); motor; largest sensory branch of the femoral nerve; supine; deep to subcutaneous tissue; tibial tuberosity; medial toward nerve; subcutaneous infiltration; 5-10; 5; distal to the medial surface of the tibial tuberosity to calf; tibial tuberosity

Question 43

The _____ nerve is the only nerve that innervates the foot from the _____, all others are by the _____. An ankle block provides surgical anesthesia for most procedures _____. There are __ terminal branches of sciatic and femoral nerves: _____, _____, _____, _____, & _____. All are from the sciatic nerve except the _____. Tibial and deep peroneal supply _____. Superficial peroneal, sural and saphenous supply _____ innervation and are blocked _____. For these blocks use __g __inch needle.

Answer 43

femoral; lumbar plexus; sacral plexus; foot; 5; sural; posterior tibial; superficial peroneal; deep peroneal; saphenous; saphenous; deep structures of the foot; sensory; superficially; 25; 1.5

Question 44

Posterior tibial nerve (___) is a branch of the _____ and is _____. It is located on the _____ of the _____, _____ to the posterior tibial artery. It gives rise to _____ behind the _____ and supplies _____. The posterior tibial artery becomes the _____ in the sole. To block this nerve make a _____ along _____ of _____ at the _____ border of _____. Insert the needle toward the _____, _____ to the artery. Elicit paresthesia in the _____. Inject ___ml.

Answer 44

L4-S3; sciatic nerve; deep; medial aspect; Achilles' tendon; posterior; terminal branches; medial malleolus; bottom of the foot; plantar artery; skin wheal; medial aspect; Achilles' tendon; superior; medial malleolus; posterior tibia; posterior; sole of the foot; 3-5

Question 45

The sural nerve is a _____ nerve from the _____ and _____ nerves. It lies _____ behind the _____ and supplies the _____ and _____. To block this nerve make a _____ _____ to _____ at the level of the _____. Insert the needle __cm toward the _____. Inject ___ml _____ in a _____ from _____ to _____.

Answer 45

cutaneous; tibial; common peroneal; subcutaneously; lateral malleolus; lateral foot; lateral part of the 5th toe; skin wheal; lateral; Achilles' tendon; lateral malleolus; 1; lateral border of the fibula; 3-5; subcutaneously; fanwise manner; lateral border of Achilles' tendon; lateral border of the fibula

Question 46

The superficial peroneal nerve (___) is a _____ nerve derived from the _____ nerve. It becomes superficial at the _____ and supplies _____. To block this nerve locate the _____ (_____ is a landmark) and _____. Extensor hallicus longus _____. This nerve is blocked by _____ of __ml _____. Make a _____ from _____ to _____.

Answer 46

L4-S2; superficial; common peroneal nerve; ankle; dorsum of foot and toes; anterior border of the tibia; extensor hallicus longus; superior aspect of lateral malleolus; extends the big toe; subcutaneous infiltration; 5; between the 2 points; subcutaneous skin wheal; extensor hallicus longus; lateral malleolus

Question 47

The deep peroneal nerve (___) is from the _____ nerve. At the level of the malleoli the nerve lies between _____ and _____ muscles (and _____ to the anterior tibial artery.....not the best landmark- use _____). It supplies motor to _____ and sensory to _____. To block this nerve identify the _____ and _____ at the level of _____ and identify the _____. Insert the needle just _____ to the artery in between _____ and inject ___ml _____.

Answer 47

L4-S2; common peroneal nerve; anterior tibial; extensor hallicus longus; lateral; tendons; the short extensors of the toes; adjacent areas of the 1st and 2nd toes; extensor hallicus longus muscle tendon; anterior tibial tendon; malleoli; artery; lateral; the 2 tendons; 3-5; deep into fascia

Question 48

The saphenous nerve originates from the _____. It courses _____ at the _____ and follows the _____ to _____. It supplies _____ to _____. Block this nerve by _____ injecting ___ml _____ and _____ to _____ to _____ (_____). The goal is a _____ from _____ to _____. This blocks the _____ and _____.

