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Principles > Neuraxial > Flashcards

Neuraxial Flashcards

1
Q

cardiac accelerator nerves

A

T1-T4

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2
Q

Phrenic nerves

A

C345

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3
Q

Spinal anesthesia definition

A

injection of LA into Subarachnoid space

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4
Q

Dose of prop for induction

A

1.5 - 2.5 mg/kg

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5
Q

onset spinal vs epidural

A

spinal = rapid
epidural = slow

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6
Q

spread spinal vs epidural

A

spinal; higher than expected; may extend extracranially

epidural; as expected can be controlled with volume of LA

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7
Q

nature of block spinal vs epidural

A

spinal; dense

epidural; segmental

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8
Q

motor block spinal vs epidural

A

spinal; dense

epidural; minimal

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9
Q

hypotension spinal vs epidural

A

spinal; likely
epidural; less than spinal

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10
Q

walking epidural

A

Ropivicain; not very dense, segmental

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11
Q

onset epidural vs spinal

A

spinal; 5 min
epidural; 10-15 min

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12
Q

duration epidural vs spinal

A

spinal; limited and fixed

epidural; unlimited

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13
Q

placement level for spinal

A

L3-L4, L4-L5, L5-S1

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14
Q

Dosage of LA for spinal vs epidural

A

spinal; dose - based (mg)

epidural; volume- based

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15
Q

Largest dose that can be given for spinal

A

3 ml

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16
Q

LA toxicity

A

IV admin of LA ( bupivacaine = most sensitive to the heart)

high risk with epidurals because of veins and volume given

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17
Q

Gravity influence on spinal

A

spinal = big effect
epidural; no gravity effect

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18
Q

Coag levels that are absolute contraindications for neuraxial

A

INR > 1.5 (ASRA), some texts > 1.2
Platelets < 100,000; 50,000 Miller; consider trends*
Nagelhout x 2 (PT, aPTT, bleeding time)
Known coagulation disorder or taking anticoagulants

increase risk of hematoma

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19
Q

Valvular disease absolute contraindications for neuraxial

A

AS < 1.0 cm2 or MS < 1.0 cm2

IHSS (Idiopathic hypertrophic subaortic stenosis)

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20
Q

relative contraindications for neuraxial anesthesia

A

Deformities of spinal column
Preexisting disease of the spinal cord
Chronic headache/backache
Inability to perform SAB after 3 attempts

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21
Q

Total number of vertebra and how much for each area

A

33 total
7 cervical
12 thoracic
5 lumbar
5 sacral
4 coccyx

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22
Q

Total spinal nerves and number/ location

A

31 nerves pairs

8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccyx

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23
Q

Distance from skin to ligamentum flavum

A

4 cm in 50% of pts and 4-6 cm in 80% of pts

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24
Q

The spinal cord ends at…

A

30% end at T12
60% end in L1
10% end in L3

board answer; L1

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25
Q

Spinal cord ends at….for peds

A

L3

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26
Q

High and low points while supine

A

high = C3 and L3
Low = T6 and S2

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27
Q

End of dural sac

A

S2

end of subarachnoid space

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28
Q

Orientation of lumbar spinous processes

A

straight/ horizontal

needle = straight

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29
Q

Orientation of Thoracic spinous process

A

caudally/ oblique

needle = point cephalad / up.

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30
Q

dura matter start and end points

A

Starts at the foramen magnum, ends in S2 (fuses with filum terminale)

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31
Q

Spinal cord blood vessels

A

one anterior spinal artery - vertebral artery
2 posterior spinal arteries- inferior cerebellar artery
segmental spinal arteries - intercostal and lumbar arteries

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32
Q

CSF volume

A

100 to 160 ml
20 -25 ml/hr
entire csf volume replaced q6h

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33
Q

dermatome looks at…

A

sensory levels

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34
Q

Umbilicus dermatome

A

T10

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35
Q

Nipple dermatome

A

T4 (csection height)

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36
Q

Thumb dermatome

A

C6

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37
Q

Hand dermatome

A

C6 - thumb
C7- pointer and middle
C8- ring and pinky

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38
Q

Tuffier’s (Intercristal) Line

A

Line between L3 and L4 interspace and is at or above the level or the superior iliac crest

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39
Q

LA for spinal spreads to the…..

