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Pain Exam 2 > Module 4: Part 2 > Flashcards

Module 4: Part 2 Flashcards

37-70

1
Q

PSA:
install the free American Society of Regional Anesthesia & Pain Medicine (ASRA) App

A
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2
Q

Spinal Anesthesia
Definition
&
Goal

A

reversible chemical blockade of neuronal transmission produced by the injection of a LA into the CSF contained in the subarachnoid space

Goal: Render patient insensitive to surgical stimuli while producing minimal physiologic alteration

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3
Q

Spinal Anesthesia
Pros and Cons

A

Pros:
* Simple
* Predictable
* Fully conscious patient
* Analgesia into the post-op period
* Ideal for lower abdomen, pelvis/perineum, and lower extremities
* Reduces risk of DVT
* Use small dose of LA, less toxicity

Cons
* Sympathetic blockade
100% of the time
HypoTN
* Intense motor blockade
* May last for hours post-op
* Urinary Retention
* Surgeons complain “It takes too long ”

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4
Q

Spinal Anesthesia
Indications

A
  • Full Stomach
  • Retain protective airway reflexes
  • Airway anomalies / difficult airways
  • Urological procedures: TURP
  • OB: Vaginal cesarean delivery

⚠️Major Abd Procedures
(use balanced regional/general)

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5
Q

T/F
Spinals generally do not affect major organ function

A

True

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6
Q

Can we use spinal anesthesia for major abdominal procedures?

A

Not a good choice for major intra-abdominal procedures

Balanced regional/general anesthetic

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7
Q

Spinal Anesthesia
Sitting Position

A
  • Place patient on an adjustable bed
  • ensures maximum anterior flexion of the spinal column
  • easier to ID the midline and assess anatomical angles
  • preserves natural spine alignment & curvature
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8
Q

Spinal Anesthesia
Site

A
  • One of four intervertebral spaces L2-S1
  • Popular site: L2-3 or L3-4
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9
Q

How to find your Landmarks

A

Palpate the back
* Superior aspect of the iliac crest
* Spinous process

Visualize a line between the iliac crest
* Tuffier’s line
* Usually crosses L4 or L4-5 interspace

L2-3 is a common site

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10
Q

Spinal Technique

A

**Strict Sterile Technique & Wear Mask
**
* Draw LA for skin wheal into a 3ml syringe (usually 1% lido)
* Draw LA for CSF into a 5 mL glass syringe
* Verify LA for spinal dose & amt in mL’s
* Cleanse skin over planned injection site & allow to dry
Chlorhexidine is cytotoxic
fluid can be tracked to IT space

  • Place drape over injxn site
  • Remove all chemicals from the site of injection
  • Identify the L2-3 interspace
  • Localize the skin
  • Introducer Needle 90° Perpendicular to Skin
  • 25g Pencan Spinal Needle through Introducer
  • Feel increase resistance/pop = Ligamentum Flavum
  • Advance feel for 2nd very distinct pop, remove stylet & assess for free-flowing CSF
  • Attach Glass LA Syringe – Aspirate for Swirl/no blood
  • Inject LA: 0.2 mL/sec
  • Remove all needles and position patient

https://www.youtube.com/watch?v=DtzI5bX7NyA

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11
Q

The Midline Approach

A

aka what we’re being taught

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12
Q

When using the Midline Approach, you will penetrate which layers?

A
  • Skin
  • Subcutaneous fat
  • Supraspinous ligament
  • Interspinous ligament
  • Ligamentum flavum
  • Dura mater
  • Subdural space
  • Arachnoid mater
  • Subarachnoid space → CSF
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13
Q

Where to insert needle for epidurals
cervical
thoracic
lumbar

A

Cervical C6-7
Thoracic T6-7
Lumbar L4-5

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14
Q

Which NA technique produces Sympathetic blockade 100% of the time?

A

Spinal

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15
Q

“Mad Cat” position is (extension/flexion) that producing rounding of the back.

A

flexion!

Note how flexion opens up the spaces

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16
Q

Midline vs Paramedian Approach

A

Paramedian approach
DOES NOT penetrate the supra & interspinous ligament.
Only penetrates ligamentum flavum & dura mater

(Midline approach penetrates all layers)

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17
Q

Lateral Position Landmarks

A
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18
Q

What verterbrae is a/w
-superior ilac crest
-posterior superior iliac spine

A

superior ilac crest: L4
posterior superior iliac spine: S2

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19
Q

Most Important Factors Affecting Block Level

A

Baricity
Dose
Patient Position (during & immediately after)
Injection Site (Thoracic, Lumbar, Caudal)

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20
Q

Which Agents are hypo/hyper/isobaric

A

CSF: specific gravity 1.003 - 1.008 at 37°C

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21
Q

How to make an LA hyper/hypo/isobaric

A
  • Hyperbaric: add dextrose
  • Hypobaric: add CSF or Sterile H2O
  • Isobaric: no additive, mix w CSF 1:1
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22
Q

How does dose/volume affect spread?