Answer 48

femoral nerve; subcutaneous; medial aspect of the knee; great saphenous vein; medial malleolus; sensory; medial aspect of the foot; subcutaneously; 3-5; proximal; anterior; medial malleolus; anterior border of tibia; front of ankle; semi circle of LA; lateral; medial malleolus; superficial peroneal nerve; saphenous nerve

Question 49

Complications of ankle blocks include: - - -

Answer 49

- neuropathy - intraneural injection - intravascular injection

Question 50

The epidural space is the area _____ the dural sac but _____ the vertebral canal. Entry of needle goes _____ ---> _____ ---> _____ ---> _____ ---> _____ ---> _____. It is a _____ compartment. The space between the _____ and the _____ close it in. Dorsal/posterior to the space - _____, ventral/anterior - _____, lateral - _____, rostral - _____, caudal - _____.

Answer 50

outside; inside; skin; subcutaneous tissue; supraspinous ligament; interspinous ligament; ligamentum flavum; epidural space; "closed"; dura; ligaments of the vertebrae; ligamentum flavum; posterior longitudinal ligament and pedicles; pedicle of vertebrae and intervertebral foramina; foramen magnum; sacral hiatus

Question 51

The epidural space extends from the ____ to the ____. It usually has a _____ pressure. It is widest at ____ (where _____) and narrowest at ____. The epidural space contains the _____ with _____ and _____, _____, _____, _____, and _____. The blood vessels are _____ and _____ (together these form _____). The blood vessels can be _____, making placement _____.

Answer 51

skull; sacral hiatus; negative; L2 (5-6mm); we put it in; C5 (1-1.5mm); spinal cord; dural; arachnoid sac; nerve roots; adipose tissue; connective tissue; lymphatic vessels; blood vessels; small arteries; veins; plexus; enlarged; of catheter more difficult

Question 52

The exact site of action of an epidural is _____ because LA in the epidural space must _____. The possible sites of action are _____, _____, _____, _____, and the _____. LA has a _____ distribution in the epidural space.

Answer 52

not known; diffuse; spinal nerve trunks in the paravertebral space; dorsal root ganglion; dorsal and ventral spinal nerve rootlets in the subarachnoid space; spinal cord itself; brain; circumferential

Question 53

So how do we decide SAB vs. epidural? Determine the _____, need for _____, and _____. When comparing SAB and epidural, SAB takes _____, has a _____, ____ and ____ quality is _____, and pain during surgery is _____ due to a _____. With epidural there is less risk of _____, less _____, can _____ block during surgery with a _____ ("_____"), and catheter can be used for _____. Also preserves _____.

Answer 53

length of the procedure; need for prolonged post op analgesia; comorbidities; less time to perform; rapid onset; sensory; motor block; better; less; denser block; PDPH; hypotension; prolong; catheter; top off; postop pain control; motor activity

Question 54

``` Indications for an epidural: similar to a SAB but different too -_____ (same) determine the _____ ~_____ ~_____ ~_____ ~_____ ~_____ (___ or _____) -_____ (different) -_____ (different) An epidural can be performed _____ ~_____ ~_____ ~_____ ~_____ ~_____ ~_____ Analgesia during the 1st stage of labor is achieved by blocking the _____ dermatomes. Analgesia for the 2nd stage of labor and delivery requires block of the ____ segments because of pain due to _____ and _____. -_____ ```

Answer 54

surgical anesthesia; height; abdomen; pelvis and perineum; lower extremities; thoracic; labor and delivery; CS; labor pain management; post op pain; acute and chronic pain; anywhere along the spine; cervical spine; low back pain; sciatica; trauma; cancer; labor pain management; T10-L1; S2-4; vaginal and pudendal distention; perineal pressure

Question 55

``` Contraindications for epidural: also similar to SAB Absolute: - - - Epidural blocks can be placed __ after the last dose of _____ and __ after the last dose of _____. INR must be _____. Platelets should be _____. Plavix dc'd _____, Ticlid dc'd _____. - - Relative: - - - - _____ or _____ to make the colors can be dragged into the space. Wait _____ after a fresh tattoo. ```

Answer 55

infection at placement site; hypovolemic shock; hemostatic alteration; 2 hours; subcutaneous Heparin; 12 hours after the last dose LMWH; 100,000; 7 days; 14 days; patient refusal; lack of appropriate monitoring tools neurologic disorder; systemic infection; symptoms of herniated disc; epidural tattoos; mercury; lead; 6 months