A

cauda equina and spreads to the nerve roots

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40
Q

Even with epi, whats the longest a spinal will last?

A

150 min = 2.5 hr

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41
Q

Spinal nerves in subarachnoid space is covered by thin…..

A

pia layer

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42
Q

factors that influence the decision on which LA to use for Neuraxial anesthesia

A

Type of sx
Length of sx
Surgeon

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43
Q

shortest acting LA

A

lidocaine

good for outpt sx

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44
Q

LA structure and difference between Ester and amide

A

aromatic ring, intermediate link (ester or amide), tertiary amine

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45
Q

opioid adjuncts does what to a blockade

A

Make “denser”
It intensifies the blockade/ sensation

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46
Q

Alpha 2 agonist adjunct with neuraxial blockade

A

Improves Density, duration, and analgesia

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47
Q

Vasopressor effect as an adjunct with neuraxial blocks

A

Extends duration only; No effect on density or analgesia
Epinephrine (good IV marker epidurals: initial bolusing)

Causes vasoconstriction

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48
Q

Epidural morphine dose

A

3-5 mg (24 hr duration)

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49
Q

epidural fent dose

A

50 -100 mcg

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50
Q

sufent epidural dose

A

10-25 mcg

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51
Q

morphine spinal dose

A

100-400 mcg (24 hrs)

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52
Q

fent spinal dose

A

10-25 mcg

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53
Q

sufent spinal dose

A

2.5-10 mcg

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54
Q

opioids spread…

A

cephalad

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55
Q

hydrophilic and lipophilic opioids

A

Hydrophilic drugs (morphine)

lipophilic drugs (Fentanyl/Sufentanil)

Hydrophilic drugs slow cephalad spread than lipophilic drugs

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56
Q

side effect of sufent

A

muscle rigidity

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57
Q

Opioid to use in out pt setting

A

sufent

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58
Q

incidence of pruritis with opioid use

A

30-100%

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59
Q

Treatment for Pruritis

A

benedryl 25-50 mg IV
Nalxone 0.1 mg IV - best
Buprenex (mixed agonist/antagonist)

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60
Q

Prophylaxis for Pruritis

A

minimize the dose of morphine < 300 mcg (100 mcg)
Ondansetron 4 mg IV
Nubain 2.5-5 mg IV (partial agonist/antagonist)

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61
Q

treatment for nausea

A

ondansetron (8mg)
Naloxone (0.1 mg)
Phenergan (12.5-25 mg IM)

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62
Q

Epi wash dose

A

0.2-0.3 mg

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63
Q

Spinal with epi is most profound increase in effect with what med?

A

Tetracaine

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64
Q

Epi with epidural has the greatest effect in the duration of anesthesia in what meds?

A

lidocaine, mepivacaine and 2 chloroprocaine

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65
Q

Where is clonidines site of action when given spinal or epidural

A

substantia gelatinosa

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66
Q

Neo wash dose

A

2- 5 mcg

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67
Q

tetracaine with epi/ neo effect

A

profound increase in effect

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68
Q

Spinal dose for Dexmedetomidine

A

3 mcg

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69
Q

clonidine dose for spinal

A

15-45 mcg

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70
Q

Factors affecting uptake of LA into neural space

A

concentration of LA in CSF
Surface are of the nerual tissue
lipid content of the nerve
Blood flow of the nerve

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71
Q

A alpha fiber

A

propioception and motor
large
heavy mylinated

last to get blocked

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72
Q

A beta fibers

A

touch, pressure
heavily mylinated

intermediate block onset

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73
Q

A gamma fibers

A

muscle tone

small

heavily mylinated

intermediate block onset

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74
Q

A delta fibers

A

pain, cold temperature, touch
small

heavily mylinated

intermediate block onset

75
Q

B fibers

A

preganglionic autonomic vasomotor

pretty small

lightly myelinated

early block onset

76
Q

C sympathetic fibers

A

Post ganglionic vasomotor

really small

no myelin

early block onset

77
Q

C Dorsal root fibers

A

pain, warm and cold temp, touch

really small

no myelin

early block onset

78
Q

Progression to differential block

A

B fibers
C fibers
A delta
A gamma
A beta
A alpha

79
Q

Progression from differential block

A

A alpha
A beta
A gamma
A delta
C fibers
B fibers

80
Q

Sympathetic level is ….