A
  • Larger Dosage/more volume
  • Density relative to CSF
  • More Molecules of LA to move around
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23
Q

Patient position & LA spread

A
  • during injection
  • immediately after injection (up to 20 mins)
  • significant role following injection
  • Most evident with hyperbaric solutions
  • Normally the level is fixed in 5-10 minutes
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24
Q

Spinal Needles have a stylet which is for….

A

to prevent occluding lumen

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25
Q

Spinal Needle Characteristics

A
  • Single use
  • Has a stylet to prevent occluding lumen
  • Most are 3-3.5 inches (7.5-9cm) long
  • In obese pt’s you may need a longer needle (5 inches)
  • Classified as cutting or spreading
  • Quincke, Whitacre, & Sprotte
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26
Q

Choosing Spinal Needle Gauge

A

Smaller gauge (25-26 gauge):
* less CSF leak
* difficult to insert, aspirate CSF, & inject medication

Larger gauge (20-22 gauge):
* improves tactile feel
* higher risk of PDPH

Most clinicians will use the 25-26 gauge needle placed through an introducer

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27
Q

⭐️
CSF Specific Gravity

A

1.003 - 1.008 at 37°C

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28
Q

Spinal Failure
Injection Errors

A
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29
Q

⭐️
Any agent used for Spinal must be…

A

PRESERVATIVE FREE

they are cytotoxic
can cause neurologc disability

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30
Q

Risk of “Cauda equina syndrome” with this mixture

A

Lidocaine 5% 2ml (50mg/ml) solution premixed with 7.5% dextrose

(hyperbaric)

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31
Q

(Spinal)
Mepivacaine

A

30ml ampule of 1.5% (15mg/ml)

Good motor block, short duration
Ambulatory surgery
minimal urinary retention issues

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32
Q

(Spinal)
Bupivicaine

A

2ml ampule of 0.75% (7.5mg/ml) with 8.25% dextrose
(packaged hyperbaric)

Onset of 3-5 minutes

Less motor block than Tetracaine
Blocks sensory nerves that modulate tourniquet pain better than Tetracaine

brand name: Marcaine

33
Q

(Spinal)
Lidocaine

A

2ml ampule of 5% (50mg/ml) solution premixed with 7.5% dextrose
(hyperbaric)

Travels downward: Risk of “Cauda equina syndrome”

34
Q

Procaine

A

2ml ampule of 10% (100mg/ml) solution

Short duration, low potency
Solutions of greater than 5% concentration are linked to neurotoxicity

35
Q

T/F
Esters placed in CSF must be absorbed into systemic circulation for metabolism

A

True
no ester metabolism in CSF

36
Q

aminoamides are metabolized…

A

lungs or liver

37
Q

T/F
Intrathecal Opioids will not produce surgical analgesia

A

True
but
Does provide better anesthesia when combined with LA

38
Q

Intrathecal Opioids
Fentanyl

A

Dose- 15-25 mcg
Higher doses produce respiratory depression, itching, and urinary retention
Onset 5-10 minutes
Duration 2-4 hours
Quick CSE Pain Relief

39
Q

Intrathecal Opioids
Sufentanil

A

Not commonly used
Dose 2-4 mcg

40
Q

Intrathecal Opioids
Meperidine

A

Preservative-free 5-50mg of 5% solution

41
Q

Intrathecal Opioids
Duramorph

A

Morphine (preservative-free)
Most commonly used

Onset of 60-90 minutes
Dose 0.1-0.5mg

Provide profound analgesia for 18-27 hours
Risk: Delay Resp Depression, PONV
-pruiritis
-decreased spO2 is late sign of resp depression

42
Q

Epi for Spinals:
Which agents will have a longer duration?
Which will not?
Does it affect spread?

A

Does prolong lidocaine & esters
Does not prolong the action of bupivicaine

Does not affect the spread of the block

43
Q

Vasoconstrictors
When added to LA it will constrict the blood vessels at the site and …

A

slow absorption of the LA

44
Q

T/F
Vasoconstrictors can produce analgesia

A

True?

45
Q

Epinephrine
receptor & analgesic action

A

Alpha-1 adrenergic agonist
Alpha-2 adrenergic effect to produce analgesia

46
Q

Phenylephrine
is a _____ agonist but it is rarely used as …..

A

Pure alpha-adrenergic agonist

Rarely used as a topical vasoconstrictor

47
Q

Alpha-2 Agonists
Spinal Adjuncts

A

All work on pre/post-junctional A-2 receptors
Analgesia

  • epinephrine
  • clonidine
  • dexmedetomidine
    (10X more alpha-2 selective)
    prolong sensory/motor block with less hypoTN
48
Q

The LA is heavier than CSF so it will sink.

