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Regional > Exam II > Flashcards

Exam II Flashcards

0
Q

risks associated with a thoracic epidural anesthetic.

A
  • Because of the proximity to cardiac accelerator fibers, smaller bolus doses of local anesthetic should be used and response checked carefully before redosing to prevent large drops in heart rate or blood pressure.
  • hypotension can occur in nearly all patients with a high thoracic epidural blockade.
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1
Q

Identify why a thoracic epidural is technically more difficult to insert.

A
  • Spinous processes are more angled
  • Spinal canal is closer to the skin (shallow)
  • there is a greater incidence of false loss of resistance in the midline thoracic approach
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2
Q

S/S of LA toxicity?

A
  1. Circumoral numbness (numbness ot the tongue or lips)
  2. Metalic taste
  3. tinnitus
  4. Lightheaded, Slurred speech, Visual Disturbances
  5. Muscle twitching
  6. Vertigo
  7. Seizures soon afterwards and unconsciousness
  8. CNS depression and Coma
  9. Respiratory Arrest
  10. Cardiovascular collapse
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3
Q

Why are opioids mixed with LA’s in epidurals?

A

They increase the duration of the sensory block, but not the motor block.

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4
Q

What are side effects of opioid given in epidurals?

A 
Resp depression
N&V
Pruritis
Urinary Retention
CNS effects (sedation, dysphoria)
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5
Q

Which is more hydrophillic Morphine or Fentanyl and what effects does this have?

A

Morphine is more hydrophillic (longer duration)

Fentanyl is hydrophobic (shorter duration is epidural space)

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6
Q

What is the duration and dosing for Fentanyl in epidurals?

A

Bolus dose= 50-100mcg
Continuous= 1-2mcg/ml added to LA
Duration= 2-6 hrs

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7
Q

What is the duration and dosing for Morphine in epidurals?

A

Bolus= 2-5

Duration=12-24 hrs

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8
Q

Why should extra caution be used when morphine is administered in epidural (spinal also)?

A

Can be associated with delayed biphasic resp depression

  • Early depression from venous absorption
  • Late depression from CSF absorption and spread to medullary centers in brain
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9
Q

What does Clonidine do when added to epidural?

A

Prolongs sensory but not motor block

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10
Q

What is the dose for clonidine in an epidural?

A

150-300mcg

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11
Q

What does the addition of Epinephrine do when added to epidural?

A

prolongs both sensory and motor for short and intermediate LA’s

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12
Q

What is the dose for Epinephrine to be added to epidural?

A

5mcg/ml (1:200,000)

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13
Q

Why will epinephrine in low doses cause more of a drop in MAP?

A

due to beta 2 vasodilation

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14
Q

What does the addition of bicarb to to LA?

A

Speeds onset

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15
Q

What is the dose of Bicarb for epidurals?

A

0.1mEq/ml

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16
Q

Identify the differences in motor, sympathetic, and sensory blockade between SABs and epidurals?

A
  • Spinals have a more rapid onset than epidurals
  • Spinals sensory and motor block quality is better
  • Epidurals will have less hypotension

Sympathetic 2 above and Motor 2 below sensory for both SAB’s and epidurals

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17
Q

How long should NSAIDs and aspirin be held before Regional anesthesia

A

No need to hold. do not increase hematoma risk, assuming the pt does not have any coagulopathy

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18
Q

How long should Herbals such as ginko, garlic, ginseng, and fish oil be held before Regional anesthesia

A

recommended to d/c for 1 week, but no research on this

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19
Q

How long should low dose heparin (Lovenox) be held before and after Regional anesthesia

A

hold for 12 hours prior to a block. (Wait 12 hrs) before inserting a SAB). Do not remove a epidural catheter for 12 hours after dose of lovenox. Do not restart lovenox for 12 hours after removing

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20
Q

How long should low dose heparin (unfractionated/Sub-Q) be held before and after Regional anesthesia

A

Wait to do a block for 2 hours after the patient was dosed. Get a PTT to confirm. Do not restart heparin for 2 hours after SAB. If a epidural catheter needs to be removed, wait 2 hours after last dose

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21
Q

What are the recomendations for coumadin levels prior SAB insertion?

A

INR < 1.3 = safe

INR > 1.5 = NO!

INR 1.3 -1.5 = must weigh the risk vs. benefits

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22
Q

What are the recomendations for platlet levels prior SAB insertion?

A

Platelets > 100,000 = OK

Platelets < 50,000 = NO!

Platelets 50,000 -100,000 = weigh risks vs. benefits, but NOT recommended

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23
Q

How long should Plavix and Ticlid be held before and after Regional anesthesia

A

Plavix- d/c for 7 days

Ticlid- d/c for 14 days

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24
Q

Identify the correct procedure in administering an epidural blood patch (how is it done? What’s administered ,where, how much?)