Question 56

Only _____ LA's should be used. LA's are chosen by their _____. _____ is a term used to describe the duration of epidural anesthetics. The amount of time it takes for a block to _____ from the block's maximum extent. Can _____ at this time. _____ is the time is takes for the patient to _____ from the _____ block. When the _____ block has completely resolved the patient is ready for discharge. _____ is used to top off or as a bolus for CS as it has the _____ and _____, ____ duration for a single dose. Intermediate acting LA's include _____ with _____ duration for a single dose and _____. _____ is decreased _____ with repeated _____ and occurs more so with _____ than the other LAs. Long acting LA's include _____ with a _____ duration. Bupivacaine provides a denser _____ than _____ so it's good for _____. It carries a risk of _____ as it binds to cardiac receptors _____. _____ is also a long acting LA and is ___ less potent than _____ in the epidural space but _____ and does not _____.

Answer 56

preservative free; duration of action; 2 dermatome regression; recede by 2 dermatomes; top off; complete resolution; recover completely from the sensory block; motor; resolved; chloroprocaine 2 or 3%; fastest onset; shortest duration; 45-60 minute; Lidocaine 1.5 or 2%; 60 minute; Mepivicaine 1 or 1.5%; tachyphylaxis; duration; injections; Lidocaine; Bupivacaine 0.5 or 0.75%; 120-140 minute; sensory block; motor block; analgesia; cardiovascular toxicity; irreversibly; ropivacaine; 40%; Bupivacaine; is less cardiotoxic; spare motor like Bupivacaine

Question 57

Adjuvants used include: -Opiods Increase the _____ of the _____ but not the _____ and also preserves the _____. Can cause _____, _____, _____, _____ and _____. Fentanyl is _____ and therefore has a _____ (___). Bolus dose is _____. Can be added to continuous epidural solution _____. Morphine (duramorph) is _____ so it has a _____ (___). Bolus dose is _____. Caution should be exercised when morphine is administered epidurally as it is associated with _____ and the patient _____. Early depression from _____ and late depression from _____ and spread to _____. -Clonidine _____ prolongs the _____ but not the _____. -Epinephrine _____ (_____) prolongs duration of _____ for _____. Epi added in _____ can cause more of a _____ in MAP due to _____. -Bicarbonate _____ speeds the _____.

Answer 57

duration; sensory block; motor block; sympathectomy; respiratory depression; N/V; pruritis; urinary retention; CNS effects (sedation, dysphoria); hydrophobic; shorter duration; 2-6 hours; 50-100 mcg; 1-2mcg/ml; hydrophilic; longer duration; 12-24 hours; 2-5mg; delayed biphasic respiratory depression; needs to be monitored; systemic venous absorption; CSF absorption; spread to the medullary ventilation centers of the brain; 150-300mcg; sensory block; motor block; 5mcg/ml; 1:200,000mg/ml; sensory and motor blocks; short and intermediate acting LAs; low concentrations; decrease; beta 2 vasodilation; 0.1mEq/ml; onset

Question 58

So how much and which one? ____, ____, and ____ are the most important to determine the height of the epidural. Dose: _____ -concentration affects the _____ -the lower the concentration, the _____ Volume: _____ -determines the _____ (how _____ the block goes) -go as _____ to the site as possible -need to give _____ volumes as you go down because the epidural space is _____ Site: identify the _____, then insert the needle at a vertebral interspace so that the catheter tip falls _____. The LA injected spreads _____ and _____ from the site of injection. Also, the ____ of the epidural space increases as one moves _____ so to anesthetize the same number of dermatomes may take __ml in the caudal epidural space but only __ml in the thoracic epidural space. -_____ epidural is the most common because it's ____ and the needle is inserted below the _____. Disadvantage: _____ must be given to reach mid thoracic nerves. -thoracic epidural space is _____. spinous processes are more _____. Spinal canal is closer to the _____ (_____). Other factors (controversial): _____, _____, _____, _____, _____, _____

Answer 58

dose; volume; site; concentration of LA; density of the block; less sensory and motor block; how many mls; spread from the catheter tip; high; close; larger; larger; spinal dermatomes of the proposed surgical incision; near the middle of the chosen dermatome; cephalad; caudad; volume; caudad; 25; 8; lumbar; easy; termination of the cord; high volumes; narrower; angled; skin; shallow and more dangerous; height; weight; age; patient position during injection; pregnancy; speed or mode of injection

Question 59

So how do I choose? Identify the surgical procedure and the _____. -lower abdominal procedures or labor insert at ____ -upper abdominal procedures insert at ____ -thoracic procedures insert at ____ -upper arm, shoulders, chest or chronic pain insert at ____ Decide the _____ of the block needed, then choose the ___ The guideline for dosing an epidural in adults is ___ml per segment to be blocked at the lumbar level; ___ml per segment for the cervical and thoracic levels. Adjust the guideline for shorter patients (____) or taller patients (____). Top off dose when _____ has occurred give ____ of the initial loading dose to _____.