A

2-6 levels higher than sensory level - B fibers

81
Q

sensory level is…..

A

2 levels higher than motor block

82
Q

which block is segmental?

A

epidural

83
Q

Elimination of LA from SAB…

A

all LAs are eliminated by reuptake

vasular reabsorption

84
Q

What drugs have a high affinity for epidural fat?

A

lipophilic drugs = slow reuptake because of the fat affinity

85
Q

Most important factors affecting LA distribution and block height for spinal

A

Dose
Baracity
CSF volume
Advanced age
pregnancy
Pt position
Epidural injection post spinal (EVE- epidural volume extension)

86
Q

Water specific gravity

A

1.000

87
Q

CSF specific gravity

A

1.00033 (pregnant)
1.00067 (men)

88
Q

what is the most reliable determinant of LA spread for spinal

A

dose

89
Q

what LA are primarily influenced by baracity

A

hyperbaric LA

90
Q

How to make hypobaric solution

A

water 3x vol SAB LA

91
Q

baracity for upper abd surgeries

A

hyperbaric

c-section

92
Q

Baracity for hemerrhoidectomy

A

hypobaric

pt is prone

93
Q

Dose of hyperbaric SAB in nonOB for T4

A

2ml

94
Q

Dose of hyperbaric SAB in nonOB for T10

A

1.5 ml

95
Q

Dose of hyperbaric SAB in nonOB for Sacral level

A

1 mL

96
Q

swirl is present in….

A

hyperbaric solution

97
Q

ED 50 for bupivacaine

A

4.7 mg - 9.8 mg

98
Q

ED 95 for bupivacaine

A

8-15 mg

99
Q

balanced anesthesia

A

muscle relaxation
analgesia
amnesia
hemodynamic stability

100
Q

CSF volume

A

100-160 ml

101
Q

small CSF volume correlates with….

A

extensive spread of LA in intrathecal space= more effect

102
Q

Bain bridge reflex

A

reflex thats mediated via sensors from the ns that feedback onto the nodal tissue through reductions in vagal tone
Involves some sensory neurons and when they see increase stretch they feed back to the vagal nerves and tell the vagal nerves to slow firing = increase hr.
Amount of hr increasing- full initiation of the bainbridge reflex by itself with nothing else = increase hr by 50%.

103
Q

LA on the heart

A

inhibition of bainbridge reflex,

block T1-T4

Bezold Jarisch reflex

block T1-L3/4 (SNS output)

104
Q

The Bezold-Jarisch reflex

A

Seratonin -> chemo and mechano receptors on LV -> inc parasympathetic, decreased sympathetic output

105
Q

zofran on hypotension

A

inhibits Bezold-Jarisch reflex

106
Q

Fluids to give for preloading/coloading

A

isotonic; NS, LR, Osmolyte A

107
Q

GI sympathetic outflow originates

A

T6-L1

108
Q

what respiratory capacity changes with SAB

A

vital capacity decreases because of loss of abd muscle contribution to forced expiration

109
Q

What sympathetic blockade affects bladder control

A

T10
urinary sphincter tone relaxed

110
Q

Why is there shivering with SAB

A

Blockade impairs central thermoregulation center of the brain

vasodilation -> redistribution of blood flow and heat to periphery

111
Q

Prevention of shivering

A

ondansetron
bare hugger

112
Q

High thoracic blockade can result in the blockade of respiratory ….

