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Spring 2020 - APA Foundations 1 > Management of Regional, Spinal, & Epidural Anesthesia - Quiz 5 > Flashcards

Management of Regional, Spinal, & Epidural Anesthesia - Quiz 5 Flashcards

1
Q

Which Local Anesthetics are Esters?

A

Procaine

Cocaine

Chloroprocaine

Tetracaine

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2
Q

Which Local Anesthetics are Amides?

A

Lidocaine

Mepivacaine

Bupivicaine

Etidocaine

Ropivacaine

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3
Q

What is the general structure of Local Anesthetics?

A

Aromatic Lipophlic Ring

+

Intermidiate Chain (Ester/Amide)

+

Amine

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4
Q

Local anesthetics with a ______ pKa will have a faster onset b/c a larger portion of the molecule is uncharged/non-ionized

A

Local anesthetics with a lower pKa value will have a faster onset b/c a larger portion of the molecule is uncharged/non-ionized

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5
Q

What is the Mechanism of Action of Local Anesthetics?

A

Directly stops influx of Na+ to block nerve conduction by inhibiting the propogation of action potentials

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6
Q

How does a lot of Protein binding affect Local Anesthetics?

A

Prolong Duration of Effect

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7
Q

What kind of nerve fibers are more easily blocked?

A

Thin, Myelinated nerve fibers are more easily blocked

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8
Q

A-Alpha Fibers

A

Biggest Diameter

Most Myelination

Fastest Conduction

Motor Function & Propioception

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9
Q

A-Beta Fibers

A

4-15µm Diameter

Second Fastest Conduction

Motor, Touch & Pressure Sensation

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10
Q

A-Gamma Fibers

A

4-15µm Diameter

Muscle Spindles & Reflex

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11
Q

A-Delta Fibers

A

3-4µm Diameter

Slowest Conducting A Fiber

Pain & Temperature Sensation

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12
Q

B Fibers

A

4µm Diameter

Slower Conduction & Less Myelination than A FIbers

Preganglionic Autonomic Nerves

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13
Q

C Fibers

A

1-2µm Diameter

Slowest Conduction

Pain & Temperature Impulses

Unmyelinated

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14
Q

What is the Order of Anesthesia with Local Anesthetics?

A
  1. Sympathetic Block, Vasodilation, ↑Skin Temp
  2. Loss of Pain & Temp Sensation
  3. Loss of Proprioception
  4. Loss of Touch & Pressure Sensation
  5. Motor Paralysis
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15
Q

How are Local Anesthetic Metabolised?

A

Esters: Cholinesterase (1 min half life)

Amides: Liver (2-3 hr half life)

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16
Q

What is Baricity in regards to Local Anesthetics?

A

LA Classification based on their density relative to Density of CSF

EX: Hypobaric, Isobaric, Hyperbaric

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17
Q

What is Epinephrine’s affect on Local Anesthetics?

A

↓Systemic Toxicity

↓Rate of Absorption

↓Bleed

↑Block Intensisty

Helps evaluate test dose

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18
Q

When should Epinephrine not be added to Local Anesthetics?

A

Blocks in places w/ poor circulation

Bier Block

Pt hx of uncontrolled HTN, CAD, Arrhythmia, Hyperthryoid, utero-Placental Insufficiency

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19
Q

How does Sodium Bicarb affect Local Anesthetics?

A

↑pH –> ↑non-ionized concentration

↑Rate of Diffusion & Speeds Onset

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20
Q

How much Bicarb should be added to Lidocaine, Mepivacaine, and Bupivacaine?

A

Lidocaine & Mepivacaine
1 mEq per 10mL

  • *Bupivacaine**
    0. 1 mEq per 10 mL
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21
Q

What is the result of adding an Opioid to Local Anesthetics?

A

Adding 50-100mcg of Fentanyl would be synergistic

Shorten Onset

↑Intensity

↑Duration of Block

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22
Q

How can Systemic Toxicity d/t accidently IV injection of Local Anesthetics be avoided?

A

Aspirate before Injecting

Epi Test Dose

Proper Technique

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23
Q

What are the early signs of CNS toxicity from Local Anesthetics?

A

Lightheadedness

Tinnitus

Metallic Taste

Blurry Vision

Toung & Lip Numbness

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24
Q

What are the later signs of CNS toxicity from Local Anesthetics?