Answer 59

level of blockade needed; L2-3; T8-10; T4-5; C7-T1; duration; LA; 1-2; 0.7-1; ; 2 segment regression; 1/3-1/2; maintain the block

Question 60

When administering the LA inject _____ in ___ml increments every ___ to get the desired level. Aspirate intermittently. _____ and ____ are good indicators of needle location if present, but their absence is not a foolproof indicator the the needle tip is not _____ or _____. A _____ is more reliable. Always administer a test dose prior to injecting the intended LA. If subarachnoid will have spinal anesthesia within ____ with rapid ___ in HR and BP. If intravascular will see ___ _____ in HR and SBP within _____. A change in SBP of _____ in patients on beta blocker is _____. May also see _____. After the initial loading dose, anesthesia can be maintained by _____ or by _____. Frequently monitor the _____.

Answer 60

slowly; 3-5; 3 minutes; Blood; CSF; subarachnoid; intravenous; test dose; 3 minutes; decrease; 20% increase; 30 seconds; >20mmHg; more indicative of an intravascular injection; s/s of LA toxicity; boluses; continuous infusion; level of the block

Question 61

Expected physiological effects of epidural blockade include: -sensory anesthesia (this is our ____) _____>_____>_____ -sympathetic: 2 _____ sensory _____ due to arterial and venous dilation. _____ is less than a SAB. _____ usually only if level is ___ as cardiac accelerators are ____. Treatment is _____. -motor: 2 _____ sensory variable, depends on _____ and _____ of LA. Bupivacaine _____ especially in _____. Muscle _____.

Answer 61

goal; sympathetic; sensory; motor; above; decreased SVR; hypotension; bradycardia; T5 or higher; T1-4; same as SAB; below; amount; concentration; spares motor nerves; lower concentrations; weakness

Question 62

Expected complications commonly seen depending on the _____ and _____: -_____ -_____ Depends on the _____ or can be due to _____. If due to the height, _____ and _____ until _____. If due to narcotics _____. -_____ The result of _____ of the _____ from _____. Unopposed _____ leads to _____, _____ and a _____. _____ is a common problem (___) following neuraxial anesthesia. Prevent by promptly treating _____ with a _____, _____ or _____. -_____ Since renal blood flow is maintained through _____ and epidural has very little effect on _____.

Answer 62

level of the block; density; hypotension; respiratory depression; height of the block; narcotic; talk to the patient, put a mask on them; assist with respirations; until the block recedes; give narcotic antagonists; gastrointestinal; blockage of the sympathetic splanchnic fibers; T5-L1 level; vagal dominance; an increase in secretions; peristalsis; small, contracted gut; nausea; 20%; hypotension; fluid bolus; ephedrine; phenylephrine; renal/genitourinary; autoregulation; renal function

