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Gen Exam 3 + Final > MM Ch 45 > Flashcards

MM Ch 45 Flashcards

1
Q

Placement to avoid potential needle trauma to the spinal cord

A

lumbar (subarachnoid) spinal puncture

adult: below L1
child: below L3

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2
Q

The principal site of action for neuraxial blockade is

A

nerve root
at least during initial onset

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3
Q

produces the sympathetic blockade seen in a neuraxial block

A

Interruption of efferent autonomic transmission at the spinal nerve roots

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4
Q

Neuraxial blocks
expected V/S fx

A

↓ BP
↓ in heart rate

Deleterious CV effects should be anticipated

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5
Q

T/F
In a normotensive pt, preloading with a fluid bolus does not prevent hypoTN

A

True
volume loading IVF 10 to 20 mL/kg in a healthy patient before of the block repeatedly fails to prevent hypotension (in the absence of preexisting hypovolemia).

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6
Q

Excessive or symptomatic bradycardia should be treated with

A

atropine

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7
Q

⭐️
Major contraindications to neuraxial anesthesia

A

lack of consent
coagulation issues
severe hypovolemia
elevated ICP
infection injxn site

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8
Q

Epidural vs Spinal
Needle insertion

A

epidural:
sudden loss of resistance (to injection of air or saline) as the needle passes through the ligamentum flavum and enters the epidural space

spinal:
advanced thru epidural space & penetrate the dura–subarachnoid membranes, as signaled by freely flowing cerebrospinal fluid

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9
Q

Where can an epidural block can be performed?

A

at the lumbar, thoracic, or cervical level

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10
Q

Epidural technique uses

A

surgical anesthesia
OB analgesia
Postop pain
chronic pain

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11
Q

Epidural vs spinal
onset

A

Epidural anesthesia is slower (10–20 min)

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12
Q

Intrathecal

A

injection into the spinal canal, or into the subarachnoid space

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13
Q

Spinal aneshesia
AKA….

A

spinal block
subarachnoid block
intradural block
intrathecal block

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14
Q

More volume of LA is needed for (epidural/spinal) block.

A

epidural

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15
Q

Neuraxial anesthesia

A

collective term for spinal, caudal, and
epidural anesthesia

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16
Q

Cesarean delivery is most commonly performed under spinal or epidural anesthesia d/t..

A

Both blocks allow a mother
to remain awake and experience the birth of her child

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17
Q

vertebral bones

A

7 cervical (C)
12 thoracic (T)
5 lumbar (L)
sacrum: fusion of 5 sacral (S) vertebrae,
small rudimentary coccygeal vertebrae

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18
Q

Cauda Equina location

A
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19
Q

All 12 thoracic vertebrae articulate with

A

their corresponding ribs

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20
Q

location in which the spinal cord and its coverings sit

A

spinal canal

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21
Q

vertebral bodies & intervertebral disks
anterior and posterior support

A

anteriorly:
anterior & posterior longitudinal ligaments

posteriorly:
ligamentum flavum
interspinous ligament
supraspinous ligament

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22
Q

midline approach

A

a needle passes through:

1) these three dorsal ligaments:
ligamentum flavum
interspinous ligament
supraspinous ligament

2) through an oval space between the bony lamina and spinous processes of adjacent vertebrae

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23
Q

spinal canal contains

A

Spinal cord & its coverings (the meninges)
fatty tissue
a venous plexus

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24
Q

The ___ mater is adherent to the spinal cord.

The arachnoid mater is usually adherent to the thicker and denser __ mater.

A

pia

dura

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25
Q

Cerebrospinal fluid (CSF) is contained…

A

between the pia and arachnoid maters in the subarachnoid space.

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26
Q

subdural space

A

generally a poorly demarcated, potential space that exists between the dura and arachnoid membranes

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27
Q

epidural space

A

better-defined potential space bounded by the dura and the ligamentum flavum

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28
Q

spinal cord normally extends from ___ to the ___ in adults ( ___ in children)

A

the foramen magnum
level of L1
L3

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29
Q

Damage to the cauda equina

A

unlikely

nerve roots float in the dural sac below L1

tend to be pushed away (rather than pierced) by an advancing needle.

