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8362 T&T Exam1 > Mod IV: Regional Anesthesia Part 4 > Flashcards

Mod IV: Regional Anesthesia Part 4 Flashcards

1
Q

Regional Anesthesia

Incidence of Pneumothorax

A

Very rare but

profound complication

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2
Q

Regional Anesthesia - Pneumothorax

Brachial plexus blocks with the Highest risk of Pneumothorax:

A

Supraclavicular block

0.5-6%

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3
Q

Regional Anesthesia - Pneumothorax

Brachial plexus blocks with the Lower incidence of Pneumothorax:

A

Interscalene block (ISB)

Infraclavicular block (ICB)

Suprascapular block

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4
Q

Regional Anesthesia - Pneumothorax

Thoracic blocks associated with a risk of Pneumothorax:

A

Paravertebral

Pectoral nerve (PECs) Blocks

Intercostal Blocks

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5
Q

Regional Anesthesia - Pneumothorax

Signs & Symptoms of Pneumothorax

A

Decreased

Breath sounds, HR, BP - O2 Sat => cyanosis

Increased

HR, RR, JVD - SOB – retractions, nasal flaring

Pain

Chest/Epigastric - May be worse with cough or deep breath

Onset is commonly sudden - sharp

Tracheal shift away from pneumothorax

Progressively expanding chest wall

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6
Q

Regional Anesthesia - Pneumothorax

Characteristics of pain a/w Pneumothorax:

A

Chest/Epigastric

May be worse with cough or deep breath

Onset is commonly sudden

Sharp!!!!

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7
Q

Regional Anesthesia - Pneumothorax

Tracheal shift - which way?

A

Away from pneumothorax!!!

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8
Q

Regional Anesthesia - Pneumothorax

Changes to chest wall a/w pneumothorax:

A

Progressively expanding

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9
Q

Regional Anesthesia - Pneumothorax

How is a Pneumothorax diagnosed:

A

Physical assessment

CT scan

Chest X-ray

Ultra sound

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10
Q

Regional Anesthesia - Pneumothorax - Diagnosis

Gold Standard for detecting Pneumo:

A

CT scan

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11
Q

Regional Anesthesia - Pneumothorax - Diagnosis

Chest X-ray sensitivity to detect Pneumo:

A

As low as 36-48% sensitivity to detect Pneumo

Not very sensitive to finding Pneumo

Small Surg. Center may not have the ability

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12
Q

Regional Anesthesia - Pneumothorax - Diagnosis

Ultra sound - Advantages:

A

Portable

May expedite diagnosis, treatment and resuscitation of unstable PT

Overall Dx sensitivity 58.9-100%, Specificity 94-100%

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13
Q

Regional Anesthesia - Pneumothorax - Diagnosis

What improves Dx reliability with Ultra sound?

A

Using multiple findings together

Pleural sliding AND Comet-tail artifact

Specificity 96.5%

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14
Q

Regional Anesthesia - Pneumothorax - Diagnosis

When is Ultrasound Negative predictive value 100%?

A

When both findings (Pleural sliding AND Comet-tail artifact) are present

100% probability pneumothorax is not present

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15
Q

Regional Anesthesia - Pneumothorax - Diagnosis

Which type of US machine is a big plus?

A

M-mode capable US machine

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16
Q

Regional Anesthesia - US assessment for Pneumothorax

US machine with Best images:

A

Linear transducer

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17
Q

Regional Anesthesia - US assessment for Pneumothorax

Why are US machines with Phase array preferred for detecting pneumo in Obese PTs, Large breasts?

A

Provides deeper images

with ↓ quality

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18
Q

Regional Anesthesia - US assessment for Pneumothorax

Assessment - Where to look?

A

Air rises to highest area

Supine - most common

Anterior chest midclav line b/t 2nd-4th rib

Probe orientated parasagittal

Midclavicular => Ant Axillary line

Examine multiple interspaces ↑and↓ the highest point

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19
Q

Regional Anesthesia - US assessment for Pneumothorax

Assessment - What are we looking for?

A

Pleural sliding during respiration

Acoustic artifacts seen when pleural layers are touching

Lung edge– where lung stops touching chest wall d/t air pocket

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20
Q

Regional Anesthesia - US assessment for Pneumothorax

US Assessment of Pleural Sliding - How?