A

accessory muscle (intercostal and abdominal muslces)

113
Q

Ester metabolite

A

paba =allergies

114
Q

3 common reasons for neuraxial failure

A

wrong dose, wrong location, wrong position

115
Q

Saddle block

A

S2 -S5

116
Q

Interlipid dose

A

20%; 1.5 ml/kg (bolus)
gtt 0.25ml/kg

117
Q

C section dermatome level

A

T4

118
Q

quincke type of spinal needle

A

cutting

119
Q

sprotte type of spinal needle

A

non cutting

120
Q

Whitacre type of spinal needle

A

non cutting

121
Q

Another name for non cutting needles

A

pencil-point

122
Q

Lateral position is good for neuraxial procedures for what surgeries?

A

Hip surgeries (can use hypobaric solution)

123
Q

Benefit of non-cutting spinal needle

A

feel more of pop when through Dura
reduced incidence of post-dural puncture HA

124
Q

Layers transverse during median approach

A

skin
subq fat
supraspinous ligament
interspinous ligament
ligamentum flavum
dura mater
subdural space
arachnoid mater
subarachnoid space

125
Q

Layers transversed during paramedian approach

A

skin
subq fat
ligamentum flavum
dura mater
subdural space
arachnoid mater
subarachnoid space

126
Q

succinylcholine brand name

A

anectine

127
Q

bupivicaine brand name

A

marcaine

128
Q

needle hits bone early in spinal

A

hitting spinous process
point the needle caudad

129
Q

needle hits bone late in spinal

A

hitting lamina
point the needle cephalad

130
Q

spinal anesthesia needle size

A

25 guage

131
Q

epidural needle size

A

18-19 guarge

132
Q

Low csf from post-dural puncture headache leads to

A

cranial nerve traction

traction causes
diplopia (CN VI)
tinnitus (CNVIII)

133
Q

Name for end of the spinal cord

A

conus medularis

134
Q

what relieves PDPHA

A

supine
nsaids and narcotics (fent)
(caffeine)
blood patch

135
Q

amount of blood used for blood patch

A

20 mL

136
Q

transient neurologic symtoms

A

develops immediately
resolves within a week in 90% of cases
11.9% incidence rate (5% lido)
severe radicular back pain
positional correlation (hip or knee flexion) -> stretched spinal roots

137
Q

cauda equina sydrome

A

permanant-> can lead to paraplegia
pooling of lido (5%) in cauda equina = dense blockade

138
Q

Cauda equina sydrome s/s

A

bowel/bladder dysfucntion
paraplegia (late sign)
back pain
saddle anesthesia
sexual dysfunction

139
Q

cauda equina location

A

L1 -S4 + coccygeal nerves

140
Q

causa equina sydrome treatment

A

if compression is a factor, then immediate laminectomy > 6hrs

141
Q

horners syndrome

A

ptosis
anyhydrosis
miosis

high sympathetic spred

142
Q

trigeminal nerve branches

A

CN5
V1 = opthalmic
V2 = Maxillary
V3 = Mandibular

143
Q

Trigeminal nerve palsy

A

ganglion bathed in CSF

144
Q

Nerves to block for awake intubation

A

Glosspharyngeal - 9- suck on tongue depressor and 4x4
Vagus - 10-
Trigeminal nerve - 5 (V2) - cotton q tip in nose

145
Q

Vagus nerve branches

A

recurrent layrngeal nerve
superior laryngeal branch - internal and external branches

146
Q

Superior laryngeal nerve

A

internal = sensory innervation for larynx
external = motor function for cricothyroid muscle

147
Q

Inflammation of meninges

A

Arachnoiditis

Leads to extensive sclerosis of arachnoid membranes and constriction of vascular supply

148
Q

Symptom of numbness/weakness confusing by the use of local anesthetics; Pain is a major symptom

A

Epidural/Spinal Hematoma

Cord ischemia reversible if laminectomy is performed in < 8 hours

149
Q

Can maintain the ability to ambulate and void if epidural is placed

A

above T10

150
Q

Epidural space extends…

A

Extends from the base of the skull to the sacral hiatus

151
Q

Epidural space is filled with….

A

filled with the fat, areolar tissue, lymphatics, veins, nerve roots and blood vessels

152
Q

onset of LA is based on….