Question 63

``` Complications that are not as common (true complications): -_____ Inadvertent SAB - accidentally puncturing the _____. If recognized during needle puncture, the _____ and _____. If it occurs after catheter insertion, either the procedure can be _____ or the _____ and _____. If a large dose of LA is given into the subarachnoid space _____ occurs. LA spreads high enough to block _____ and occasionally the _____. Because anesthesia extends into the cervical levels the _____ are affected with _____, _____ and _____. _____ follows as a result of the effect of LA action on the brainstem. Treatment is ____. -_____ -_____ -_____ more common with a ____. Treatment is _____ at _____. Can be _____ if _____. ____ml, ____ procedure. -_____ -_____ -_____ -_____ Long term is _____. Consider _____ or _____ to LA as cause. -_____ due to _____ Reduce _____, _____, _____ and switch to _____ -_____ due to _____ Give _____ or _____ -_____ due to _____ Give _____ or _____ -_____ _____, _____ or _____. -No _____ Catheter not in _____ or _____ -unable to _____ Catheter is _____ most likely at _____, ____ is screwed on _____ or _____. Remove _____ and _____. -Difficulty _____ _____ may help. If not, get _____. ```

Answer 63

- high spinal; dura; needle should be removed and another interspace chosen; changed to a continuous spinal; catheter can be removed; the procedure repeated at another interspace; total spinal anesthesia; the entire spinal cord; brainstem; cardiac accelerator fibers; profound hypotension; bradycardia; apnea; unconsciousness; ABC's - LA toxicity - subdural injection - PDPH; SAB; autologous blood patch; or one interspace below the level of the dural puncture; repeated 24 hours later; first patch was not successful; 10-15; 2 person, sterile - backache - hematoma - epidural abscess - neurologic injury; rare; additives; contamination - patient cannot stand or walk; numbness in legs; concentration of LA; basal rate; incremental dose; pure narcotic analgesia - pruritis; narcotic; Nalmafene; Benadryl - N/V; narcotic; Nalmafene; anti-emetic - urinary retention; Foley catheter; straight cath; d/c epidural analgesia - pain relief; epidural space; inadequate dose of medication - push medication through catheter; kinked; insertion site; hub; too tightly; filter is clogged; filter; discard - removing catheter; position change; xray

Question 64

Caudal epidural anesthesia is common in _____ for _____ or _____ for _____. It is also used in adults for procedures requiring blockage of the _____ and _____ nerves and for _____. It is usually identified as a _____, identify using the _____. Perform like a ____. Either a _____ (___ga) or a __ga ____ needle is advanced at a _____ from the ____ with the bevel _____. A distinct ____ or ____ is felt when the needle pierces the ____. The needle angle is _____ to _____ (_____) toward the back. It is advanced not more than ___cm (usually between ____) in adults and not more than ____cm in children. Aspirate for _____ or _____ before injecting LA. The epidural catheter can then be _____.

Answer 64

pediatrics; epidural catheter placement; single injection; postop analgesia; sacral; lumbar; chronic pain treatment; groove above the coccyx; sacral cornu/hiatus; SAB; smaller gauge IV catheter; 18-23; 20; epidural; 45 degree angle; back; bevel up; pop; snap; sacrococcygeal membrane; lowered; 160 degrees; almost flat; 1.5; 5-7mm; 0.5; blood; CSF; inserted through the needle to the desired level

Question 65

The needle used for epidural is a _____. It is ____ga, __cm in length with surface markings at __ intervals. It has a ___ degree curve at the tup with a ____bevel. Epidural catheters are ____, _____ plastic and are designed to pass through _____. There are markings every __. Dressing for the puncture site a tape to secure the catheter to the patient's back. Usually a large ____ dressing with ___ silk or cloth adhesive.

Answer 65

styletted Tuohy needle; 16-18; 9; 1cm; 15-30; blunt; durable; flexible; the lumen of the Tuohy needle; 1cm; Opsite; 2 inch

Question 66

Midline epidural approach is most commonly used for ____ or ____ placement in the ____ position. Identify the vertebral level to be entered by surface landmarks (_____). Entry level is usually ____ or ____. Infiltrate skin with LA using __ga ___in needle at ____ between 2 adjacent vertebrae to raise a large skin wheal. Without _____ the needle, infiltrate ____ tissues to alleviate _____ and to assist _____. Insert epidural needle with stylet through _____. The ____ of the CRNA's _____ hand rests on the _____ with the ____ and _____ holding the _____ (_____ grip). Advance the needle through the _____ and into the _____ (approximately __cm depth) at which point the needle should sit firmly in the midline. Once the needle is firmly in the _____ or _____, the ____ is _____. A syringe filled with ___ml of ____ or __ is firmly attached. The needle is slowly advanced by application of ____ on the needle. Once the bevel passes through the _____ and enters the _____, an immediate ____ occurs. The catheter is threaded into the epidural space ___cm. If a ____ is encountered due to ____, _____. If it doesn't resolve, _____ and _____. Never remove a catheter _____.

