Neuraxial Anesthesia Flashcards

1
Q

what are the different names for a spinal

A

subarachnoid
intrathecal

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2
Q

How many of each kind of vertebrae are there?

A

7 cervical
12 thoracic
5 lumbar
5 sacral
4 coccygeal

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3
Q

what structure is different on the 7th cervical vertebrae when compared to the others

A

7th does not have a bifid spinous process

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4
Q

what direction do thoracic vertebrae spinous processes point

A

downward

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5
Q

what direction do spinous process point on lumbar verebrae

A

straight out

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6
Q

where do lumbar vertebrae connect

A

facet joint
the meeting of the inferior and superior articular processes

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7
Q

what does redicular mean

A

nerve root

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8
Q

what two ligaments bind the vertebrae

A

anterior longitudinal
posterior longitudinal

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9
Q

what are the three layers covering the spinal cord

A

pia mater
arachnoid mater
dura mater

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10
Q

Where is the conus medullaris?

A

L1-L2

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11
Q

What is the conus medullaris?

A

end of spinal cord

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12
Q

where do we not do epidurals and spinals above

A

conus medularis/ L1-L2

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13
Q

how many cervicle nerve roots are there

A

16 total (8 pairs)

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14
Q

how many total nerve roots are there

A

31 pairs

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15
Q

anterior roots are __________ nerves

A

motor

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16
Q

posterior roots are __________ nerves

A

sensory

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17
Q

what structure differentiatres anterior and posterior nerve roots

A

posterior root ganglion

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18
Q

What is the filum terminale?

A

A pia mater extension that tethers the tip of the conus medullaris to the end of the sacrum, around S2

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19
Q

what is the filum terminale made from

A

pia mater

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20
Q

what are the layers you go through for an epidural

A

skin
sub q tissue
muscle
supraspinous ligament
interspinious ligament
ligamentum flavum
epidural space

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21
Q

what are the layers you go through for a spinal

A

skin
sub q tissue
muscle
supraspinous ligament
interspinious ligament
ligamentum flavum
epidural space
dura mater
subdural space
arachnoid mater
subarachnoid space

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22
Q

where is CSF found

A

subarachnoid space

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23
Q

what is the total volume of CSF

A

120-150 ccs

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24
Q

how much CSF is in the spinal subarachnoid space

A

20-30 ccs

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25
Q

how much CSF is produced in a day

A

500ccs

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26
Q

what makes CSF

A

choroid plexus

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27
Q

how does lasix affect CSF production

A

decrease production

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28
Q

what is the specific gravity of CSF

A

1.002-1.009

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29
Q

what is the blood supply for the posterior spinal cord

A

posterior spinal arteries
paired arteries fed by many radicular arteries

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30
Q

what is the blood supply for the anterior spinal cord

A

anterior spinal artery
single artery, midline that has many circumfrential vessels

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31
Q

what can happen when anterior spinal arteryis damaged

A

bilateral lower extremity motor loss 2/2 damage to this artery during aorta sx or by a stray epidural needle

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32
Q

what is the the name of the anterior spinal artery

A

artery of adamkiewicz

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33
Q

where is the artery of adamkiewicz located on

A

78% on the left side of vertebral column
between T8-L3

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34
Q

what is a high take off artery of adamkiewicz

A

artery comes through at T5

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35
Q

what are epidural veins called

A

Batson’s Plexus

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36
Q

how do you make sure you are not in the epidural vein

A

test dose

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37
Q

the top of the scapula correlates with what vertebrae

A

T3

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38
Q

the botton of the scapula correlates with what vertebrae

A

T7 or T7-T8 interface
thoracic epidural insertion

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39
Q

what is Tuffiers line

A

A line drawn between the highest points of both iliac crests will yield either the body of L4 or the L4-L5 interspace.

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40
Q

What does S2 correlate with?