A

closer PKA is to physiologic Ph = faster onset

exception to the rule = 2-chloroprocaine 3%

153
Q

Uptake of LA based on regional anesthetic technique

A

IV
Tracheal
Intercostal
Caudal
Paracervical
Epidural
Brachial
Sciatic
SubQ

154
Q

Epidural injection diffuses…

A

diffuses through the dural sheath of spinal nerves, roots, rootlets, and CSF where nerve transmission is altered

155
Q

Determinants of block spread for epidural

A

Volume and dose of LA

156
Q

increased epidural pressure can _______ spread in epidurals

A

increase spread

pregnancy, coughing,Valsalva, obesity

157
Q

Lumbar epidural injection produces a preferential ______spread

A

cephalad

due to the narrowing of the epidural space at the lumbosacral junction
The larger diameter of the L5-S1 nerve roots may delay the onset or result in patchy anesthesia.

158
Q

Thoracic epidural injection produces _____ spread of anesthetic solution

A

symmetrical

A reduced volume of local anesthetic solution should be used at this level because of the potential for higher block and resultant hemodynamic instability

159
Q

Caudal injection predominantly results in…..

A

sacral and low lumbar anesthesia

160
Q

what determines epidural dermatome spread?

A

volume

A larger volume will block a greater number of segments

161
Q

incremental dosage = _______

A

5 mL at a time

162
Q

Epinephrine increases the ________ of useful epidural anesthesia with all the agents

A

duration

Greatest with lidocaine, mepivacaine, and 2-chloroprocaine

163
Q

Dose of bicarb and what it does to the LA

A

Alkalinization - Adding NaHCO3 (1 mEq/10 mL of local anesthetic)
Increases the pH of LA
Increase the concentration of nonionized free base

164
Q

2- chloroprocaine can only be used in….

A

epidural

metabolized by plasma cholinesterase

165
Q

medication with greatest motor function depression for epidural

A

Lidocaine

ropivacaine is the least

166
Q

Fastest to slowest onset and shortest to longest duration

A

2 - chloroprocaine 3%
lidocaine 2%
mepivacaine 2%
ropivicaine 0.7%
bupivacaine 0.5%

167
Q

Test dose dose

A

3 ml of lidocaine 1.5% with epidural (1:200,000)

168
Q

Epidural needle with the most curvature (30 degrees) blunt tip is less likely to puncture subarachnoid space

A

Tuohy

169
Q

Epidural needle with 15 degree curve

A

Hustead

170
Q

Medication that decreases efficacy of subsequent epidural opioids?

A

2 chloroprocaine

171
Q

Epidural needle preferred when catheter placement is difficult or the angel is steep (thoracic epidural)

A

Crawford

172
Q

Epidural needle markings

A

Each mark = 1 cm
9 cm length - hub
10 cm - window
12.5 cm = hub

173
Q

Epidural cath placed _____ within the epidural space

A

placed 3-5 cm

174
Q

Epidural catheter markings

A

thicker marking = 11 cm
small marking = 5 cm increments

175
Q

Distance from Skin to Epidural Space

A

Average adult is 4-6 cm (80% of patients)

176
Q

Reason for test dose

A

Identify unintentional IV or SAB

177
Q

A change of ______ or greater in heart rate after the test dose indicates a probable intravascular injection

A

20%

178
Q

S/S of IV injection of LA = Positive test dose

A

Tinnitus
Metallic taste
Circumoral numbness

179
Q

The intrathecal injection of lidocaine will produce a significant______ block consistent with_______ anesthesia in _____ mins

A

The intrathecal injection of lidocaine will produce a significant motor block consistent with spinal anesthesia in 3 mins

A dense motor block within 5 min of a test dose should prompt a suspicion of a spinal block

180
Q

Spinal nerves in subarachnoid space is covered by thin…..

A

pia layer

181
Q

Saddle block

A

S2 -S5

182
Q

Spinal hematoma treatment

A

cord ischemia is reversible if laminectomy is performed in 8 hrs.

183
Q

Major symptom of spinal hematoma

A

pain

184
Q

res ipsa loquitur

A

the principle that the occurrence of an accident implies negligence.

Principles (34 decks)

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