A

Respiration causes visceral and parietal pleura to slide over each other

US can see this sliding motion

Air between pleural layers disrupts US beam

No pleural sliding = Air present = Pneumothorax

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21
Q

Regional Anesthesia - US assessment for Pneumothorax

US Assessment of Pleural Sliding - 2D mode

A

Dynamic measure of movement

Hyper-echoic pleural layers slide back and forth

“Shimmering effect” can be seen along pleural line

No Shimmer = Pneumothorax

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22
Q

Regional Anesthesia - US assessment for Pneumothorax

US Assessment of Pleural Sliding - M-mode

A

Views motion over time, static measurement

Easier to appreciate small movements

Normal Lungs – Sea Shore pattern

Water waves – Static Soft tissue above pleura

Shoreline – hyper-echoic Pleural line

Sand – sliding lung motion à granular sand appearance

Pneumothorax – Stratosphere or Barcode pattern

No motion seen à same appearance above/below pleural line

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23
Q

Regional Anesthesia - US assessment for Pneumothorax

Acoustic Reverberation:

A

A-Lines, B-Lines, and Comet-tails

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24
Q

Regional Anesthesia - US assessment for Pneumothorax

Acoustic Reverberation present in normal lung:

A

B-Lines and Comet-tails

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25
Q

Regional Anesthesia - US assessment for Pneumothorax

Assessment of Acoustic Reverberation - B-Lines artifact due to:

A

Acoustic differences of air/water in lung tissue

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26
Q

Regional Anesthesia - US assessment for Pneumothorax

Assessment of Acoustic Reverberation - Comet-tails artifact due to:

A

US waves bouncing off interface of the pleural layers

Move synchronously with respiration

27
Q

Regional Anesthesia - US assessment for Pneumothorax

Assessment of Acoustic Reverberation - IF B-Lines and Comet-tails Absent =

A

Pneumothorax

28
Q

Regional Anesthesia - US assessment for Pneumothorax

Assessment of Acoustic Reverberation - IF even 1 B-Lines and Comet-tails present =

A

NO Pneumo

29
Q

Regional Anesthesia - US assessment for Pneumothorax

Assessment of Acoustic Reverberation - A-Lines

A

Present in Pneumothorax

Horizontal lines equally spaced emanating from pleural line

A-Lines = Pneumothorax

30
Q

Regional Anesthesia - Pneumothorax - Diagnosis

Shows location on chest where lung stops touching chest wall

A

Lung Point Assessment

Most Specific sign for Pneumo

Most difficult to find

Difficult even for experienced operators

31
Q

Regional Anesthesia - Pneumothorax - Diagnosis

How to estimate Pneumo size?

A

By finding edges of air pocket on the chest

A calculation can be made to estimate Pneumo size

32
Q

Regional Anesthesia - Pneumothorax

Treatment:

A

Admission to the hospital

Monitor closely

Supportive therapy

Chest Tube possible

May resolve spontaneously over time

33
Q

Complications of Peripheral Nerve Blocks

Nerve injury:

A

Infrequent Complication

Transient Deficits most common

Transient paresthesia reported in up to 10%

s/s last days - weeks

s/s rarely last weeks - months

34
Q

Complications of Peripheral Nerve Blocks

Permanent injuries:

A

Very rare – 1.5/10,000

Can range from localized numbness => paralysis

35
Q

Regional Anesthesia

Risk Factors Associated with Injury:

A

Technique

Anatomic

Pre-existing pathology

Procedural

36
Q

Regional Anesthesia

Technical Risk Factors Associated with Injury:

A

Paresthesia, NS, US

Blunt needle ↓ risk

Needle movement around partially anesthetized nerves

Injection pressure/pain

LA selection and dosing

Skill of CRNA

37
Q

Regional Anesthesia

Anatomic Risk Factors Associated with Injury:

A

Block performed

↑ risk proximal

↓ risk distally

38
Q

Regional Anesthesia

Pre-existing pathologic Risk Factors Associated with Injury:

A

Diabetes

PVD

Atherosclerosis

39
Q

Regional Anesthesia

Procedural Risk Factors Associated with nerve Injury:

A

Surgical risks – surgeon skill

Position, tourniquet, length,

Dressing, cast

40
Q

Regional Anesthesia

T/F: Frequently see multiple factors present with nerve injury.