A

the caudal limit of the dural sac in most adults

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41
Q

what is the most prominent spinous process in the cervicle area

A

C7

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42
Q

how do you find the sacral haitus

A

felt as a depression just above or between the gluteal cleft and above the coccyx

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43
Q

where is conus medullaris located

A

L1

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44
Q

where is Tuffiers line located

A

L4-L5 interface, L4 body, correlates with the iliac crest

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45
Q

where does the Dural sac end

A

S2
correlates with superior iliac spine

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46
Q

where is the sacral hiatus and sacrococcygeal ligament

A

S5

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47
Q

how does obesity affect epidural space

A

increased epidural fat

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48
Q

how does advanced age affect epidural space

A

decreased epidural fat, decrease dose

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49
Q

what are the borders of the ligamentum flavum

A

ligamentum magna to sacral hiatus

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50
Q

what is the cranial border of the epidural space

A

foramen magnum

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51
Q

what is the caudal border of the epidural space

A

sacrococcygeal ligament

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52
Q

what is the anterior border of the epidural space

A

posterior longitudinal ligament

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53
Q

what is the lateral border of the epidural space

A

vertebral pedicles

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54
Q

what is the posterior border of the epidural space

A

ligamentum flavum
vertebral lamina

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55
Q

what causes a patchy block

A

epidural space is discontinous
lacks uniformity

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56
Q

what can cause an epidural to have a one sided block

A

possible midline band in epidural space called plica mediana dorsalis

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57
Q

what is the most narrow portion of the epidural space

A

anterior

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58
Q

what is the widest/deepest part of the epidural space

A

posterior space in midlumbar region

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59
Q

T/F there is free fluid in the epidural space

A

F, if there is free fluid you are in subarachnoid space

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60
Q

what is the pressure of the epidural space

A

subatmospheric (negative)

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61
Q

once you inject fluid in epidural space where does it go

A

superior- foramen magnum
inferior- sacral haitus, caudal canal
lateral- intervetebral foramen to spinal nerve roots AND to dural cuff into CSF
anterior-to anterior epidural space

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62
Q

what is the area that spinal nerve roots pass through

A

intervertebral foramen

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63
Q

what is the sight of action of epidurals

A

spinal nerve roots

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64
Q

what are the advantages of an epidural

A

delay in response
gradual onset
fewer episodes of hypotension
more time to manage

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65
Q

how long does a spinal last

A

3 hrs

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66
Q

what kind of neuraxial block do you use for a procedure lasting 4-6 hours

A

epidural

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67
Q

what is sympathectomy

A

decrease SNS decreased HR, BP and vasodilation

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68
Q

which has a greater control of the level of sensory and motor blockade (spinal or epidural)

A

epidural

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69
Q

an increase in LA concentration causes an increase in (motor/sensory) block

A

motor

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70
Q

a decrease in LA concentration and increase in volume causes an increase in (motor/sensory) block

A

sensory

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71
Q

T/F epidurals are good for postoperative pain relief

A

true

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72
Q

do epidurals or spinal have a lower incidence of systemic hypotension

A

epidurals

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73
Q

what are disadvantages of epidurals

A

delay response
longer procedure
patchy block
greater tissue trauma
greater risk for local anesthetic toxicity
paralysis
epidural hematoma
spinal HA

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74
Q

what is the name of the needle used in epidurals

A

Touhy needle

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75
Q

what size is a Touhy needle

A

16-18 g

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76
Q

what is the shape of a Touhy needle

A

curved tip

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77
Q

what is the angle of the Touhy needle

A

30*

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78
Q

what is the angle of the Hustead needle

A

15 degrees

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79
Q

what is the angle of the crawford needle

A

0 degrees

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80
Q

what are indications for epidurals

A

surgery
post op pain control
labor and delivery
chronic pain
sympathetic blockade

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81
Q

what are contra indications of epidural

A

increased ICP
Coagulopathy
aortic stenosis
infection at insertion site
watch for tattoo

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82
Q

what is the platelet cutoff for epidural

A

80,000-100,000

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83
Q

why are epidurals contraindicated in aortic stenosis

A

decreased SNS, decreases SVR, code

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84
Q

when do you use an epidural for a single shot injection

A

steroid
post op pain

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85
Q

what layers do you pass through with midline epidural

A

skin and SubQ
supraspinous ligament
interspinous ligament
ligamentum flavum
epidural space

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86
Q

how does the supraspinous ligament feel

A

small pop

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87
Q

how does the interspinous ligament feel

A

gravel

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88
Q

how does the ligamentum flavum feel

A

wall

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89
Q

how do you place needle in Paramediaum approach

A

needle is inserted 1.5-2 cm lateral to spinous process
at transverse process below selected level
angle upwards