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30
Q

Nerve blocks close to the ___ carry a risk of subdural or subarachnoid injection

A

intervertebral foramen

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31
Q

Spinal block inject LA into ___.
Epidural block injects LA into ___.

A

spinal = CSF, subarachnoid space

epidural = epidural space

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32
Q

Injxn Site
epidural

A

midpoint of the dermatomes that must be anesthetized

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33
Q

Blockade of neural transmission in
posterior nerve root fibers
vs
anterior nerve root fibers

A

posterior: interrupts somatic and visceral sensation

anterior: prevents efferent motor and autonomic outflow

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34
Q

Neuraxial blocks provide excellent operating conditions by (2)

A

interrupting afferent transmission of painful stimuli

abolishing efferent impulses for skeletal muscle tone

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35
Q

Sensory blockade interrupts (2)

A

somatic and visceral painful stimuli

somatic stimuli: light touch, vibration, pressure, cutaneous tension

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36
Q

What characteristics make a fiber easier to block

A

Smaller
myelinated

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37
Q

Differential blockade

A

LA [ ] decreases further from the level of injection

sympathetic blockade (judged by temperature sensitivity) may be 2+ segments more cephalad than the sensory block (pain, light touch)

sensory block ~several segments more cephalad than the motor blockade.

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38
Q

(AUTONOMIC BLOCKADE)
what produces sympathetic blockade?

A

interruption of efferent autonomic transmission at the spinal nerve roots during neuraxial blocks

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39
Q

Sympathetic outflow
vs
parasympathetic outflow

A

SNS = thoracolumbar

PNS = craniosacral

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40
Q

Neuraxial anesthesia does not block the _____. This means…

A

vagus nerve (tenth cranial nerve)

response to block result from:
↓ sympathetic tone
and/or
unopposed parasympathetic tone

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41
Q

Cardiovascular Manifestations

A

varying ↓BP
possible ↓HR
(more cephalad dermatomal levels & extensive sympathectomy)

T5 to L1 block:
viscera and lower extremity blood pooling

Arterial vasodilation

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42
Q

arterial vasodilation may be minimized by…

A

compensatory vasoconstriction above the level of the block

ex: lower thoracic dermatome block

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43
Q

high sympathetic block
CV fx

A

prevents compensatory vasoconstriction

block sympathetic 🩷 accelerator fibers (T1 to T4)

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44
Q

Unopposed vagal tone a/w spinal anesthesia

A

(occasional)
sudden bradycardia
complete heart block
cardiac arrest

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45
Q

How can we position OB in 3rd trimester to minimize obstruction of venous return?

A

Left uterine displacement

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46
Q

Autotransfusion

A

placing the patient in a head-down position

hypoTN measure

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47
Q

HypoTN d/t block
interventions

A

Autotransfusion: head-down position

IVF bolus 5–10 mL/kg

Phenylephrine preferred for OB

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48
Q

GI fx

A

decrease hepatic flow (d/t decreased MAP)

faster return of GI fxn after open abd Sx
(use minimal opioid with the block)

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49
Q

GU fx

A

little renal effect if BP normal

urinary retention until block wears off

no foley = use shortest acting possible

hx of retention = assess bladder distention

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50
Q

Metabolic & Endocrine fx

A

Surgery = neuroendocrine stress response

HTN
tachy <3
hyperglycemia
protein catabolism
↓ immune response
altered renal function

LA can suppress/block this
admin before incision and continue postop

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51
Q

Indications

A

used alone or in conjunction with general anesthesia for many procedures below the neck

lower abdominal, inguinal, urogenital, rectal, and lower extremity surgery

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52
Q

Relative c/a

A
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53
Q

Upper abd Sx with neuroaxial (NA) block

A

difficult to safely achieve a sensory level adequate for patient comfort

less commonly used

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54
Q

preexisting neurological deficits or demyelinating diseases

A

may report worsening symptoms following a neuraxial block

may not be able to tell if it was the block or Dz

document existing deficits

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55
Q

warfarin use

A

normal PT & INR documented prior to the block, unless the drug has been discontinued for weeks