Answer 66

lumbar; low thoracic epidural; sitting; crest of iliac spines L4-5; L2-3; L3-4; 25; 1-1.5; midpoint; removing; deeper tissues; pain; with locating midline; same skin puncture; dorsum; noninjecting hand; patients back; thumb; index finger; hub of the epidural needle; Bromage; supraspinous ligament; interspinous ligament; 3; interspinous ligament; ligamentum flavum; stylet; removed; 2-3; air; pressure; yellow ligament; epidural space; loss of resistance; 3-5; paresthesia; nerve root stimulation; STOP; remove the catheter; go to a different interspace; through the needle

Question 67

Paramedian approach to epidural injection offers a ____ into the epidural space than the midline approach. For entry level at ____, the midline approach is difficult if not impossible to use due to _____. The skin wheal is placed ___cm _____ to the midline opposite the center of the selected interspace in the ____ and _____ levels. The epidural needle is advanced at that site ____ to the skin until the ____ is encountered. The needle is _____ and advanced at a ___ degree angle toward the _____. If ____ is encountered the needle is _____ into the _____. The _____ and _____ are midline structures. The paramedian approach is ____ to these ligaments. The epidural needle penetrates _____ with little resistance before entering the _____.

Answer 67

much larger opening; T3-7; angulation of the spinous processes; 1.5-2; lateral ; lumbar; lower thoracic; perpendicular to; lamina; redirected; 10-25; midline; bone; walked off the bone; ligamentum flavum; supraspinous; interspinous ligaments; lateral; paraspinous muscles; ligamentum flavum

Question 68

The paramedian approach is easier especially in the _____ (there is a greater incidence of ____ in the midline thoracic approach). Because of the proximity to ____, smaller bolus doses of LA should be used and response checked carefully before _____ to prevent ____. Hypotension can occur in nearly all patients with a _____. Epidural anesthesia is ideally suited for _____. Placement and activation are similar to _____. The tip of the catheter should be placed at _____ level, usually _____. The sharp angulation of the spinous processes especially in the _____ area can made the _____ difficult.

Answer 68

midthoracic region; false loss of resistance; cardiac accelerator fibers; redosing; large drops in HR or BP; high thoracic epidural blockade; thoracic surgery; lumbar epidural placement; midincision; above T8; midthoracic; midline approach

Question 69

Combined spinal-epidural (CSE) allows _____ and a _____ of a _____ with the ability to _____ with an epidural catheter. Since the _____ is entered with the SAB needle this technique is only good for _____ (_____, ____, ____, ____). It allows immediate analgesia and anesthesia with the _____, then the ability to ____ with the _____. In stage one labor, _____ (without _____) provide _____ lasting ____, without _____ or _____. Patient can still _____. The epidural can be dosed _____. Often just the _____ is enough pain relief and the epidural extension of analgesia is not needed. If needed, the ____ component can be used for _____ and/or for _____. It can be ____ for _____. During the SAB component of analgesia, there is no ability to predict if the epidural cath will _____. Thus, CSE may not be appropriate when _____.

Answer 69

rapid onset; dense block; spinal; extend the spread and duration of the block; subarachnoid space; lumbar sites; GYN; lower extremity; obstetric; perineal surgery; SAB; extend the block; epidural; intrathecal opioids; local; quick pain relief; 70-90 minutes; sympathetic; motor blockade; ambulate; whenever it is needed; intrathecal component; epidural component; laboring; CS; left in; post op pain relief; function properly later; a reliable block is necessary

Question 70

Technique for CSE: Patient may be ____ or ____. Find the epidural space with an __ga ____ needle (do not use saline for loss of resistance because you won't be able to ____). Pass a __inch ___ga ____ needle through the Tuohy until it enters the _____. When CSF flows freely, inject the LA and/or opioid solution. Remove the _____ but do not displace the ____. Change syringe and inject ___ml saline to _____, then pass a catheter into the epidural space. Remove the _____ and leave the _____ in place. Secure and monitor the patient at least _____. If Morphine is used for intrathecal injection the patient needs ___ of monitoring due to _____. No test dose is given now because _____. Administer the test dose when _____. Always ____ first. Every dose is a _____.

Answer 70

sitting; lateral; 18; Tuohy; identify CSF; 5; 24-27; pencil point; subarachnoid space; spinal needle; Tuohy needle; 2-3; dilate the epidural space; needle; catheter; 30 minutes; 16 hours; delayed respiratory depression; inadvertent subarachnoid injection can't be detected; the intrathecal drugs are wearing off; aspirate; test dose