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90
Q

what layers do you go through in paramedian approach

A

skin and SubQ
ligamentum flavum
epidural space

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91
Q

what is the first ligament you hit in paramedian approach

A

ligamentum flavum

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92
Q

what nerve root are you at if you get thumb (first digit) numbness

A

C6

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93
Q

what nerve root are you at if you get 2nd and 3rd digit numbness

A

C7

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94
Q

what nerve root are you at if you get numbness in the 4th and 5th digits

A

C8

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95
Q

what nerve root are you at if you get numbness at the nipple line

A

T4

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96
Q

what nerve root are you at if you get numbness at the xiphoid process

A

T6

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97
Q

what nerve root are you at if you get numbness at the umbilicus

A

T10

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98
Q

what nerve root are you at if you get numbness at the pubic symphysis

A

T12

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99
Q

what nerve root are you at if you get numbness at the anterior knee

A

L4

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100
Q

what dermatome do you want to be at for upper abdominal surgery/C section

A

T4-T5 (nipple)

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101
Q

what dermatome do you have to be at for intestinal sx, gynecologic pelvic exam, ureter and pelvic surgery

A

T6-T8 (xiphoid)

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102
Q

what dermatome do you have to be at for TURP, vaginal delivery, hip surgery

A

T10 (umbilicus)

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103
Q

what dermatome do you have to be at for thigh surgery, lower limb amputations

A

L1

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104
Q

what dermatome do you want to be at for foot surgery

A

L2-L3

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105
Q

what dermatome do you want to be at for perineal surgery, hemorrhoidectomy and dilation

A

S2-S5 (saddle block, sit up for spinal to settle)

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106
Q

where is the cardioaccelerator blockade

A

T1-T4

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107
Q

what nerve roots control the diphragm

A

C3, C4, C5

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108
Q

what happens with a block at level t1-t4

A

cardioaccelerator blockade
(central sympathetic blockade)
venous pooling
Bradycardia

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109
Q

what nerve roots make up the peripheral sympathetic blockade?

A

T1-L2

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110
Q

what happens in the peripheral sympathetic blockade

A

venous pooling
CO maintained by an increase in HR and vasoconstriction above the level of the block

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111
Q

how do you determine if you are in the epidural space

A

tough insertion through ligamentum flavum
loss of resistance entering epidural space
hanging drop
test dose

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112
Q

what can happen if you put too much air in epidural space

A

pneumocephalus

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113
Q

the hanging drop helps you know you are in the

A

epidural space

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114
Q

if you hit a bone early when inserting the needle what did you hit

A

spinous process

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115
Q

if you hit a bone early how do you adjust your needle

A

up or down

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116
Q

if you hit a bone deep what did you hit

A

transverse process

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117
Q

if you hit a bone deep how do you adjust your needle

A

left or right

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118
Q

how far should epidural catheter be inside epidural space

A

3-5 cm into epidural space

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119
Q

if your needle is in 8 cm in epidural space, how far should your catheter be in

A

11-13

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120
Q

what can happen if epidural catheter is too deep in epidural space

A

increase chance of hitting vessel, pull catheter back

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121
Q

what do you inject for a test dose

A

3 ml of 1.5% lidocaine (45 mg)
5 mcg/ml of epi (15 mcg)

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122
Q

what happens with test dose if epidural catheter is in subQ/tissue

A

nothing will happen

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123
Q

what will happen with test dose if epidural catheter is in epidural space

A

nothing will happen

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124
Q

what will happen with test dose if epidural catheter is in subarachnoid space

A

spinal anesthesia will occur within 3 minutes

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125
Q

you do a test dose to confirm your epidrual and your patient has numbness in sacrum and legs, where is your epidural

A

subarachnoid (spinal)

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126
Q

what will happen with test dose if epidural catheter is in a vessel

A

20% raise in HR and BP within 30 sec

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127
Q

local anesthetic for epidurals must be _____________ free

A

preservative

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128
Q

what can be added to epidurals to lenthen the duration of the block

A

epi/steroids (dexamethasone)

