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Spr25 AdvPrin A > Labor & Analgesia Pt. 2 (Exam III) > Flashcards

Labor & Analgesia Pt. 2 (Exam III) Flashcards

1
Q

Name the anatomy pertinent to an epidural/spinal.

A
  1. Skin
  2. Subcutaneous tissue
  3. Supraspinous ligament
  4. Interspinous ligament
  5. Ligamentum flavum
  6. Epidural space
  7. Dura mater
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2
Q

What three interspinous spaces are typical for epidural placement?

A

L2-3
L3-4
L4-5

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3
Q

What are the disadvantages of a continuous epidural?

A
  • 10 - 15 min onset of analgesia (slow)
  • Higher drug requirement
  • ↑ Maternal LAST risk
  • ↑ fetal drug exposure
  • Risk of sacral “sparing” slow blockade.
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4
Q

What is the standard “test dose” used for epidurals?

A

Lidocaine 1.5% w/ 1:200k epi (3mls)

Change in HR indicates intravascular epinephrine.

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5
Q

What would intrathecal placement of an epidural present like when injecting your test dose?

A

Leg numbness & warmth (Lidocaine 1.5% going intrathecal). Heavy and high spinal risk.

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6
Q

Can a test dose be administered during a contraction?

A

No because then the change in HR can’t be solely attributed to the test dose.

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7
Q

What are the disadvantages of a CSE (combined spinal epidural) ?

A
  • ↑ risk of fetal bradycardia
  • ↑ risk of PDPH
  • ↑ risk of neuraxial infection
  • Uncertainty of proper epidural catheter placement (until spinal wears off).
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8
Q

Why can fetal bradycardia sometimes occur with CSE ?

A
  • Due to sympathetic blockade & maternal HoTN.
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9
Q

What is a Dural Puncture Epidural?

A

Similar to CSE but no medications are injected into the spinal space.

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10
Q

What are the advantages of a Dural Puncture Epidural?

A
  • Faster onset than regular epidural
  • Transdural migration of medications injected into epidural space
  • More rapid anaglesia
  • ↓ risk of maternal HoTN and fetal bradycardia compared to CSE.
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11
Q

When is a continuous spinal utilized?

A

After a “Wet Tap”.

Accidental placement of epidural Tuohy into the spinal space.

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12
Q

What are the disadvantages of a continous spinal?

A
  • Large dural puncture = PDPH
  • Risk of other provider mistaking catheter for an epidural catheter instead of a spinal.
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13
Q

What types of pain do epidural local anesthetics treat?

A
  • Visceral Pain: lower uterine & cervical distention
  • Somatic Pain: Fetal birth canal descent
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14
Q

Which two LA’s are most commonly used for labor?

A

Bupivacaine & Ropivacaine

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15
Q

What is a differential block?

A
  • Separation of motor & sensory effects
  • Sparing of A-α motor neurons
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16
Q

What are the advantages of Bupivacaine?

A
  • Differential Block
  • Long duration
  • No tachyphylaxis
  • Safety (↓ placental transfer)
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17
Q

What are the disadvantages of neuraxial bupivacaine?

A
  • Slow onset time (10 - 15 min)
  • Risk of CV & neuro toxicity
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18
Q

How can the latency time of bupivacaine/ropivacaine be improved?

A

Addition of a lipophillic opioid.

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19
Q

What epidural dosing of bupivacaine is typical?

A

0.0625 - 0.25%
10 - 20mls

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20
Q

What are the advantages of Ropivacaine?

A
  • Differential Block (even better than bupivacaine).
  • Safety (less toxic than bupivacaine)
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21
Q

What are the disadvantages of ropivacaine?

A
  • Slow onset (10 - 15 minutes)
  • CV & Neuro toxicity
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22
Q

What epidural dosing of ropivacaine is typical?

A
  • 0.1 - 0.2%
  • 10 - 20mls
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23
Q

Why is lidocaine not routinely used for labor analgesia?

A
  • Poor differential block
  • Tachyphylaxis risk
  • ↑ placental transfer / ion trapping
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24
Q

What is neuraxial lidocaine useful for?

A
  • Identification of non-functional catheter
  • Need for rapid sacral analgesia
  • Instrumented vaginal delivery/perineal repair
  • Emergent operative delivery
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25
Q

What dose of neuraxial lidocaine is used for emergent operative delivery?

A

2% Lidocaine 10 - 20 mls w/ 2mls of Na⁺Bicarb

Bicarb (2mls) w/ 18mls of 2% Lido

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26
Q

What will bicarbonate do when paired with lidocaine in neuraxial anesthesia?

A

Speed up onset

Good for emergent operative delivery.

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27
Q

What dose of lidocaine is used for identification of a non-functional catheter?

A

5 - 10mls of 2% Lidocaine

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28
Q

What dose of Lidocaine is used for rapid sacral analgesia?

A

0.5 - 1% Lidocaine 5-10mls

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29
Q

What dose of Lidocaine is used for an instrumented vaginal delivery or for perineal repair?

A

Lidocaine 1.5 - 2% +/- epinephrine (5-10mls)

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30
Q

What are the advantages and disadvantages of Chloroprocaine?

A

Advantages:
-Rapid onset

Disadvantages:
- Short duration
- Poor differential blockade

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31
Q

What are the disadvantages of chloroprocaine?

A
  • Short duration of action
  • Interferes with bupivacaine/opioids
32
Q

When is neuraxial chloroprocaine useful?

A

Emergent instrumented or operative delivery and/or perineal repair

33
Q

What dose of chloroprocaine is used for emergent instrumented delivery?

