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Pain Exam 2 > Module 4: Part 4 (105-138) > Flashcards

Module 4: Part 4 (105-138) Flashcards

1
Q

⭐️
The primary objective of the epidural is to block the __

A

afferent fibers located in the dorsal roots

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2
Q

Autonomic Block

A

Blockade of fibers occurs quickly
Blockade is 2 dermatomes higher than sensory
Effects accentuated in the hypovolemic patient
A quick drop in BP may be an early sign that a “spinal” is setting up
Rapid decrease in BP  nausea or dizziness
Cardioaccelerator fibers (T1-4)

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3
Q

Temperature
& Light Touch

A

Unmyelinated C & myelinated A-delta fibers
Follows autonomic blockade
Alcohol sponge
Correlates with sensory loss
May report lower extremity feels warm

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4
Q

Initial Motor
Impairment & Touch

A

Myelinated A-beta & A-gamma
Onset of motor weakness and impaired perception of strong tactile stimulation
Follows loss of temperature and touch
Sharpened device, such as a popsicle stick

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5
Q

Profound Motor & Proprioception

A

Myelinated A-alpha fibers
Profound motor block develops with loss of proprioception
Feel “Phantom Limb”
Assess motor block
Dorsiflex feet (S1-S2)
Flex toes (L4-L5)
Raise knees (L2-3)
Lift shoulders of the bed (T6-T12)

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6
Q

⭐️
Desired Level of Block Will be determined by ______

A

-Drug volume
-Drug concentration
-level of the epidural catheter placement

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7
Q

Injection of 10-15 ml of LA into the epidural space in the lumbar area will produce a______

A

T 7-9 level in the average-sized adult patient

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8
Q

inadequate block

A

The concentration or volume of the drug may have been too weak or too low to penetrate the spinal nerves

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9
Q

If the block does not reach the desired level, you can give a top-off dose:

A

One-half of the initial volume can be re-injected
Wait 10-15 minutes before re-injection

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10
Q

_____ is the key factor in the height of the block

A

Volume

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11
Q

The guideline for dosing an epidural in adults:

Adjust the guideline for:

A

1–2 ml per segment to be blocked.

shorter patients (< 5 ft 2 in.)
taller patients (> 6 ft 2 in.).

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12
Q

T10 block from L3-4 injection: ____ ml of local anesthetic.

A

6-12

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13
Q

Ultimate LA target are the ____ and _____

A

spinal nerves & roots

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14
Q

The _____ serves as a barrier to diffusion of LA

A

dura

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15
Q

Most LA is absorbed into the ______, some will stay in the ______ and the rest will enter the spinal nerves and nerve roots

A

circulatory system; epidural space

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16
Q

The LA will spread horizontally and longitudinally once in the _____

A

epidural space

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17
Q

The spinal nerves in the epidural space are larger and covered by _____ and _____

A

arachnoid and dura matter

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18
Q

It takes _____ times the dose (mass) of LA to accomplish the same blockade as a spinal

A

6-8

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19
Q

What factors influence the level and duration of action?

A

Volume, dose, and concentration
vasoconstrictors
level and rate of injection

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20
Q

________ injected into the epidural space the greater vertical spread

A

Larger volume

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21
Q

Increase in dose will produce______

A

intense analgesia and prolonged duration of action

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22
Q

Increase in _______ will produce a faster onset and more intense block

A

concentration

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23
Q

Vasoconstrictors

A

Epinephrine 1:200,000
Marker for intravascular injection
(+/-) Prolong duration of action of LA

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24
Q

The closer the injection site is to the spinal nerve to be blocked, the _______

A

more rapid the onset of analgesia

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25
Q

Slowly titrate LA into the epidural space:

A

(3-5 ml increments)
Patients may complain of HA
Will not detect intravascular injection

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26
Q

Patient position does not really influence the level and duration of the block T/F