A

15-20 ml (15 ml) of autologous blood aseptically injected into the next lower interspace. Avoid lifting, straining, and air travel for 24-48 hours after to allow c/ot tosecure. Can be repeated

25
Q

Describe the characteristics of the epidural space.

A

Extends from the skull to the sacral hiatus

26
Q

What can be found in the epidural space?

A
27
Q

Explain what surrounds the epidural space in each direction?

A
28
Q

Describe the procedure in administering an epidural anesthetic with midline technique?

A
  1. Identify the vertebral level to be entered by surface landmarks (e.g.,crest of iliac spines L4 to L5, entry level usually L2-3 or L3-4).
  2. Infiltrate skin with local anesthetic using 25-gauge11/2-in.needleat midpoint between two adjacent vertebrae to raise a large skin wheel
  3. Without removing needle, infiltrate deeper tissues to alleviate pain and to assist with locating midline.
  4. Insert epidural needle with stylet through same skin puncture. The dorsum of the CRNA’s noninjecting hand rests on the patient’s back with the thumb and index finger holding the hub of the epidural needle (Bromage grip).
  5. Advance the needle through the supraspinous ligament and into the interspinous ligament (approximately 3 cm depth) at which point the needle should sit firmly in the midline

• Loss of Resistance: once the needle is firmly in the interspinous ligament or ligamentum flava, the stylet is removed. A glass or plastic syringe filled with 2-3 mL of air or normal saline is firmly attached. The needle is slowly advanced by application of pressure on the needle. Once the bevel passes through the yellow ligament and enters the epidural space, an immediate loss of resistance occurs.
o The catheter is threaded into the epidural space 3-5 cm
o If a parasthesia is encountered, due nerve root stimulation

29
Q

Describe the procedure in administering an epidural anesthetic with paramedic technique?

A

This approach offers a much larger opening into the epidural space than the midline approach. For entry level at T3 to T7, the midline approach is difficult if not impossible to use due to angulation
of the spinous processes.

  1. The skin wheal is placed 1.5–2.0 cm lateral to the midline opposite the center of the selected interspace in the lumbar and lower thoracic levels
  2. The epidural needle is advanced at that site perpendicular to the skin until the lamina is encountered
  3. The needle is redirected and advanced at a 10- to 25-degree angle toward the midline
  4. If bone is encountered, the needle is “walked off” the bone into the ligamentum flavum.
  5. The supraspinous and interspinous ligaments are midline structures. The paramedian approach is lateral to these ligaments. The epidural needle penetrates paraspinous muscles with little resistance before entering the ligamentum flavum.
30
Q

What is the significance of a test dose.

A
  • Always administer a test dose prior to injecting the intended LA 3 ml of 1.5% lidocaine with 1:200,000 epinephrine
  • If subarachnoid: spinal anesthesia within 3 minutes, rapid ↓ in HR and BP. May also see s/s of sensory and motor blockage.
  • If in a blood vessel (intravascular) : 20% increase in HR and SBP within 30 seconds. A change in systolic blood pressure of > 20 mm Hg in patients on beta-blocking agents is more indicative of an intravascular injection.
  • May also see s/s of LA toxicity
31
Q

Describe structures passed as inserting epidural

A

skin→subQ→supraspinous lig.→interspinous lig→ligamentum flavum→epidural space

32
Q

Reasons and treatment of Respiratory depression from epidural

A

o Depends on the height of the block or can be due to narcotic
o If due to the height, talk to the patient and assist with respirations until
the block recedes.
o If due to narcotics, Give narcotic antagonists.

33
Q

Reasons and treatment of Gastrointestinal complications from epidural?

A
  • Is result of blockage of the sympathetic splanchnic fibers from the T5 through L1 level. Unopposed vagal dominance leads to an increase in secretions; peristalsis; and a small, contracted gut.
  • Nausea is a common problem (20%) following neuraxial anesthesia.Due to increased gastric peristalsis secondary to unopposed vagal activity.
  • prevent by promptly identifying and treating hypotension with a fluid bolus, ephedrine, or phenylephrine.
34
Q

Are there Renal/Genitourinary complications from epidural?

A

o Since renal blood flow is maintained through autoregulation, an epidural has very little effect on renal function.

35
Q

What is the expected Neuroendocrine result from epidural insertion?

A

o Surgical stress response can be completely abolished by an appropriate level of sensory blockade.

36
Q

Why might a high spinal occur from epidural insertion? What are the S/S and TX?