A

True

41
Q

Regional Anesthesia

Mechanisms of Nerve Injury:

A

Mechanical

Stretch

Pressure/compression

Chemical

Vascular

Intraneural injection

42
Q

Regional Anesthesia - Mechanisms of Nerve Injury

Causes of Pressure/compression Nerve Injury:

A

Hematoma

Neural edema

Intraneural or intrafascicular injection

43
Q

Regional Anesthesia - Mechanisms of Nerve Injury

Chemical causes of nerve Injury:

A

LA, EPI, Chemo

All LA drugs are neurotoxic to some degree

Histological changes present after injection

Usually no clinical significance

Ropivicaine less toxic

44
Q

Regional Anesthesia - Mechanisms of Nerve Injury

Least neurotoxic LA:

A

Ropivicaine

45
Q

Regional Anesthesia - Mechanisms of Nerve Injury

Vascular causes of nerve Injury:

A

Prolonged disruption of blood flow to nerve

Lidocaine inhibits Neural blood flow

This effect is Dose dependent

↓ BF shown even after Lido wash out

46
Q

Regional Anesthesia - Mechanisms of Nerve Injury

Which was historically thought to be primary mechanism of nerve injury?

A

Intraneural injection

47
Q

Regional Anesthesia - Mechanisms of Nerve Injury

Intraneural injection - US techniques introduced - What was the thinking?

A

Thinking was US would prevent intraneural injection

Post surgical neuropathies would then plummet right?

Neural injury rates have not changed after introduction of US

48
Q

Regional Anesthesia - Mechanisms of Nerve Injury

Studies done using Stimulator to place needle for block. US monitoring of injection was then performed. What were the findings?

A

Turns out we have been routinely injecting nerves for years

Intra-Neural – vs – Intra-Fascicular

49
Q

Regional Anesthesia - Nerve Anatomy

Protective connective tissue - Outer covering, inner supportive tissue of nerve aslo known as:

A

Epineurium

50
Q

Regional Anesthesia - Nerve Anatomy

Injury to the Epineurium from Injection of LA is far less likely - Depends on:

A

Freedom to swell

51
Q

Regional Anesthesia - Nerve Anatomy

Bundles of nerves surrounded by tough fibrous Perineurium

A

Fascicles

Blunt needle less likely to pierce

Not easily distended to compensate

Higher injection pressure

↑ Fascicular pressure

52
Q

Regional Anesthesia - Nerve Anatomy

Why do risks of nerve injury increase proximally?

A

Fewer large Fascicles

↑ Fascicle density

Tightly bound by sheath

Easy to needle

53
Q

Regional Anesthesia - Nerve Anatomy

Why do risks of nerve injury decrease distally?

A

Many small fascicles

Lower Fascicle:Epinural density, without sheath

Needle has trouble entering fascicle

54
Q

Regional Anesthesia - Nerve Anatomy

Vasculature ischemia could lead to nerve Injury. Where is intrinsic nerve vasculature located?

A

Within the epineurium

55
Q

Regional Anesthesia - Nerve Anatomy

Vasculature ischemia could lead to nerve Injury. Where is Extrinsic plexus nerve vasculature located?

A

Around nerve, anastomosis with inner

56
Q

Regional Anesthesia - Nerve Anatomy

Why may some PTs be at ↑ risk for vasculature-ischemia related nerve Injury?

A

Microvascular Bloof Flow issues

LA has been shown to ↓ BF

Possible mechanism for injury

57
Q

Regional Anesthesia - Post-op Neuropathy

Management of Post-op Neuropathy requires communication with:

A

Pt

Surgeon

Neurology

58
Q

Regional Anesthesia - Post-op Neuropathy

Management of Post-op Neuropathy - Communication with Pt involves:

A

Reporting of S/s

Ensure them your on it!!

Don’t blow them off

59
Q

Regional Anesthesia - Post-op Neuropathy

Reversible cause of Post-op Neuropathy:

A

Cast

Compartment syndrome

Hematoma

60
Q

Regional Anesthesia - Post-op Neuropathy

Management of Post-op Neuropathy - Communication with Surgeon involves:

A

Possible procedural component

61
Q

Regional Anesthesia - Post-op Neuropathy

Management of Post-op Neuropathy - Communication with Neurology involves:

A

Earlier involvement

Invole neurology immediately if Motor deficit

Electrophysiological testing

Follow up until symptoms resolve or stabilize

62
Q

Regional Anesthesia - Post-op Neuropathy

Resolution of sensory symptoms:

A

95% in 4-6 weeks

99% within a year

63
Q

Regional Anesthesia - Post-op Neuropathy

Resolution of Motor symptoms:

A

Motor involvement bad sign

8362 T&T Exam1 (16 decks)

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