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8362 T&T Exam 2 > Mod VII: EPIDURAL ANESTHESIA > Flashcards

Mod VII: EPIDURAL ANESTHESIA Flashcards

1
Q

When a local anesthetic (may also add opioid, epi, bicarb) is injected into the epidural space, initially blocking spinal nerve roots and then diffusing into the subarachnoid space creating a conduction blockade of the spinal nerves, this technique is known as:

A

Epidural Anesthesia (EA)

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2
Q

Epidural Anesthesia (EA)

Placement of a flexible catheter into the epidural space via needle, remains in place for

A

the anesthetic and dosing is intermittent/continuous

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3
Q

Epidural Anesthesia

Indications for EA

A

Sole anesthetic for operations below the umbilicus

Lower extremities (esp. hip and knee)

Pelvis

Perineum

Lower abdomen

Obstetrical procedures (very popular in this population)

Adjunct anesthetic or post-op pain control

Upper and lower abdominal procedures

Thoracic procedures

Treatment of Acute / Chronic pain

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4
Q

Epidural Anesthesia (EA)

Advantages: (compared to GA)

A

Similar to spinal anesthesia!!!

Awake patient, reflexes

Decreased stress response

Decreased cost

Early ambulation, eating, less PONV

Decreased blood loss

Postoperative analgesia

Flexibility

Increased patient satisfaction

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5
Q

Epidural Anesthesia (EA)

Disadvantages

A

Technically more difficult to place

Takes longer to set up than SAB or GA

Less dense block than SAB

Catheter may migrate from epidural space

Less reliable (higher failure rate or patchy block)

Greater chance for LA toxicity

Infection

Epidural hematoma

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6
Q

Epidural Anesthesia (EA)

Absolute Contraindications

A

Inadequate resuscitation drugs or equipment

Patient refusal or uncooperative

Uncorrected coagulopathies

Infection at site of injection

Septicemia

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7
Q

Epidural Anesthesia (EA)

Relative Contraindications

A

Hypovolemia

Fixed CO states

Anatomical deformities of spine

Neurological disease

Increased ICP

Chronic back pain

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8
Q

Epidural Technique

Most components are very similar to spinal administration - including:

A

Patient position, prep, drape, local

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9
Q

Epidural Technique​

Major difference in technique between epidural and spinal are:

A

Introduction of tuohy needle

Identification of epidural space

Threading the catheter

Removal of tuohy needle

Test dose of catheter

Securing catheter for dosing

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10
Q

Epidural Technique​

Technique for dentification of epidural space

A

Loss of resistance technique

(to be demonstrated in lab)

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11
Q

Epidural Anesthesia (EA)

Dosing Techniques

A

Test Dose

LA solutions should be injected in increments of 3-5 ml every 3-5 minutes (always aspirate prior to injecting) and titrate to desired anesthetic level

Block should set up in about 20 min.

When block recedes 1-2 dermatone levels, re-dose with 30-50% of initial dose to maintain initial level of anesthesia (if continuous infusion, increase rate or concentration)

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12
Q

Epidural Anesthesia (EA) - Dosing Techniques

How should LA solutions be injected?

A

In increments of 3-5 ml every 3-5 minutes

Always aspirate prior to injecting

Titrate to desired anesthetic level

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13
Q

Epidural Anesthesia (EA) - Dosing Techniques

Block should set up in about

A

20 min.

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14
Q

Epidural Anesthesia (EA) - Dosing Techniques​

What could you do When block recedes 1-2 dermatone levels in order to maintain initial level of anesthesia ?

A

Re-dose with 30-50% of initial dose to maintain initial level of anesthesia

If continuous infusion, increase rate or concentration

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15
Q

Epidural Anesthesia - Assessment of block

Three classes of nerves blocked:

A

Autonomic nervous system

Sensory nerves

Motor nerves

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16
Q

Epidural Anesthesia - Assessment of block

Dermatomes

A

Dermatomes

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17
Q

Epidural Anesthesia (EA)

Factors influencing spread of LA in the epidural space

A

Injection site (Most important determinant)

Drug Volume

Drug Dose

Drug concentration

Patient position

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18
Q

Factors influencing spread of LA in the epidural space

Injection site - Epidural anesthesia produces a segmental block that spreads in which directions from site of injection?

A

Caudally & Cranially

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19
Q

Factors influencing spread of LA in the epidural space

Caudal spread (or is it caudal injection?!) of LA restricted to which dermatomes?

A

Sacral and lower lumbar dermatomes

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20
Q

Factors influencing spread of LA in the epidural space

Under which condition can Caudal spread (or is it caudal injection?!) of LA reach Lower thoracic levels? what’s a possible disadvantage of this approach?

A

Larger volumes (30ml)

Block is “patchy” and short lived

21
Q

Factors influencing spread of LA in the epidural space

Which dermatomal levels can be reached with Lumbar site injection/spread?

A

Midthoracic levels (T4-T6) with 20ml

22
Q

Factors influencing spread of LA in the epidural space

Lumbar site injection/spread can reach caudally with only what volume of LA?

A

only 10mL of LA

23
Q

Factors influencing spread of LA in the epidural space

Thoracic injection/spread

A

Produces a symmetric segmental block

With mid to upper thoracic injection sites, reduce dose by 30-50% to prevent excessive cephalad spread

Not feasible to produce surgical anesthesia in lower lumbar region with this site

24
Q

Factors influencing spread of LA in the epidural space

With mid to upper thoracic injection sites, reduce dose by what % ? - why?

A

30-50%

To prevent excessive cephalad spread

25
Q

Factors influencing spread of LA in the epidural space

Thoracic injection/spread Not feasible to produce surgical anesthesia in which region?