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129
Q

what is the provided concentration of chloroprocaine

A

2-3%

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130
Q

what is the time of onset of chloroprocaine (epidural)

A

5-10 min

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131
Q

what is the provided concentration of lidocaine

A

1-2%

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132
Q

what is the onset of lidocaine (epidural)

A

10-15min

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133
Q

what is the provided concentration of Bupivicaine

A

0.25-0.5 %

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134
Q

what is the onset of Bupivicaine (epidural)

A

15-20 min

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135
Q

what is the provided concentration of Ropivicaine

A

0.25-1%

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136
Q

what is the time of onset of ropivicaine

A

10-20 min

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137
Q

what is Duramorph

A

preservative free morphine

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138
Q

what is the least lipid soluble narcotic you can give in epidurals

A

duramorph

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139
Q

low lipid solubility means that it has a __________ spread in CSF

A

higher

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140
Q

what is the most lipid soluble epidural narcotics

A

fentanyl/sufentanil

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141
Q

being lipid soluble means that it is taken up by

A

epidural fat

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142
Q

what opioids can you give with epidurals

A

Duramorph
Fentanyl
sufentanil
Meperidine
Hydromorphone

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143
Q

what is the general lipid solubility of Morphine

A

1

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144
Q

what is the onset of epidural Morphine

A

30-60min

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145
Q

what is the general lipid solubility of Hydromorphone

A

10

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146
Q

what is the onset of epidural Hydromorphone

A

15-30min

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147
Q

what is the general lipid solubility of Meperidine

A

30

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148
Q

what is the onset of epidural Meperidine

A

5-10 min

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149
Q

what is the general lipid solubility of Fentanyl

A

800

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150
Q

what is the onset of epidural Fentanyl

A

5 min

151
Q

what are factors that affect epidural blockade

A

-site of injection
-nerve root size
-posture
-local anesthetic drug, concentration, and volume
-addition of epinephrine
-addition of sodium bicarb

152
Q

how does the addition of sodium bicarb affect epidurals

A

faster (shorter) onset

153
Q

how does the addition of epi affect epidurals

A

increases DOA

154
Q

what can you add to epidural for an emergency C-sec

A

sodium bicarb

155
Q

larger nerve roots are __________ resistant to blockade

A

more

156
Q

what nerve roots are the largest

A

L5-S1

157
Q

where is epidural analgesia most concentrated

A

around site of injection

158
Q

how does young age affect epidural dose

A

increased dose requirement from age 4-18

159
Q

how does advancing age affect dose requirement for epidural

A

gradual decrease

160
Q

with a patient >60yo how do you change epidural dose

A

decrease by 50%

161
Q

what causes decreased epidural dose requirement in advancing age

A

decreased epidural fat content
leakage through intervertebral foramina

162
Q

how does pregnancy affect epidural dose

A

decreased requirement by 30%(smaller epidural space)

163
Q

how does sever atherosclerosis affect epidural dose

A

decrease by 50%

164
Q

what conditions causes a decreased requirement for epidural dose

A

pregnancy
severe atherosclerosis
elderly

165
Q

how doe sitting vs supine effect epidural

A

no difference in cephalad spread
maybe greater caudad when siting

166
Q

how does lateral position affect epidural

A

favors spread of analgesia to dependent side (increased onset, longer doa, more intense block)

167
Q

Dose = _________________ X_________________

A

Concentration x volume

168
Q

increasing dose will increase block in 4 ways, what are they

A

^ height (volume)
^ duration
^ depth (concentration)
decreased onset time

169
Q

how does increasing volume affect block

A

increased height

170
Q

how does increasing concentration affect block

A

decreased onset time (faster)
increased intensity of motor blockade and depth of sensory blockade

171
Q

addition of epinephrine to epidural LA works better with LA of ____________ concentration

A

lower

172
Q

addition of epinephrine to epidural increases __________ and _________ of blockade

A

duration and depth

173
Q

what kind of redose can you give to consolidate block

A

repeat dose of 20% 20 min after main dose

174
Q

what kind of redose can you give when analgesia has receded 1-2 dermatomes

A

50% of original

175
Q

when do you redose to increase length of epidural

A

when analgesia has receded 1-2 dermatomes give 50% of original dose

176
Q

what happens if you wait to redose till block height decreases

A

could lose anesthesia intraop

177
Q

how would administering the original dose of an epidural in a redose affect block

