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Pain Exam 2 > Module 4: Part 3 > Flashcards

Module 4: Part 3 Flashcards

71-104

1
Q

T/F
Do not place pts in trendelenburg position within 20 minutes of receiving a hyperbaric spinal anesthetic

A

False
within 30 minutes

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2
Q

in pts w/Intercostal muscle paralysis. where will sensory loss be located?

A

chest and abdomen

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3
Q

Intercostal muscle paralysis complications (4)

A

Loss of sensory awareness of chest and abdominal motion
May cause anxiety in the pt
Give the pt O2 and reassure them
Diminished ability to cough

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4
Q

Neurologic injuries complications (4)

A

Paresthesias or paraplegia
Do a thorough pre-op interview and document any deficits
If symptoms occur get an immediate neuro consult
Most resolve within 1-6 months

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5
Q

Apnea/ Phrenic nerve paralysis complications (4)

A

Immediate intervention
Secure the airway
Weak/Hoarse/Soft voice
Guppy Breathing

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6
Q

Traumatic puncture/Paresthesia complications (2)

A

If paresthesia is encountered during needle placement- STOP
If paresthesia continues after needle removal, abandon procedure

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7
Q

Subarachnoid or Epidural Hematoma complications

A

-Appearance of symptoms & neurologic impairment makes this a neurological emergency
-If block lasts longer than expected, rule out hematoma
-Reappearance of blockade should warrant investigation
-Severe post-op back pain or spasm warrants investigation

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8
Q

Anterior Spinal Artery Syndrome complications (5)

A

Caused by a compromise in blood supply
Aorta clamping
Artery of Adamkiewicz
Signs and symptoms are sudden
Flaccid paralysis

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9
Q

Epidural Abscess complications (6)

A

Use sterile technique (MASK)
Symptoms occur within 1-3 days
Severe back pain and tenderness, fever, and paralysis
Elevated WBC
Urgent surgical evacuation of abscess
Antibiotics

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10
Q

Cauda Equina Syndrome symptoms

A

Numbness, tingling, and motor weakness of the lower extremities

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11
Q

cause of cauda equina syndrome

A

Caused by a hyperbaric concentration of LA confined to a small area

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12
Q

back pain complications are related to

A

duration of blockade

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13
Q

back pain complications (2)

A

bruising
local inflammation

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14
Q

Autonomic blockade of bladder muscle and sphincter causes

A

urinary retention

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15
Q

level of block that can cause autonomic blockade of bladder

A

Block S2-S4 fibers

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16
Q

Because of the larger amount of LA administered, accidental ____ injection of LA during attempted epidural is dangerous

A

Subdural block

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17
Q

location of subdural block

A

between the dura & arachnoid mater

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18
Q

Onset similar to high spinal but slower

A

Subdural block

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19
Q

If this block is done by accident, there is a need for support of circulatory and respiratory function

A

Subdural block

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20
Q

Cephalgia that is occipital and radiates to the frontal or orbital regions

A

PDPH (spinal headache)

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21
Q

signs and symptoms of PDPH (8)

A

-Cephalgia: occipital & radiates frontal or orbital
-Cervical muscle spasms
-Hallmark – Postural Headache
-Worse when head is elevated
-N/V, photophobia, tinnitus, dizziness, cranial nerve palsies
-CSF loss > Production
-Reduces CSF pressure
-Traction on cranial nerves

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22
Q

Treatment of PDPH (3)

A

Will resolve within 5-7 days
Conservative therapy for 24 hours
Bed rest, hydration, analgesics, and IV caffeine
Epidural blood patch

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23
Q

Epidural blood patch steps

A

20 ml Autologous blood injected into epidural space
Blood will move cephalad direction so inject one interspace below
The blood will increase subarachnoid & epidural pressure; forms a clot sealing the dural tear

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24
Q

It is the reversible chemical blockade of neuronal transmission produced by the injection of a LA drug into the epidural space

A

Epidural Anesthesia

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25
Q

interrupts transmission of sensory, autonomic, and motor nerve fiber transmission in the anterior and posterior nerve roots

A

Epidural Anesthesia

26
Q

Advantages of epidural anesthesia (6)

A

Predictable
Pt can remain fully conscious
Analgesia can be extended into the post-operative period
Can provide a segmental blockade
Ideal for lower abdomen, pelvis/perineum, or lower extremities
Reduce risk of thrombosis

27
Q

Disadvantages of epidural anesthesia (4)

A

Time consuming to perform
May require 10-20 minutes to establish a level
Sympathetic blockade
Surgeon complains, “It takes too long.”

28
Q

indications for epidural (6)

A

An epidural can be employed as a component of a “balanced” regional/general anesthetic
Patient has a full stomach
Upper airway anomalies
Urological procedures
TURP
Lower limb surgery
Post-op pain relief
Obstetrics

29
Q

absolute contraindications for an epidural(11)

A

Patient refusal
No consent
Severe psychiatric disease
Aortic/mitral stenosis or asymmetric septal hypertrophy
Preexisting CNS disease
Herpetic infection
Increased ICP
Coagulopathy
Infection at the site
Septicemia or bacteremia
Allergy to LA

30
Q

Relative contraindications for an epidural (8)

A

HIV infections
Surgery of unknown duration
Untreated chronic HTN
Surgical procedures above the umbilicus
Obesity/ deformities of the spinal column
Chronic HA or backache
Multiple attempts
Minor blood clotting abnormalities
ASA or mini heparin doses
Check coags **
PLTs > 100,000

31
Q

informed consent steps (5)