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56
Q

Rivaroxaban (Xarelto) use

A

discontinued 72 hours before block

if earlier, can order anti-factor Xa but no values have been established

remove catheter 6 H before postop dose

if dosed before removal, wait ~24 H

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57
Q

Apixaban (Eliquis) use

A

same as Xarelto but wait 26-30 H to remove cath if dosed before removal

58
Q

Stop Plavix use how long before NA block

A

5 to 7 days

59
Q

By themselves, ….. do not increase the risk of spinal hematoma from neuraxial anesthesia procedures or epidural catheter removal

A

aspirin and other (NSAIDs)

60
Q

Heparin use

A

Avoid NA block: if on therap dose + ↑PTT

Low-dose SQ prophylaxis not a contraindication to block or removal

block/removal 4 to 6 h after dosing with 5000 units

Intra op Heparin:
block 1 H before dose
d/c 1 h before or 2 to 4h after subsequent heparin dosing

61
Q

No set guidelines, but ___ & ___ blocks are best done while the patient is awake to warn us of toxicity SEs.

A

thoracic and cervical

62
Q

In this position, CSF
will not freely flow through the needle, so subarachnoid placement must be confirmed by CSF aspiration.

A

Jackknife

63
Q

Midline approach

A

Skin wheal using 25G

increase in tissue resistance
(supraspinous & interspinous ligaments)

an obvious increase in resistance (ligamentum flavum)

not deep & hit bone:
lower spinous process

deep & hit bone:
a) superior spinous process
b) lamina (too lateral)

64
Q

Paramedian Approach

A

for those difficult to position (arthritis, spine issues)

skin wheal:
2 cm lateral to the inferior aspect of the superior spinous process of
the desired level

approach is lateral to most of the interspinous ligaments & penetrates the paraspinous muscles

deep & hit bone:
(lat lower lamina)
adjust slightly toward midline

65
Q

Spinal Needles

A

tightly fitting, removable stylet completely occludes lumen to avoid tracking epithelial cells → subA space

blunt tip = less PDPH

sproutte: more vigorous CSF flow; ↑PDPH

66
Q

(Spinals)
What are the two “pops” that are felt?

A

first: penetrate ligamentum flavum

second: penetration dura–arachnoid membrane

67
Q

If free flow occurs initially but CSF cannot be aspirated after attaching the syringe…

A

the needle likely will have moved

68
Q

Signs you need to adjust your spinal needle position

A

Persistent paresthesia or pain with injection of drugs

withdraw and redirect the needle

69
Q

Factors Influencing Level of Spinal Block

A

most important:
-agent’s baricity
-pt position (during & immediately after injection)
-dosage

others:
level of injection
ptheight
vertebral column anatomy
age
spine curvature
IAbd pressure
pregnancy
drug volume

70
Q

migration of the local anesthetic
cephalad in CSF depends on its

A

density relative to CSF (baricity)

CSF specific gravity: 1.003 - 1.008 at 37°C

71
Q

CSF specific gravity

A

1.003 - 1.008 at 37°C

72
Q

hyperbaric vs hypobaric

A

hyper = heavier/denser than CSF
hypo = lighter ‘ ‘

73
Q

Positioning to manipulate LA migration using hyper/hypobaricity

A

head-up position:
hypobaric ↑ to head
hyperbaric settle ↓ to feet

lateral position:
hyperbaric affects dependent (down) side more
hypobaric to nondependent (up) side

74
Q

How to make LA solution hyper/hypobaric

A

hyperbaric: add glucose

hypobaric: add sterile water or fentanyl

agents lacking glucose may be
mixed with CSF (at least 1:1) to make their solutions isobaric

75
Q

this type of solution tends to
remain at the level of injection

A

isobaric

76
Q

higher levels of anesthesia are
achieved if the injection is directed __ than if the point of injection is
oriented…