A

Lower lumbar region

26
Q

Factors influencing spread of LA in the epidural space

Drug Volume - Increase the volume, what happens?

A

…

27
Q

Factors influencing spread of LA in the epidural space

Drug Volume - Suggested volumes of LA per spinal segment spread (how many interspaces you need LA to spread) - Cervical & Thoracic epidural vs Lumbar epidural?

A

Cervical & Thoracic epidural = 0.7-1.0 ml per segment (~10ml)

Lumbar epidural = 1-2 ml per segment (~15-20ml)

28
Q

Epidural Anesthesia

Factors influencing spread of LA in the epidural space

A

Drug Dose

Drug concentration

Patient position

29
Q

Epidural Anesthesia

Factors influencing duration

A

Local anesthetic drug (principle determinant of duration)

Common LA used (Table 56-6)

Shortest duration: chloroprocaine

Intermediate duration: lidocaine, mepivacaine

Longest duration: bupivacaine, ropivacaine, etidocaine

LA’s exhibit different effects of intensity and duration of sensory and motor block

Etidocaine : most intense motor block vs. sensory

Bupivacaine: more intense sensory block vs. motor

Dose (concentration)

Increasing dose = increased duration and intensity

Addition of epinephrine, sodium bicarbonate

30
Q

Factors influencing duration - Local anesthetic drugs

Common LA used

A

(Table 56-6)

31
Q

Factors influencing duration - Local anesthetic drugs

Shortest duration:

A

Chloroprocaine

32
Q

Factors influencing duration - Local anesthetic drugs​

Intermediate duration:

A

Lidocaine, Mepivacaine

33
Q

Factors influencing duration - Local anesthetic drugs​

Longest duration:

A

Bupivacaine - Ropivacaine - Etidocaine

34
Q

Factors influencing duration - Local anesthetic drugs​

LA’s exhibit different effects of intensity and duration of sensory and motor block - most intense motor block vs. sensory

A

Etidocaine

35
Q

Factors influencing duration - Local anesthetic drugs​

LA’s exhibit different effects of intensity and duration of sensory and motor block - more intense sensory block vs. motor

A

Bupivacaine

36
Q

Epidural Anesthesia

Effect of adding opioids

A

Provides intense visceral analgesia without affecting motor or sympathetic function

Associated with Side effects

37
Q

Epidural Anesthesia

Common opioids drugs added to epidural anesthesia with dose, time of onset and DOA

A

Fentanyl

[50-100 mcg]

(rapid onset 5 min, DOA 2-4 hrs)

Duramorph (PF Morphine)

[2-5 mg]

(slow onset .5- 1 hr, DOA 6-24 hrs)

Sufentanil

[20-30 mcg]

(rapid onset 5 min, DOA 2-4 hrs)

38
Q

Epidural Anesthesia

Cardiovascular Physiology

A

Similar to Spinal Anesthesia

With less magnitude

39
Q

Epidural Anesthesia

Treating hypotension:

A

IVF administration

Ephedrine 5-10 mg IV bolus

Phenylephrine 50-100 mcg IV bolus

40
Q

Epidural Anesthesia (EA)

Problem Solving During Placement of Epidural

A

Pain upon insertion

Malpositioned epidural needle

CSF flow

Blood

Unable to advance epidural needle

41
Q

Epidural Anesthesia (EA)

Signs and Symptoms of Subarachnoid injection

A

CSF flows from tuohy needle or epidural catheter

Hypotension

Bradycardia (not Tachycardia)

Spinal anesthesia

Increasing anxiety

Numbness or tingling in arms, hands, fingers

Dyspnea

Cardiovascular collapse

Loss of consciousness

Seizure

Coma

42
Q

Epidural Anesthesia (EA)

Signs and symptoms of intravascular injection

A

Hypertension (at first, if dose contains epi)

Hypotension

Tachycardia (at first, if dose contains epi)

Bradycardia - Tinnitus - Dizziness

Circumoral numbness - Metallic taste in mouth

Increasing anxiety - Numbness or tingling in arms, hands, fingers

Dyspnea - Cardiovascular collapse - Loss of consciousness

Seizure - Coma - Death

43
Q

Epidural Anesthesia (EA)

Signs and symptoms of High epidural block

A

…

44
Q

Epidural Anesthesia (EA)

Treatment of High epidural block or Subarachnoid injection

A

Call for assistance!!!

Airway => Intubate

Breathing => Positive pressure ventilation with 100% FIO2

Circulation => Treat hypotension and bradycardia => IV fluids, ephedrine, phenylephrine, epinephrine, norepinephrine, atropine

45
Q

Epidural Anesthesia (EA)

Complications and Treatment - Similar to

A

Spinal anesthesia

(backache, systemic toxicity, total spinal, neurologic injury, spinal hematoma)

46
Q

Epidural Anesthesia (EA) - Complications and Treatment

Complications a/w dura puncture:

A

PDPH

47
Q

Epidural Anesthesia (EA) - Complications and Treatment

Treatment of PDPH

A

Supine

Fluids

Analgesics

Caffeine

Abdominal binder prior to ambulating

48
Q

Epidural Anesthesia (EA) - Complications and Treatment

Epidural blood patch

A

Forms a clot over meningeal hole, preventing further CSF leak

10 to 20 ml autologous blood aseptically injected into epidural space at or near interspace where meningeal puncture occurred

Produces relief in 85-95% of pt within 1-24 hrs

Side effects include back pain and radicular pain

Prophylactic blood patch is effective in preventing PDPH in patients after accidental dura puncture during attempt at EA

8362 T&T Exam 2 (4 decks)

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