A

increase height

178
Q

with an epidural sympathetic block occurs at _____________ level as the sensory block

A

the same

179
Q

with an epidural motor block occurs at _____________ than the sensory block

A

2-4 dermatomes lower

180
Q

how do you assess epidural blockade

A

pinprick at dermatome level (distinguish sharp)
alcohol wipe (distinguish cold)

181
Q

which epidural blockade method is most sensitive

A

alcohol wipe

182
Q

how does using epidural with anesthesia affect general anesthetic requirement

A

decreased requirement

183
Q

how does epidural with anesthesia affect post op pain

A

decreases

184
Q

how does periop epidural affect hospital stays

A

decreased

185
Q

which has a denser block primary or post op pain epidural

A

primary

186
Q

what are complications of epidural anesthesia

A

IV injection (LAST)
Subarachnoid injection (high spinal)
Neurological damage
infection
hypotension (decreased SNS)

187
Q

what is LAST

A

Local Anesthetic Systemic Toxicity

188
Q

how does IV injection of epidural dose happen

A

inadvertant injection into epidural vein

189
Q

what are toxic effects of LA

A

CNS/CV

190
Q

CNS toxicity from LA occurs at ___________ levels

A

lower

191
Q

CV toxicity from LA occurs at ___________ levels

A

much higher doses

192
Q

which LA is least CV stable

A

bupivicaine

193
Q

which LA is most CV stable

A

ropivicaine

194
Q

what are negative results of epidural test dose

A

no numbness of feet
no significant HR changes

195
Q

how long do you wait after test dose to see results

A

3-5 min

196
Q

if epidural cap comes out what do you do

A

pull out and replace, dont reinsert

197
Q

do you pull medications through rubber top vial

A

no

198
Q

how does epidural affect BP

A

causes hypotension

199
Q

onset of hypotension is __________ in epidural than with spinal

A

slower

200
Q

how long do crystalloid fluid last in intravascular space

A

30 min

201
Q

ephedrine is _________ acting

A

indirect

202
Q

what is the affect of ephedrine

A

increase HR
increase BP

203
Q

what is the max dose of ephedrine before tachphylaxis occurs

A

30-40 mcg

204
Q

what is a normal push dose of ephedrine

A

10-20 mcg

205
Q

what kind of drug is phenylephrine

A

DIRECT alpha 1 agonist

206
Q

what are the effects of phenylephrine

A

increase BP, decreased HR

207
Q

what causes the decrease in HR with phenylephrine

A

Baroreceptor reflex

208
Q

what can you give with phenylephrine to counteract the barorecptor reflex

A

glycopyrrolate

209
Q

what is a normal dose of phenylephrine

A

50-100mcg

210
Q

what is a normal push dose of epi

A

10mcg

211
Q

how do you give fluid to work with sympathomimetics in anesthesia

A

preload and co-load with crystalloid

212
Q

what is another med we can give to treat hypotension in anesthesia

A

atropine?

213
Q

T/F every epidural causes a CSF leak

A

false

214
Q

what causes a CSF leak in epidural placement

A

SAB puncture

215
Q

which is more likely to cause CSF leak misplaced epidural or spinal

A

epidural, needle is much larger

216
Q

how do we treat CSF leak

A

blood patch, increases pressure and forms clot

217
Q

what innervates the diaphragm

A

C3 C4 C5

218
Q

what do intercostal muscles do for resp

A

used for expiration and for inspiration for pts with lung disease
blockage can cause resp difficulty

219
Q

T/F intercostal muscles are blocked below level of block

A

True

220
Q

an epidural for post op pain relief (increases/decreases) resp complication

A

decreases

221
Q

T/F epidurals have more neurologic injuries than other anesthetics

A

False

222
Q

what causes adhesive arachnoiditis

A

preservative in 2-chloroprocaine

223
Q

what causes epidural hematoma or abscess

A

bleeding or infection

224
Q

what can epidural hematoma or abscess lead to

A

neurological damage

225
Q

epidural hematoma or abscess is _______ common in epidurals than spinals, why?