A

Make sure you document that you have discussed the advantages & disadvantages of the anesthetic
Discuss risk
GETA is always be “plan B”
Document
Previous Epidural Complications

32
Q

pre-op meds considerations (4)

A

Pt should ideally be NPO; varies among practices
Do not over-sedate the patient
OB patients are not sedated
Consider midazolam, if not a parturient

33
Q

epidural can be done in what positions

A

sitting or lateral position

34
Q

safety considerations and setup before starting epidural (4)

A

Make sure the patient is on an adjustable bed
Make sure someone is there to stand in front to support the patient
-Not the spouse or family member
-Support person can sit in front of patient
Inform the patient of what to expect throughout the procedure
Make sure patient has a FUNCTIONING IV, monitors, O2, WORKING Suction (SOAPME)

35
Q

epidural landmarks

A

Same Landmarks for Spinal
L3-4 preferred location, straightest entry to epidural space

36
Q

equipment setup for epidural (6)

A

Set up equipment
STRICT Sterile technique (MASK) – Cath left in situ
Draw up the LA to be used for the skin wheal in a 3 ml plastic syringe
Get Loss-of-Resistance Syringe
Check integrity of epidural catheter
Test dose 1.5% w Epi on tray

37
Q

after cleansing the skin on pts back before epidural, what is the next step

A

Place fenestrated drape over the proposed site of injection
*Full or half drape
*Make sure you remove all chemicals from the injection site

38
Q

after identifying spinous process of L3-4, what is the next step

A

Raise a small intradermal skin wheal of LA with a 27-gauge needle

39
Q

epidural technique after skin wheel (7)

A

Recheck patient position
Grasp the Touhy needle with stylet, keep hand in contact with back
Bed Touhy Needle about 2.5 cm in back through skin wheal site
Remove Stylet and Attach LOR syringe
Advance slowly 0.5 cm tell resistance changes tapping lightly on LOR syringe – checking for LOR
LOR achieved, remove LOR, note LOR at skin level
Slowly insert Epidural Cath, goal to leave 4-5 cm of cath in Epidural space

40
Q

layers that you penetrate in midline approach to epidural (6)

A

Layers you will penetrate with needle:
Skin
Subcutaneous tissue and fat
Supraspinous ligament
Interspinous ligament
Ligamentum flavum
Epidural space

41
Q

how far is Ligamentum flavum from skin

A

Ligamentum flavum is normally 4 cm from the skin

42
Q

Markings along the shaft of the needle are at 1 cm increments

A

Epidural Needle

43
Q

9 cm from the tip of the needle to the proximal edge of the hub

A

Epidural Needle

44
Q

11 cm to the distal edge of the hub

A

Epidural Needle

45
Q

Toughy needle specifics (5)

A

Epidural needle
3.5 inches long
17-18 gauge
Has an inner stylet that prevents occluding the lumen with tissue
Rounded tip to prevent puncture of the dura and easier to thread the catheter

46
Q

skin to epidural space percentages in pts

A

4-6 cm in 60% of patients
2-4 cm in 25% of patients
6-8 cm in 10% of patients
>8 cm in 5% of patients
Will usually leave 3-5 cm of catheter in the epidural space

47
Q

Epidural Catheter markings in 1st through 4th marking

A

1st marking= 5 cm
Each marking after that is 1 cm
2nd double marking= 10 cm
Thick mark is 12 cm
When inserted to this point, you are at the tip of the needle in the epidural space
3rd triple mark= 15 cm
4th quad mark= 20 cm

48
Q

which end of epidural catheter has single hole and multiple ports

A

Single hole at the end vs multiple ports on its distal side
BLUE TIP – blunt end

49
Q

When advancing catheter, the patient may feel

A

transient paresthesias

50
Q

May not aspirate CSF in the catheter; may puncture ___ and you will get CSF passively from catheter

A

dura

51
Q

In some facilities, an ____ ____ is attached to the end of the catheter

A

antibacterial filter

52
Q

T/F
A negative aspiration ensures you are not in a vessel or the subarachnoid space

A

False
A negative aspiration DOES NOT ensure you are not in a vessel or the subarachnoid space

53
Q

3 ml of 1.5-2% Lidocaine with 1:200,000 epinephrine

A

Test dose

54
Q

Test dose will only produce _____ a block if injected into the CSF

A

T10

55
Q

Test Dose: Intravascular injection Symptoms

A

20% Increase in HR of 15 -20 bpm for 2-3 minutes
Systemic toxicity- numb tongue, dizziness, ringing in the ears

56
Q

Test Dose: Subarachnoid injection (3-5 minutes) symptoms

A

Immediate onset of sensory and motor block in the buttocks and lower extremities (T10 block)

57
Q

Subdural space is a potential space between

A

dura and arachnoid mater

58
Q

If test dose is negative, what is the next steps

A

Administer the pre-calculated volume in 3-5 ml increments every 60 seconds
Tape the catheter in place
Document the marking of the catheter at the skin

59
Q

T/F onset of epidural is faster than spinal

A

False

60
Q

what to evaluate after finishing epidural insertion

A

After repositioning, evaluate pt for 10 - 30 minutes
Evaluate BP, ECG, SpO2
BP Q1 min for 3-5 minutes, then Q2 - 3 min until block is set
Determine level Q2 - 3 min (alcohol sponge then sharp until level is set)
Check level every 30 - 45 minutes

61
Q

The distribution of the LA in the epidural space is dependent on the ____injected

A

volume

62
Q

Positioning (will/will not) aid in distribution of the LA, although anecdotal experience may suggest otherwise

A

will not

Pain Exam 2 (13 decks)

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