A
  • If a large dose of local anesthetic is given into the subarchnoid space → total spinal anesthesia occurs, i.e. LA spreads high enough to block the entire spinal cord and occasionally the brainstem. Because the anesthesia extends into the cervical levels, the cardioaccelerator fibers are affected.
  • Profound hypotension, bradycardia, and apnea will occur. Unconsciousness follows as a result of the effect of local anesthetic action on the brainstem.
  • Tx: ABC
37
Q

What should you do if patient cannot stand or walk due to numbness in legs?

A
  1. Reduce concentration of local anesthetic.
  2. Reduce basal rate.
  3. Reduce incremental dose.
  4. Switch to pure narcotic analgesia.
38
Q

What causes Pruritis from epidural and how can you treat it?

A
  • due to narcotic

- Give Nalmafene or Benadryl. Change to a straight local solution.

39
Q

What causes N&V from epidural and how can you treat it?

A
  • Due to narcotic

- Treat with Nalmafene or anti-emetic

40
Q

What should be done if no pain relief?

A

o Catheter not in epidural space.

o Inadequate dose of medication.

41
Q

What should be done if unable to push medicine through catheter.

A

Catheter may be kinked:

  • Most likely at insertion site.
  • Hub is screwed on too tightly.
  • Filter is clogged (Remove filter and discard)
43
Q

What should be done if difficulty removing catheter?

A

o Position change may help

o Get a xray

44
Q

If you had 2ml of a 1% solution of Bupivicaine how would you get a 0.5%, 0.25%, 0.125%, and 0.0625% solution?

A

To Get:

  1. 5%= add 2ml 0.9NS
  2. 25%= add 6ml 0.9NS
  3. 125%=add 14ml 0.9NS
  4. 0625%= add 30ml 0.9NS
45
Q

How are hemodynamics affected from an epidural?

A

o Decreased SVR due to arterial and venous dilation. Hypotension is less than a SAB.

o Bradycardia. Usually only if level is T5 or higher, remember, cardiac accelerators are T1-4

o Tx: same as SAB- Ephedrine, Phenylephrine, Atropine, Fluids

46
Q

What is a caudal anesthetic?

A

Common in pediatrics for epidural catheter placement or single injection for postoperative analgesia. Also used in adults for procedures requiring blockage of the sacral and lumbar nerves and for chronic pain tx.

47
Q

Explain Caudal epidural procedure?

A
  • It is usually identified as a groove above the coccyx, identify using the sacral cornu
  • Perform like a SAB. Either a smaller gauge IV catheter (18- to 23-gauge) or a 20-gauge epidural needle is advanced at a 45-degree angle from the back with the bevel up.
  • A distinct “pop” or “snap” is felt when the needle pierces the sacrococcygeal
    membrane.
  • The needle angle is lowered to 160 degrees (almost flat) toward the back. It is
    advanced not more than 1.5 cm (usually between 5 and 7 mm) in adults and
    not more than 0.5 cm in children.
    -Aspirate for blood or CSF before injecting local anesthetic.
  • The epidural catheter can then be inserted through the needle to the desired
    level.
48
Q

What is Nerve Fiber TypeA Alpha”s Function

A

Proprioception, large motor

49
Q

What is Nerve Fiber TypeA Beta”s Function

A

Touch, pressure, small motor

50
Q

What is Nerve Fiber TypeA Gamma”s Function

A

Muscle spindles

51
Q

What is Nerve Fiber TypeA Delta “s Function

A

Pain, temperature (fast pain, touch, cold temperature)

52
Q

What is Nerve Fiber Type B’s function

A

Preganglionic autonomic

53
Q

What is Nerve Fiber Type C dorsal root’s function

A

Pain (“slow” pain and temperature)

54
Q

What is Nerve Fiber Type C sympathetic’s function

A

Postganglionic

55
Q

Describe how to identify the depth for catheter insertion using the epidural needle as a guide, knowing how deep a catheter should be in the epidural space.

A
  • Styletted Tuohy epidural- 9 cm in length,with surface markings at 1-cm intervals.
  • The catheter is threaded into the epidural space 3-5 cm
56
Q

What roots are the afferent and efferent nerves found in?

A
  • Afferent in the dorsal

- Efferent in the ventral

57
Q

What is the block level need for Perirectal and Perineal (ex. Hemorrhoidectomy, transvaginal slings)

A

S4-L1,2

58
Q

What is the block level need forLower extremity surgery with tourniquet use

A

T10-T8

59
Q

What is the dermatome level needed for a lower abdominal surgery (TAH, C-section, Inguinal hernia, appendectomy)

A

T4-T6

60
Q

What is the dermatome level needed for TURP, Vaginal Delivery, Total Hip replacement, fem-Pop bypass

A

T6-T8

61
Q

What is the dermatome level needed for Upper Abdominal (open cholecystectomy, abdominal exploration)

A

T1 (rare)

Regional (4 decks)

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