A

Muscle Twitching

Loss of Consciousness

Grand Mal Seizure

Coma

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25
What is the treatment for CNS Toxicity from Local Anesthetics?
Give O2 Versed 1-2mg Thiopental 50-200mg Propofol
26
What are the symptoms of CV Toxicity from Local Anesthetics?
↓Contractility ↓Conduction Loss of Vasomotor Tone **CV Collapse (Especially from Bupivacaine/Etidocain)**
27
What is the treatment for CV Toxicity from Local Anesthetics?
Give O2 Volume Pressors Inotropes Cardioversion Takes a while to treat
28
What are the Categories of Regional Anesthesia?
**Central/Neuraxial** Spinal, Epidural, Caudal ## Footnote **Peripheral** **Pain Management**
29
The use of Neuraxial blockade is found to ________ post-op mortality & morbidity
The use of Neuraxial blockade is found to **reduce** post-op mortality & morbidity (Overall its better... less complications, earlier return of GI fxn)
30
How is a Neuraxial block achieved and what are the advantages?
Inject LA into CSF in the Subarachnoid/Intrathecal Space Easy to Perform Uses less LA Less Discomfort on Placement More Intense Block
31
What are some indications for a Spinal?
Surgery of Lower Abdomen, Lower Extremities, & Perineum
32
Wat are **_Absolute_** Contraindications to Spinal?
Pt. Refused or Lack of Cooperation ↑ICP Pre-existing Coagulopathy Skin Infection @ Site Hypovolemia Spinal Cord Disease
33
What are some **_Relative_** Contraindications to Spinal?
Fixed Cardiac Output Sepsis Difficult Airway Indeterminate Neuro Disease
34
When should NSAIDs be stopped before Neuraxial Interventions?
No Contraindication
35
When should Plavix & Abciximab be stopped befor Neuraxial Interventions?
7 Days Before
36
When should Ticlopidine & Tirofiban be stopped before Neuraxial Interventions?
14 Days
37
When shoudl Eptifibatide be stopped before Neuraxial Interventions?
4-8 hours before
38
What are symptoms of a Spinal/Epidural Hematoma?
New Lower Limb Numbness & Weakness New Back Pain New Bowel/Bladder problems
39
Why is timing important for treating Spinal/Epidural Hematoma?
Must be surgically decopressed in \< 8 hours for best outcomes
40
What is the minimal segmental level of Spinal Anesthesia for Lower Extremities?
T12
41
What is the minimal segmental level of Spinal Anesthesia for Hip, Bladder, Vaginal, & Prostate surgeries?
T10
42
What is the minimal segmental level of Spinal Anesthesia for Testes, Ovaries, & Lower Extremities?
T8
43
What is the minimal segmental level of Spinal Anesthesia for Lower Intraabdominal?
T6
44
What are the Vertebral Column Regions?
7 Cervical 12 Thoracic 5 Lumbar 5 Sacral 4 Coccygeal
45
What are the three Intralaminar Ligaments that Binds vertebrae together?
**Supraspinous** - Apices of Spinous Processes **Interspinous** - Spinous Processes **Ligamentum Flavum** - Caudal Edge to Cephalad Edge
46
How far does the Spinal Cord extend during Fetal Life?
Extends length of Vertebral Canal & ends at L3 at birth.
47
Which direction does the Spinal Cord form as it reaching Adult Position?
Forms Cephalad until reaches Adult Position of L1 by 2 y.o.
48
What structures form the Cauda Equina?
Conus Medularis Lumbar, Sacral, & Coccygeal Nerve Roots
49
Why are Spinal Needles placed below L2?
Mobility of Spinal Nerves reduce needle trauma
50
What are the 3 Meninges that cover the Spinal Cord?
**Pia Mater** **Arachnoid** - b/t dura & pia **Dura Mater** - tough fibrous sheath
51
What is found in the Subarachnoid and is clear & colorless?
Cerebrospinal Fluid
52
What is the Total Volume of CSF and how much of it is in the Spinal Canal?
Total CSF: ~ 140 mL Spinal Canal CSF: 30-80 mL
53
How much CSF does the body produced per day?
500 mL/day made by the choroid plexuses of cerebral ventricles.
54
What is the Specific Gravity of CSF?
1.004 - 1.009
55
What Factors affect Level of Spinal Block?
* **Drug Dose** * **Site of Injection** * **Baricity of LA** * **Pt. Position during and after injection** * Drug Volume * Turbulence of CSF * increases spread (rapid injection, coughing, movement) * Intra-Abdominal Pressure * Preggos, Obese, Ascities, Abd. Tumors * Spinal Curve
56
How does Intra-Abdominal Pressure affect Level of Spinal Block?