A

more
location of epidural veins
larger touhy needle

226
Q

for pain control give epidurals with a (high/low) concentration LA with an _________ adjuvent

A

low concentration
opiod

227
Q

what is an example of bupivicaine concentration for pain control epidural

A

0.125%

228
Q

what is an example of narcotic/LA concentration for pain control epidural

A

fent 5 mcg/ml, bupivicaine 0.625%

229
Q

what does epidural fent cause

A

itching

230
Q

what is a cool way to treat epidural fent itching

A

narcan in 1 L bag in IV

231
Q

what rate do you not go above in epidural infusion

A

15cc/hr

232
Q

for surgery you use (higher/lower) concentrations

A

higher

233
Q

where is the conus medullaris located

A

L1-L2

234
Q

where is the dural sac located

A

S2

235
Q

where is sacral hiatus located

A

S5

236
Q

caudal anesthesia uses a __________ approach to the epidural space

A

distal

237
Q

caudal anesthesia acts first on the __________ dermatomes

A

sacral

238
Q

what is caudal anesthesia useful for

A

perirectal
ulologic
urologic
hernia
orthopedic surgery of the lower extremity

239
Q

what is an advantage of caudal anesthesia

A

less medication use

240
Q

what position is patient in for caudal anesthesia

A

prone

241
Q

what is the pediatric dose of caudal block

A

1ml/kg

242
Q

what is the adult dose of caudal block

A

20-30 ml

243
Q

spinal anesthesia uses (more/less) volume than epidural

A

less

244
Q

spinal anesthesia is (more/less) dense than epidural

A

more

245
Q

T/F spinal anesthesia uses multiple injections

A

F a single shot

246
Q

what are advantages of spinals

A

-simple
-rapid
-optimal for lower extremity
- to decrease the intensity and duration of postop pain

247
Q

what are indications for spinal

A

airway distortion
type of procedure (rectal, TURP)
OB/CSEC
patient preference

248
Q

what are contraindications for spinals

A

infection at injection site
dermatologic conditions
septicemia
shock/sever hypovolemia
spinal cord disease
increased ICP
blood clotting
length of surgery
surgical skills

249
Q

what is a hyperbaric spinal injection

A

more dense/higher specific gravity than CSF
meds fall with gravity

250
Q

what is a hypobaric spinal injection

A

less dense/lower specific gravity than CSF
floats

251
Q

what is isobaric spinal injection

A

doesnt float or sink, same specific gravity as CSF

252
Q

what position do we give spinal in

A

lateral decubitus

253
Q

in femals the spine tilts

A

downward

254
Q

in males the spine tilts

A

upward

255
Q

what size are spinal needles

A

22-25g

256
Q

spinal needle types

A
257
Q

spinal procedure

A
258
Q

where do we give spinal

A

L4-L5

259
Q

spinals cause a sympathetic blockade _________ than the sensory block

A

2-6 dermatomes higher

260
Q

spinals cause a sensory blockade _________ than the motor block

A

2 dermatomes higher

261
Q

Distribution of spinal anesthetic in CSF is influenced by

A

baricity of solution
contour of the spinal canal
patient position

262
Q

T/F volume has a large effect on spinal anesthetic

A

false

263
Q

what effects the duration of spinal anesthetic

A

drug selected
presence of epi/phenyl in LA

264
Q

during recovery anesthesia regresses from the __________ dermatome to the __________

A

highest to lowest

265
Q

what can the settling of LA in sacral area cause

A

urinary retention

266
Q

what is barbatoge

A

mixing LA with CSF to make it isobaric

267
Q

what is the DOA of tetracaine spinal

A

60-120 min

268
Q

what is the DOA of Bupicicaine spinal

A

60-120

269
Q

what are ways to exend the DOA of spinals

A

epi wash
precedex

270
Q

how much precedex do you put in a spinal

A

5 mcg

271
Q

how much precedex do you put in an epidural

A

20 mcg

272
Q

where does hyperbaric spinal settle in spine (when supine)

A

T 567 (lowest curvature in supine position)