A

10mls of 2-3% chloroprocaine

34
Q

What are the benefits of neuraxial opioids?

A
  • ↓ LA dosage (20 - 30% reduction)
  • ↓ latency
  • ↑ analgesia
  • ↑ duration of analgesia
35
Q

Which opioids will have a faster onset?

A

Lipophillic (fentanil, sufentanil, etc)

36
Q

Which neuraxial opioids will have a later onset (but provide postoperative pain relief) ?

A

Hydrophillic

Morphine.

37
Q

What is the dose of neuraxial clonidine?

A

75 - 100 mcg

38
Q

What are the advantages of neuraxial clonidine?

A
  • Analgesic
  • ↓ LA requirement
  • ↑ block quality/duration
  • No motor blockade
39
Q

What are the disadvantages of neuraxial clonidine?

A
  • Maternal HoTN & bradycardia
  • Maternal sedation
40
Q

What is the typical dose of neuraxial dexmedetomidine?

A

0.25 - 0.5 mcg/mL

41
Q

What is precedex used for in neuraxial anesthesia?

A
  • ↓ latency
  • ↑ duration of block
  • ↓ LA requirement
42
Q

What adverse effects can occur with higher concentration of neuraxial dexmedetomidine?

A

Maternal sedation & anxiolysis

43
Q

What is the MOA of neuraxial Precedex?

A
  • Suppressed C-fiber transmission
  • Hyperpolarization of postsynaptic dorsal horn neurons.
44
Q

What is typical dose of bupivacaine in a continuous epidural infusion?

A

0.05 - 0.125% Bupivacaine

8 - 15 mL/hr

45
Q

What is typical dose of ropivacaine in a continuous epidural infusion?

A
  • 0.08 - 0.2%
  • 8 - 15 mL/hr
46
Q

What is a PCEA?

A

Patient controlled epidural anesthetic

  • Less motor blockade
  • Less dosing by provider
47
Q

What is the main factor in determination of LA dosing for a spinal?

A

Patient height & level of anesthesia desired.

48
Q

How many mg of bupivacaine is being administered to a patient receiving 1.7mls of 0.75% bupivacaine?

A

1.7 x 7.5 = 12.75mg Bupivacaine

49
Q

Can opioids be used as a solo agent for neuraxial anesthesia?

A

Yes

Analgesia w/ no numbness, motor blockade, or sympathectomy.

More commonly used as an additive however.

50
Q

What is the dose of hyperbaric bupivacaine?

A

0.75%

51
Q

What is the dose of isobaric bupivacaine?

A

0.5%

52
Q

What is the isobaric dose of spinal ropivacaine?

A

0.5%

Not commonly used.

53
Q

What is the dose of spinal dexmedetomidine?

A

2.5 - 10mcg

54
Q

What is the purpose of spinal dexmedetomidine ?

A
  • Prolongs analgesia
  • ↓ latency
55
Q

What is spinal dose of epinephrine?

A

2.25 - 100mcg

56
Q

What is the purpose of intrathecal epinephrine?

A
  • Prolonged analgesia
  • increased motor blockade (with higher dosing)
57
Q

What would a higher dose of spinal epinephrine (100 - 200mcg) do?

A

↑ motor blockade

58
Q

How is neuraxial hypotension typically treated?

A
  • IV fluids
  • Positioning
  • Vasopressors (last)
59
Q

What is the most common complaint associated with neuraxial opioids?

A

Pruritus

60
Q

Why does pruritus occur with neuraxial opioid administration?

A

Central μ-opioid receptors

61
Q

What dose of diphenhydramine (Benadryl) is used for neuraxial opioid pruritus?

A

Trick question. Itching is not due to histamine release. Benadryl will not work.

62
Q

What drug is used to treat neuraxial opioid pruritus?

A

Centrally acting μ-opioid antagonist
- Naloxone 40 - 80mcg IV
- Naltrexone 6mg PO
Partial Agonist-Antagonist
- Nalbuphine 2-5mg IV
- Butorphanol 1-2mg IV

63
Q

What are the conservative treatment options for a “wet tap”?

A
  • Caffeine
  • Laying down (positioning)
64
Q

What are the more invasive treatment options for PDPH?

A

Epidural blood patch

65
Q

Should CSF be reinjected after wet-tap occurs with a Tuohy needle?

A

No. ↑ risk for infection/pneumocephalus

66
Q

Why is bupivacaine 0.75% not used for epidural blocks?

A

Risk for CV toxicity if injected

67
Q

What are the mild/moderate signs/symptoms of LAST?

A
  • Tinnitus
  • Circumoral numbness
  • Restlessness
  • Difficulty speaking
68
Q

What is the treatment for LAST?

A

1.5 mL/kg Lipid emulsion bolus & benzodiazepines

69
Q

What are the signs/symptoms of a high spinal?

A
  • Agitation
  • Dyspnea
  • Inability to speak
  • Profound hypotension
  • Apnea
70
Q

How is a high spinal treated?

A
  • Ventilation assistance
  • Volume resuscitation
  • Vasopressors
71
Q

Pinky/hand numbness is associated with what spinal level?

A

C8

72
Q

Cardioaccelerator fibers originate from what spinal levels?

A

T1-T4

73
Q

Diaphragmatic ennervation comes from which spinal levels?

A

C3-C5

74
Q

Thumb numbness is associated with what spinal level?

A

C6

75
Q

What are the signs/symptoms of a subdural block?

A
  • Unexpectedly high blockade w/ patchiness
  • Profound HoTN
  • Minimal motor blockade
  • Horner’s syndrome
  • Apnea
  • LOC changes
76
Q
A

Spr25 AdvPrin A (11 decks)

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