Pressure on Inferior Vena Cava = Epidural Venous Engorgement and **reduces** CSF volume LA spreads farther
57
What is the most common Local Anesthetic solution for Spinal Anesthesia and how does it work?
Hyperbaric Solution - contain Glucose Flow to most Dependent part of CSF Column
58
How do Hypobaric Solutions work?
Contain Sterile Water Flows to Highest part of CSF Column (Perineal procedures in **Prone**)
59
What are the advantages of using Isobaric Solutions?
Predictable spread regardless of position Increase dose = Increase Duration more than Spread
60
What is the Paramedian approach to placing a Spinal?
For patients who can flex all the way or have Ossified spine ligaments Place needle next to midline and aim upwards & towards the middle
61
Which Spinous Process is aligned along the upper borders of the Iliac Crests?
L4 or L3-L4 Space Spinals are usually between L2-L3, L3-L4, L4-L5 spaces
62
What are the steps to Spinal Needle Placement?
1. Place needle w/ bevel parallel to longitudinal fibers to reduce headache 2. Advance until increased resistance then POP w/ loss of resistance 3. Remove stylet - you should see free flow of CSF 4. Withdraw & Reposition if there is paresthesia 5. Rotate needle 90 degrees until good CSF flow
63
How is the LA given once the Spinal Needle is placed?
1. Aspirate CSF to confirm 2. Slowly Inject LA 3. Reaspirate to confirm placement in subarachnoid 4. Gently remove needle
64
How long does it take for fixation of Local Anesthetic?
20 minutes
65
What is the sequence of Local Anesthetic Blockade?
Autonomic \> Sensory \> Motor | (each by 2 segments)
66
What are possible CV complications to Spinal Local Anesthesia?
Hypotension & Bradycardia
67
What are treatments for CV complications to Spinal Anesthesia?
500-1000cc **before** Spinal Oxygen Vasopressors Atropine Epinephrine CPR
68
What are the Pulmonary Effects of Spinal Anesthesia?
Minimal change to Tidal Volume Dyspnea for pts w/ lung disease relying on accessory muscles
69
What are the complications of Spinal Anesthesia?
* Failure of Block * Post-Dural Puncture Headache * High Spinal * Nausea * Urinary Retention * Hypoventilation * Backache
70
How wide is the Epidural space at Midline Lumbar and at the Mid-Thoracic Region?
Lumbar: 5-6 mm wide Mid-Thoracic: 3-5 mm wide
71
How does an Epidural Block work?
Acts directly on Spinal Nerve Roots Gets access to CSF via uptake through dura Slow Onset & Less Intense Segmental Anesthesia Selective Blockade
72
How is Epidural Anesthesia different from Spinal Anesthesia?
Titratable for Pain or Anesthesia Greater Control of Sensory & Motor Block than Spinal
73
How does Epidural Anesthesia Spread?
* Anatomically along Spinal Canal * Horizontally: Dural Cuffs & into CSF * Longitudinally: * Cephalad along Paravertebral trunks * Intradural Spinal Roots * Dorsal & Ventral Spinal Roots * Dorsal Root Ganglia * Spinal Cord * Brain
74
Why must large amounts of Local Anesthetics be used for Epidurals?
Diffusion Dependent This is why onset is so long
75
Why should the needle always enter the Epidural midline regardless of approach?
Widest area to reduce risk of puncturing epidural vein, spinal artery & spinal nerve root.
76
What is the Technique for Lumbar Epidural?
Loss of Resistance or Hanging Drop Technique Use Long 25g Needle inserting upward to get into ligaments
77
What is the Technique for Thoracic Epidurals?
Same as Lumbar, but insert Needle _more_ upward Needs smaller dose of local Anesthestic
78
What is the Epidural Test dose and Why is it Given?
3mL of LA w/ 1:200,000 Epinephrine No effect if placement is correct If in CSF: Rapidly Behaves like Spinal If in Epidrual Vein: 20-30% HR Increase
79
What are Factors that affect Epidural Block?
* Volume of LA * Age * Pregnancy * Speed of Injection * Position * Spread of Block
80
What are the Adjuncts to Local Solution for Epidural?
Epinephrine Opioid (Fentany/Duramorph) Bicarb
81
How does SNS block with Regional compare is Inhaled Anesthetics?
SNS block is Slower w/ less risk of abrupt hypotension
82
What are ways to use Epidural Anesthesia?
Single Shot Epidural Continous Epidural Combined Spinal - Epidural Combined Epidural - General Caudal Anesthesia

Spring 2020 - APA Foundations 1 (10 decks)

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