273
Q

where is the high point in spine when patient is supine

A

L2 L3 L4

274
Q

how do you make a spinal solution hyperbaric

A

addition of dextrose

275
Q

how do you achieve the greatest cephalad spread of hyperbaric spinal

A

supine

276
Q

what is the most common spinal solution bariciy

A

hyperbaric

277
Q

what are the commercially available hyperbaric solutions

A

bupivicaine 0.75% with dextrose
lidocaine 5% with dextrose
tetracaine 1% with dextrose

278
Q

when do we use hypobaric solutions

A

reserved for patients undergoing perineal procedures in the prone jackknife position or undergoing hip arthroplasty where anesthetic can “float up” to nondependent operative site

279
Q

what is a common technique to create a hypobaric solution

A

dilute the commercial 10% solution with sterile water

280
Q

how do you make an isobaric solution

A

mix with CSF, barbitage

281
Q

what is the advantage of an isobaric solution

A

more profound motor block
more prolonged doa

282
Q

is isobaric solution affected by gravity

A

no

283
Q

what can we add to spinals to increase DOA

A

vasoconstrictors like epinephrine (0.1-0.2 mg)

284
Q

what dose of fentanyl prevents itching

A

10-15 mcg

285
Q

which is blocked first sensory or motor nerves

A

sensory

286
Q

what does dorsiflexion of foot test

A

S1-S2

287
Q

what does raising knees test

A

L2-L3

288
Q

what does raising abd muscles test

A

T6-T12

289
Q

how does motor anesthesia affect respiration

A

decreased ability to cough and expel secretions

290
Q

above level_______ inhibits the SNS innervation to the GI tract and the unopposed PNS results in what

A

T5
contracted intestines and relaxed sphincters

291
Q

how does SNS block affect urinary system

A

ureters are contracted and ureterovesical orifice is relaxed

292
Q

decreaesd bleeding post block may reflect a decrease in __________

A

systemic BP/PVR

293
Q

after doing neuraxial anesthesia you document __________ before patient leave PACU

A

spinal level

294
Q

what is sensory level for hemorrhoidectomy

A

S2-S5

295
Q

what is sensory level for foot surgery

A

L2-L3 (knee)

296
Q

what is sensory level for lower extremity surgery

A

L1-L3 (inguinal)

297
Q

what is the sensory level for Hip surgery/TURP/Vaginal delivery

A

T10 umbilical

298
Q

what is the sensory level for lower ABD, appendectomy

A

T6-T7 xiphoid

299
Q

what is the sensory level for upper ABD/C-sec

A

T4 nipple

300
Q

if the fifth digit is numb, what is the segmental block and what is the significance

A

C8
all cardioaccelerator fibers are blocked

301
Q

if the inner arm/forearm is numb, what is the segmental block and what is the significance

A

T1-2
some cardioaccelerator is blocked

302
Q

if the apex of the axilla is numb, what is the segmental block and what is the significance

A

T3
easily determined landmark

303
Q

if the nipple is numb, what is the segmental block and what is the significance

A

T4-5
possible cardioaccelerator block

304
Q

if the tip of xiphoid is numb, what is the segmental block and what is the significance

A

T7
splanchnics blocked

305
Q

if the umbilicus is numb, what is the segmental block and what is the significance

A

T10
SNS block limited to legs

306
Q

if the inguinal ligament is numb, what is the segmental block and what is the significance

A

T12
No SNS block

307
Q

if the outer side of foot is numb, what is the segmental block and what is the significance

A

S1
confirms block of most difficult root to anesthetize

308
Q

what can cause a failed spinal anesthetic

A

inability to identify subarachnoid space
failure to inject all or part of the local anesthetic solution
maldistribution of the local anesthetic
bad local anesthetic

309
Q

if you have to repeat a dose of spinal anesthetic, you shout assume the patient received _________ of the first dose

A

all

310
Q

what causes hypotension in spinals

A

SNS block
-partially due to decrease in SVR
-mostly due to decrease in venous return to the heart and decreased CO