A

cephalad

laterally or caudad

77
Q

Agents specific gravities

A

note: CSF is 1.003 - 1.008 at 37°C

78
Q

T/F
↑ CSF volume = greater spread

A

False
decreased CSF volume = greater dermatomal spread

79
Q

Only use these types of solutions for spinals

A

preservative-free local
anesthetic solutions

can add pressors, opioids, clonidine

80
Q

“saddle block”

A

sitting position
keeping the patient sitting for 3 to 5 min following injection so
that only the lower lumbar nerves and sacral nerves are blocked

81
Q

We would make the LA solutio (hyper/iso/hypo)baric for a fracture surgery.

A

Hypo & iso
so the pt doesn’t have to lay on the fractured side

82
Q

The epidural space
anatomy

A

surrounds the dura mater posteriorly, laterally,
and anteriorly

Nerve roots travel here as they exit laterally via foramen and become P nerves

fatty connective tissue, lymphatics, & a rich venous (Batson) plexus

83
Q

Epidural is (more/less) dense than Spinal.
What are the benefits?

A

less

relatively dilute LA [ ] + opioid
can provide analgesia w/o motor block

segmental block possible b/c can be confined close to level of injection

84
Q

segmental block

A

epidural anesthesia

well-defined band of anesthesia at certain nerve roots, leaving nerve roots
above and below unblocked.

ie: thoracic epidural providing upper abdominal anesthesia while sparing cervical and lumbar nerve roots

85
Q

Thoracic vs lumbar epidural
ease & risks

A

Thoracic:
can be harder d/t more overlap of spinous processes

higher risk accidental dural puncture

86
Q

How do epidural catheters affect postop ventilation requirements?

A

prolonged durations of analgesia

may obviate or shorten postop ventilation in pts w underlying lung Dz and following chest surgery

87
Q

Epidural needles

A

17 to 18 gauge, 3 or 3.5 inches

Tuohy:
blunt, curved tip pushes dura away after passing through the ligamentum flavum w/o penetrating it

straight = ↑ risk dural puncture

88
Q

Epidural catheter
needles

A

19- or 20-G catheter
introduced thru 17- or 18-G epidural needle

advance catheter 2 to 6 cm into the epidural space
too little: risk dislodgement
too far: unilateral block or penetrate epidural vein

89
Q

T/F
Test doses can only detect accidental
intravascular injection

A

False
Can detect both subarachnoid and
intravascular injection

90
Q

Test Dose

A

LA + epi
typically 3 mL of 1.5% lido + 1:200,000 epi
(0.005 mg/mL)

45 mg lido if injected intrathecally, will
produce spinal anesthesia that should be rapidly apparent

91
Q

T/F
aspirating prior to injection rules out/confirms accidental intravenous injection

A

False
Simply aspirating prior to injection is insufficient to avoid accidental intravenous injection

false-negative aspirations
possible w/ both a needle and a catheter

92
Q

Using epi as test dose

A

not ideal

False positives
(uterine contraction: pain or ↑ HR coincident to test dosing)

false negatives
(brady🩷 & exaggerated ↑TN in response to epi in patients taking β-blockers)

93
Q

⭐️
LA intravascular injection S/S

A

tinnitus
metallic taste
slurred speech
altered mentation

94
Q

Incremental dosing

A

(“each dose is a test dose”)
very effective to r/o accidental IV injxn

avoids serious complications

  1. aspiration negative
  2. inject a fraction of the dose (5 ml)

large enough to produce mild symptoms/signs

small enough to avoid seizures or CV compromise

95
Q

Epidurals
Ways to prevent systemic toxic SEs & accidental intrathecal injection

A

use an initial test dose

aspirate prior to each injection

always use incremental dosing
(“each dose is a test dose”)

96
Q

⭐️
You did an epidural block & local anesthetic systemic toxicity is now occurring. What do you do?