A

TRUE

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27
Q

Extremes of age does affect spread T/F

A

FALSE
does NOT

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28
Q

Older patients require _____ dose as younger patient

A

half the

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29
Q

Height does not affect the dose T/F

A

TRUE

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30
Q

There may be a larger _____ spread in the obese patient

A

cephalad

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31
Q

May need to ______ the dose in the obese patient

A

decrease

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32
Q

Pregnant pts need a _____ dose due to the engorgement of epidural veins

A

lower

33
Q

Pregnant pts need ______the dose of LA than the normal person

A

1/3

34
Q

During the anesthetic, do not allow _______

A

the level of blockade to recede

35
Q

If the pt has an adequate level but not a solid block

A

Re-dose with a top-off dose or 20% of the initial volume
Will increase the intensity of the block but not the height of the block

36
Q

If the level has regressed 1-2 dermatomes

A

Re-dose with ½ to 1/3 of the initial volume

37
Q

Clinical Effects of Epidurally Injected LAs

A
38
Q

Agents for Epidural Anesthesia

A
39
Q

Fentanyl Epidural Opiod

A

Highly lipid soluble
Profound sensory analgesia
Dose: 50-100 mcg (Higher doses result in significant respiratory depression)
Onset: 10-20 mins
PCA: (2mcg/ml concentration)
- Base 30mcg
- Bolus 40mcg
- With 10 minute lock-out
Pruritis: Benadryl, Nubain

40
Q

Morphine Epidural Opiod

A

Preservative-free
Dose: 2-5 mg
Onset: 45-60 mins
Provides analgesia for up to 20 hours
Highly polarized, not soluble in lipid elements
Slowly crosses dura and drifts freely in the CSF
6-8 hours after injection
Delayed respiratory depression
Pt must be monitored

41
Q

Blocking effects of the sympathetic nervous system

A

Sympathetic T1-L2
Cardiac accelerator fibers T1-4
Sympathetic blockade is 2-4 dermatones more cephalad than the sensory level

42
Q

CV Complications

A

Blocking effects of the sympathetic nervous system
Sympathetic T1-L2
Cardiac accelerator fibers T1-4
Sympathetic blockade is 2-4 dermatones more cephalad than the sensory level

Hypotension
Caused by peripheral vasodilation and a decrease in CO
Slower onset with an epidural 8-10 mins

43
Q

How should you treat the CV complications?

A

Auto transfuse - slight head-down position
Prophylactically administer fluid bolus - 500 ml to 1L
Ephedrine 5-10 mg IV bolus

44
Q

Epidural is a benefit for patients with _______

A

respiratory disease or difficult airway

45
Q

Respirations unaffected if the level of the block remains below ____

A

T4

46
Q

May make the patient anxious due to loss of sensory awareness of chest and abdominal motion and to feel a deep breath

A

intercostal muscle paralysis

47
Q

⭐️
_______ is an absolute contraindication to regional anesthesia

A

Coagulopathy

48
Q

Subarachnoid/Epidural hematoma

A

Neurological emergency and warrants immediate neurosurgical evaluation*

S/S- reappearance of motor or sensory impairment, post-op back pain, muscle spasm, and low extremity paresthesias
MRI or CT scan

49
Q

Subarachnoid/Epidural hematoma Treatment

A

Neuro-Surgical intervention
Emergency decompression/laminectomy

50
Q

Paresthesia is a complication of epidurals T/F

A

true

51
Q

Anterior Spinal Artery Syndrome

A

Sudden S/S
Flaccid paralysis with little or no sensory loss
Avoid hypotension

52
Q

Septic Meningitis/ Epidural Abscess

A

Not common
Use sterile technique (MASK)
Avoid an epidural in a patient with sepsis or bacteremia
S/S occur in 1-3 days
Back pain, tenderness, fever, sensory and motor disturbances and elevated WBC
Treatment
Surgical evacuation of abscess

53
Q

Aseptic Meningitis

A

Injection of wrong drug or solution

54
Q

Cranial Nerve Palsy: what is it? what causes it?