311
Q

what percent of spinal patients have bradycardia

A

10-15%

312
Q

what happens with high spinal anesthesia

A

systemic hypotension
nausea
agitation

313
Q

what happens with ischemic paralysis of the medullary ventilatory centers

A

apnea
LOC
profound hypotension
decrease in CBF

314
Q

what is treatment for high spinal anesthesia

A
  1. Maintain airway and ventilation
  2. Sympathomimetics and IV fluids
  3. trendelenburg to increase venous return
    NO reverse trendelenburg 2/2 decreased venous return
  4. intubation
315
Q

what is cauda Equina syndrome

A

neurotoxity from high concentration of LA

316
Q

what are s/s cauda equina

A

bowel and bladder dysfunction
sensory deficits
weakness
paralysis

317
Q

what is treatment for cauda equina

A

supportive

318
Q

what are signs and symptoms of transient neurologic syndrome

A

severe back and butt pain that radiates to both legs

319
Q

when do transient neurologic system develop

A

6-36 hours, persists from 1-7 days

320
Q

what is treatment for transient neurologic syndrome

A

NSAIDs, opiod analgesics, trigger point injections

321
Q

what is CSE

A

combined spinal epidural

322
Q

what is benefit of Dural hole with epidural

A

allows local/opioid to leak in to subarachnoid space

323
Q

T/F catheter is more likely to fail in CSE

A

F, it is less likely to fail

324
Q

do you test dose a CSE

A

no

325
Q

what is CSE dosing for spinal

A

1.75-2.5 mg bupivicaine
10-15 mcg fentanyl
precedex 5 mcg

326
Q

does isobaric have faster/slower onset than hyperbaric spinal

A

faster

327
Q

what is a DPE

A

CSE without injection of medication into spinal

328
Q

what does DPE help you confirm

A

confirm you are not in subdural space by poking hole in dura and seeing CSF

329
Q

what is benefit of DPE hole in dura

A

increased spread of local (block of S1 or higher)
decreased hot spots
decreased unilateral blocks
possible faster onset

330
Q

what is benefit of intermittent bolusus over continous infusion of epidural

A

continuous only comes out of the proximal port, less effective block
boluses come out of multiple ports, better coverage

331
Q

T/F spread of epidural medication is better with continous infusion

A

F, it is better with bolus

332
Q

boluses helps epidural medication spread to ________ and ________

A

DRG
segmented nerves

333
Q

in epidural fentanyl boluses act on the ___________ while infusion act on____________

A

spinal
supraspinal

334
Q

what are pros of spinal sonography

A

correct spinal level (obese patients)
increased 1 stick rate
decrease need for needle redirects
correct for scoliosis
determine depth of ligamentum flavum/dura

335
Q

what percentage of spinal levels are correctly identified by palpation

A

30%

336
Q

what percentage of spinal levels are correctly identified by ultrasound

A

71%

337
Q

ultrasound of spine pic

A
338
Q

atlas and axis

A
339
Q

what are unique structures on atlas

A

no body
no spine
anterior arch
posterior arch

340
Q

what are unique structures of axis

A

odontoid process

341
Q

which vertebrae is this

A

C 3-6

342
Q

name this vertebrae

A

C7

343
Q

what vertebrae is this

A

thoracic

344
Q

what vertebrae is this

A

lumbar

345
Q

review lumbar anatomy

A
346
Q

spinal cord layers

A
347
Q

spinal cord ligaments

A
348
Q

epidural layers

A
349
Q

landmarks

A
350
Q

Tuffiers line

A
351
Q

landmarks for spinal/epidural

A
352
Q

sacral haitus landmark

A
353
Q

needle angles

A
354
Q

whole body dermatomes

A
355
Q

sacral anatomy

A
356
Q

sacrum haitus

A
357
Q

spinal position

A
358
Q

spinal needles

A
359
Q

spinal needle

A
360
Q

spine countours for spinal

A
361
Q

dermatomes

A
362
Q

dermatomes

A
363
Q

CSE

A
364
Q

continous vs intermittent infusion

A
365
Q

epidural ports

A
366
Q

US spine

A
367
Q

US lumbar

A
368
Q

transverse US

A
369
Q

Dermatome level for upper abdomen surgery or c section

A

T4-T5

370
Q

Dermatome for intestinal surgery, gyn surgery, pelvic surgery

A

T6

371
Q

Dermatome for TURP, vaginal delivery or hip surgery

A

T10

372
Q

Dermatome for thigh surgery, lower limb amputation

A

L1

373
Q

Dermatome for foot surgery

A

L2-L3

374
Q

Dermatome for perineal surgery or hemorrhoidectomy

A

S2