A

Rescue lipid emulsion
(20% Intralipid 1.5 mL/kg)

followed by a 0.25-mL/kg infusion

97
Q

What pt factors affect epidrual dose requirement?

A

decreases with age (↓ epidural sapce size/compliance)

height affects extent of cephalad spread
taller = more mL per segment

❌ weight

98
Q

Chloroprocaine
considerations

A

ester
rapid onset
short duration

extremely low systemic toxicity

may interfere w/ analgesic fx of epidural opioids

99
Q

bupivacaine vs ropivacaine

which produces less motor block w/ satisfactory sensory block?

A

ropivacaine

100
Q

Local anesthetic solutions have a ___ pH for chemical stability and bacteriostasis.

A

acidic

w/ epi = even more acidic

101
Q

LAs are ____ & exist primarily in the ionic form in commercial preparation.

A

weak bases
preparation = acidic

102
Q

How do we get a faster onset of commercially prepared LA?

When do we not want to do this?

A

Increase the pH

add sodium bicarb (1 mEq/10 mL of local anesthetic) immediately before use

typically not added to bupivacaine, which precipitates above a pH of 6.8.

103
Q

Spinal vs Epidural
onset
ease
predicatability

A

spinal:
-endpoint more clear (free-flowing CSF)
-onset is very fast
-technique has a very high success rate

epidural:
-dependent on the detection of a more
subjective loss of resistance (or hanging drop)
-onset slower
-more variable anatomy (epidural space)
-less predictable spread

104
Q

Epidural Issues:
unilateral block

A

catheter either exited epidural space or went laterally

esp if threading catheter longer

withdrawing catheter 1 to 2 cm
reinject with pt placed unblocked side down

105
Q

NA complications

A

Adverse/exaggerated phys responses:
Urinary retention
High block
Total spinal anesthesia
Cardiac arrest
Anterior spinal artery syndrome
Horner syndrome

d/t needle/catheter placement:
Backache
Dural puncture/leak
Postdural puncture headache
Diplopia
Tinnitus
Neural injury
Nerve root damage
Spinal cord damage
Cauda equina syndrome
Bleeding
Intraspinal/epidural hematoma
Misplacement
No effect/inadequate anesthesia
Subdural block
Inadvertent subarachnoid block
Inadvertent intravascular injection
Catheter shearing/retention
Inflammation
Arachnoiditis
Infection
Meningitis
Epidural abscess

Drug toxicity:
Systemic local anesthetic toxicity
Transient neurological symptoms
Cauda equina syndrome

106
Q

Spinal anesthesia ascending into the cervical levels causes

A

severe hypotension, bradycardia, and respiratory insufficiency

107
Q

“total spinal”

A

block extends to cranial nerves

accidental intrathecal injection

108
Q

T/F
LAST is more of a concern with epidurals.

A

True
LAST is seen after epidural and caudal (but not spinal) blocks.

dose for spinal anesthesia is relatively small

109
Q

Lipid emulsion for LAST rescue
MoA

A

reservoir in the blood to collect and transfer LA away from the heart and brain

110
Q

Epi dosing in LAST

A

Incremental 1-mcg/kg doses rather than larger 10-mcg/kg doses

cardiac fxn not restored:
additional lipid emulsion up to
10 mL/kg.

111
Q

LA toxicity comparison
(potency matches ability to cause toxic SEs)

A

Chloroprocaine: low potency; rapid metab

lidocaine & mepivacaine: intermediate in
potency and toxicity

most potent & toxic:
levobupivacaine, ropivacaine, bupivacaine,
tetracaine

112
Q

Why is accidental intrathecal admin bad?