A

Ischemia of the 6th cranial nerve (Abducens)
Caused by prolonged hypotension or loss of CSF from a dural puncture
Strabismus

55
Q

Cauda Equina Syndrome

A

Appearance of a sacral distribution radiculopathy
characterized by sensory and motor deficits
Numbness, tingling and motor weakness in the lower extremities

56
Q

Be careful with positioning d/t….

A

Isolated Neuropathy, Focal Pain, Paralysis

57
Q

Association between the use of Morphine and reactivation of ____

A

HSV1

58
Q

If unable to remove catheter…..

A

Do not be forceful when removing the catheter
Have patient flex their back and try again
X-ray may confirm a kink

59
Q

for retained catheter you should document ____

A

blue tip intact

60
Q

catheter failure can occur from:

A

Improper placement, dislodgement, and threading

61
Q

muscular backache is common after epidural T/F

A

TRUE

62
Q

How to tx muscular backache after epidural?

A

Analgesics, heat and bedrest

63
Q

_____ usually is hypotension (OB 1st sign)

A

Nausea
first complaint with the onset of hypotension

64
Q

Urinary retention with epidurals

A

autonomic blockade of bladder muscle and sphincter innervation
R/O other causes of urinary retention before blaming the epidural
Incisional pain, trauma to bladder, BPH, prolonged hypotension, IV fluids, and epidural opioids
OB why nurses put a Foley

65
Q

Visceral pain during abdominal surgery is d/t

A

Due to manipulation of the viscera
Unblocked vagal nerve

66
Q

Subdural block is Similar to a______ but much slower in onset

A

high spinal

67
Q

Total/High Spinal: what is it? what are the s/s?

A

Dural puncture
Symptoms are rapid and dramatic
Sudden and extensive motor block, inability to talk, progresses to apnea, unconsciousness, hypotension and dilated pupils

68
Q

Total/High Spinal Treatment

A

Controlled ventilation, ETT, 100% O2, and cardiovascular support

69
Q

PDPH =

A

Spinal headache

70
Q

What is a caudal?

A

Technically, an epidural, which simply uses a “caudal” approach.
You should utilize sterile technique.

71
Q

What is the caudal dosing for peds?

A

0.5 to 1.0 mL/kg of 0.125% - 0.25% bupivacaine(orropivacaine) with or withoutepinephrine
Opioids (eg, 30–40 mcg/kg ofmorphine).
Clonidine
Analgesic block may extend for hours into the postoperative period.

72
Q

Adults undergoing anorectal procedures

A

dense sacral sensory blockade
limited cephalad spread.
Prone position for injection
Dose:15 to 20 mL of 1.5% - 2.0%lidocaine, with or withoutepinephrine
Fentanyl, 50 to 100 mcg,

73
Q

why should caudals be avoided in pts undergoing anorectal procedures?

A

Avoided in patients with pilonidal cysts because the needle may pass through the cyst track and can potentially introduce bacteria into the caudal epidural space.

74
Q

Combined Spinal-Epidural (CSE) Advantages

A

Provides a rapid reliable analgesia/ anesthesia via the spinal technique with the flexibility to extend or enhance analgesia/anesthesia via the epidural catheter
Can be used for post-op pain control

75
Q

Combined Spinal-Epidural (CSE) disadvantages

A

More complex technique
Requires more time
Risk of subdural or subarachnoid catheter placement
Unable to test epidural catheter

76
Q

CSE - Technique

A

sitting or lateral position
ID epidural space (L2-3) with a 17-18 g Touhy needle (loss of resistance technique)
Pass a 5-inch, 24 - 27 gauge pencil-point needle through the Touhy needle until it enters SAB space
Free flow of CSF, attach syringe, and inject desired LA, withdraw the spinal needle
Inject 2 - 3 cc of sterile saline into the epidural needle to dilate the epidural space
Insert epidural catheter and secure with tape
No test dose

77
Q

No test dose is given for CSE technique T/F
Why is this?

A

TRUE
as inadvertent subarachnoid catheter placement will not be discernable

78
Q

When the spinal begins to wear off in a combined spinal-epidural _____

A

test dose the epidural and dose it or start infusion

79
Q
A

Pain Exam 2 (13 decks)

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