A

Hyperbaric

49
Q

Spinal Block
Evaluation

A
  • Begin to assess blockade immediately
  • BP, ECG, pulse-ox, respirations
  • BP Q 3-5 min’s until block is set
  • Emergency Drugs

Determine the progress of the block every minute:
* First with alcohol
* Then with a sharp device (tongue blade)

Once level is achieved:
* assess every 30-45 minutes
* Determine dermatome level
* May adjust the horizontal angle of the table to increase or stop the spread of the LA

50
Q

⭐️
earliest sign that the spinal is working

A

Decrease in BP

51
Q

Due to their small size, ____ fibers are blocked quickly

A

autonomic

52
Q

Sympathectomy is accentuated in the ____ patient

A

hypovolemic

53
Q

Treat drops in BP quickly with

A

ephedrine or phenylephrine

54
Q

A rapid drop in BP
Symptoms

A

nausea and dizziness

55
Q

Testing Temp/light touch fibers
vs
Motor Impairment/touch

A

Temperature & Light Touch:
Unmyelinated C & myelinated A-delta
* follows autonomic blockade
* Alcohol sponges
* Loss of temperature = sensory loss

Motor Impairment & Touch
Myelinated A-beta & A-gamma
* follows loss of light touch & T discrimination
* Differential block (Motor block is 2 dermatomes below sensory block)
* sharpened device/pinch to assess level

56
Q

Do NOT place patient in ____ position within ___ mins of giving a hyperbaric spinal anesthetic.

A

Trendelenburg
30 mins

57
Q

T/F
Motor Impairment & Touch assessment can be done with a sharp item such as a needle.

A

False

58
Q

⭐️
Profound Motor Block is a/w _____ fibers

A

Myelinated A-alpha

59
Q

Profound Motor Block
S/S

A
  • Myelinated A-alpha
  • Motor block & loss of proprioception
  • Pt’s will feel legs are still in the air after being prepped
60
Q

Profound Motor Block
wyd?

A

Make sure pt knows that this is normal and it will wear off

Assess block
* S1-2- dorsiflex his feet
* L4-5- flex his toes
* L2-3- raise his knees
* T6-T12- lift shoulders off the bed

61
Q

Desired levels of block

A

S2-5 (Saddle block)
* No affect on the ANS
* Surgical anesthesia limited to perineum, perianal, & genitalia

T10 (umbilicus)
* Low spinal
* Blocks S1-5 & L1-5
* Produce vasodilation, lower BP
* Good for GYN, vaginal delivery, lower extremity surgery, TURP, & cysto

T4 (nipple)
* High spinal
* Used for upper abdominal surgery
* Can feel traction
* Can cause vasodilation and block cardioaccelerator fibers

C8 (little finger)
* Total spinal
* Dyspnea➡️respiratory & cardiac arrest

62
Q

Which vertebral level is a/w
-High Spinal
-Total Spinal

A
  • T4 (nipple): High spinal
  • C8 (little finger): Total spinal
63
Q

T/F
High spinal is a/w difficulty breathing & can lead to respiratory & cardiac arrest

A

False
Total spinal (C8/little finger): dyspnea & CV + Resp arrest

T4 (nipple)/High spinal: vasodilation & block cardioaccelerator fibers

64
Q

Spinal
CV Complications

A
  • Blockade of sympathetic fibers
  • Blockade of cardioaccelerator fibers
  • Causes hypotension and bradycardia
  • BP is decreased by 15-20% in most healthy patients
65
Q

HypoTN & Spinal Anesthesia
-Prevention
-Treatment

A

prevention:
* Preload (Only if dry)
* Supplementary O2
* pt’s w/ essential HTN: Treat drops in BP aggressively

Treatment:
* Slight head down position – Trendelenburg (auto transfuse)
* Bolus of crystalloid
* Ephedrine 5-10mg IV

66
Q

Solution that has a density greater than the CSF (>1.008)

A

Hyperbaric

67
Q

T/F
Dextrose is used to make solution hypobaric

A

False
hyperbaric

68
Q

Which type of baricty is most commonly used?

A

hyperbaric

69
Q

Hyperbaric Spinal
positioning

A

Allows us to inject at the lumbar area, then place pt in a slight Trendelenburg position and allow the LA to move cephalad to bathe the upper lumbar and thoracic nerve roots

Sitting the pt after injection of LA for 3-5 minutes after injection confines the LA to the lower lumbar and sacral roots (saddle block)

70
Q

Hypobaric
Solution that has a density less than _____ (the CSF where injected)

A

1.008

71
Q

Hypobaric will travel to…

A

float up to the least dependent area within the spinal cord

not necessarily towards to head

72
Q

To make an agent hypobaric, dilute it with ___________ water

A

preservative-free sterile

73
Q

Hypobaric Agents
Very dilute solutions require _____________ to deliver an effective mass of drugs

A

a larger volume of LA
5-10mL

74
Q

Which baricity has limited clinical application?

A

Isobaric

75
Q

Isobaric Agent
pros and cons

A
  • Difficult to obtain a high level
  • No spread with position change
  • Limited clinical application
  • Ideal when repositioning is required
76
Q

Spinals
Uptake factors
(4)

A
  • Concentration of the agent in the CSF
  • Surface area of exposed nerve tissue in the CSF
  • Lipid content of the nerve tissue
  • Blood flow
77
Q

After injection, how often do we assess the block progress?

A
  • every minute
    First with an alcohol sponge
    Then, with a sharp device (tongue blade)
  • Once level is achieved, assess every 30-45 minutes
  • determine dermatome level
78
Q
A

Pain Exam 2 (13 decks)

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