A

epidural & caudal anesthesia dose
is 5 to 10 times that required for spinal anesthesia

113
Q

Subdural Injection

A

if epidural dose:
worse outcome
looks like “high spinal” (extends intracranially)
but
onset delayed ~15-30 min & “patchy” block

114
Q

spinal subdural space

A

potential space between dura &
arachnoid

extends intracranially, so LA injected here can ascend to higher levels than when injected into the epidural space

115
Q

Backache

A

usually benign

but can be part of serious complications, such as epidural hematoma and abscess

116
Q

Postdural Puncture Headache (PDPH)

A

if needle enters subarach space

may be the result of just the tip of the needle scratching through the dura

bilateral, frontal, retroorbital, or occipital and extends into the neck

photophobia and nausea

Traction on CNs = possible diplopia

117
Q

hallmark of PDPH

A

its association with body position

aggravated by sitting or standing

decreased by lying flat

118
Q

PDPH is believed to result from

A

leakage of CSF from a dural defect and
subsequent intracranial hypotension

119
Q

PDPH greatest risk scenario

A

accidental dural puncture with a large
epidural needle in a young pregnant woman

120
Q

PDPH Tx

A

recumbent positioning
analgesics
hydration (IV, PO)
caffeine

hydration and caffeine stimulate CSF prodxn

epidural blood patch

121
Q

epidural blood patch

A

15 to 20 mL autologous blood into the
epidural space at, or one interspace below puncture

stop further leakage of CSF by either mass effect or coagulation

Headache resolution is usually immediate and complete

122
Q

PDPH diff dx

A

migraine
caffeine withdrawal
meningeal infection
subarachnoid hemorrhage

123
Q

Neurological Injury

A

epidural hematoma or abscess
peripheral neuropathies
(some permanent)

124
Q

sustained paresthesia during neuraxial
anesthesia/analgesia

A

redirect the needle

125
Q

if the injection is associated with pain

A

immediately stop and withdraw needle

126
Q

Direct injection into the spinal cord can
cause

A

paraplegia

127
Q

Spinal or Epidural Hematoma
S/S

A

more sudden than epidural abscess

sharp back & leg pain with motor weakness &/or sphincter dysfunction

STAT MRI/CT

128
Q

Epidural Abscess (EA)

A

Back pain & fever after epidural
Radicular pain or neurological deficit

4 stages
-back pain intensified by spine percussion
-nerve root or radicular pain
-motor/sensory deficits; sphincter dysfxn
-Paraplegia or paralysis

129
Q

Epidural Abscess (EA)
interventions

A

remove catheter & culture tip
culture any site pus
blood Cx (staph aureus & epidermis)
MRI/CT
antiBX
decompression (laminectomy)

130
Q

Epidural Abscess (EA)
prevention

A

-minimize catheter manipulation
-maintain closed system when possible
-micropore (0.22-μm) bacterial filter
-removing/exchange catheter, filter, & solution @ certain time intervals

131
Q

Sheering of an Epidural Catheter

A

always withdraw catheter & needle together

132
Q

Local Anesthetic Systemic Toxicity

A

Absorption of excessive amounts of LAs can produce toxic blood levels (“Intravascular Injection”)

rare if appropriate dose

133
Q

transient neurological symptoms (TNS)
“transient radicular irritation (TRI)”

A

back pain radiating to the legs w/o sensory or motor deficits

after the resolution of spinal anesthesia & resolving spontaneously within several days

esp w/ hyperbaric lidocaine

134
Q

Lidocaine & Mepivacaine
max doses

A

4.5 mg/kg

w/epi: 7 mg/kg

135
Q

Lidocaine vs. Mepivacaine
uses

A

Both: infiltration, epidural, spinal, PN

Lido: IV regional, topical

136
Q

Prilocaine max dose

A

8 mg/kg

137
Q

Medium DoA agents

A

Prilo
Mepiv
Lido

138
Q

short DoA agents

A

chloro + procaine

139
Q

long DoA agents

A

Bupiv
Ropiv
Tetra

“BuRT”

140
Q

Max dose of 3mg/kg

A

Cocaine
Tetracaine
Bupivacaine
Ropivacaine

CocTBuR

141
Q

Chloroprocaine and Procaine
max dose

A

12 mg/kg

both short DoA

Procaine: S, I
Chloro: S, I, E, P

(S=spinal, I=infiltr8, E=epidurl, P=perip nerve)

Gen Exam 3 + Final (13 decks)

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