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N934 Adv Principles Fa 21 > Neuraxial Anesthesia: A Review > Flashcards

Neuraxial Anesthesia: A Review Flashcards

1
Q

which interspace is tuffiers line

A

L4-L5

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2
Q

where does the spinal cord end

A

L1/L2

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3
Q

what is the target for the spinal and the epidural

A

nerve roots

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4
Q

anatomical considerations for the parturient

A

engorged epidural veins, makes dura small and creates exaggerated spread during spinal administration

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5
Q

what is the solution mixed with an epidural always

A

normal saline

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6
Q

spinal: what does it depend on (4 most important factors)

A

dosage, baricity, patient positioning, site of injection

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7
Q

what kind of block is an epidural/what does it depend on?

A

the volume of LA which determines the dermatome level

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8
Q

absolute contraindications to neuraxial anesthesia

A 
patient refusal
increased ICP
severe aortic or mitral valve stenosis *
coagulopathy or bleeding diathesis
severe hypovolemia
infection at injection site
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9
Q 
aortic valve stenosis: mild. 
jet velocity (m/sec), mean gradient (mmHg), valve area (cm^2)
A 
jet velocity (m/sec) <3
mean gradient (mmHg) <25 
valve area (cm^2) >1.5
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10
Q 
aortic valve stenosis: moderate. 
jet velocity (m/sec), mean gradient (mmHg), valve area (cm^2)
A 
jet velocity (m/sec) 3-4
mean gradient (mmHg) 25-50
valve area (cm^2) 1-1.5
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11
Q 
aortic valve stenosis: severe. 
jet velocity (m/sec), mean gradient (mmHg), valve area (cm^2)
A 
jet velocity (m/sec) >4
mean gradient (mmHg) >50
valve area (cm^2) <1
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12
Q 
aortic valve stenosis: critical. 
jet velocity (m/sec), mean gradient (mmHg), valve area (cm^2)
A 
jet velocity (m/sec) >5
mean gradient (mmHg) >80
valve area (cm^2) < .7
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13
Q

relative contraindications to neuraxial anesthesia (7)

A 
uncooperative patient
LA allergy (esters >amide)
patient on anticoagulant or thrombolytic therapy
preexisting neurologic deficit
chronic headache or backache
severe spinal deformity
valvular stenosis
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14
Q

informed consent: document the following

A

advantages and disadvantages
block appropriate for procedure but not guaranteed
risks and benefits
ensure patient understands
allow patient to ask questions
do not attempt to dissuade from general if already agreed to

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15
Q

consider having these two things started before spinal administration

A

bolus and phenylephrine infusion

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16
Q

at minimum, monitor these things during neuraxial administration

A 
peripheral IV patency
suction
airway sypplies
EKG, BP, pulse ox, possibly O2
supportive meds (induction agent, paralytic, atropine, vasoactive medication)
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17
Q

how to create larger interspinous spaces

A

aside from angry cat or shrimp position, have them push against your thumb

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18
Q

prior to starting procedure, verify

A

patent IV
monitoring devices, oxygen attached and functioning
resuscitation equipment available

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19
Q

what is the most commonly used interspace for a spinal

A

L3-L4

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20
Q

describe a touhy needle used for epidurals

A

pronounced curve
blunt tip
easier for novices
directional placement of catheter

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21
Q

describe a crawford needle used for epidurals

A

not curved
easier to insert
higher rate of dural punctures

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22
Q

for an epidural, distance to ligamentum flavum varies with

A

body habitus

level of plcement

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23
Q

standard depth of ligamentum flavum

A

4-6cm

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24
Q

does an epidural needle require an introducer

A

no, theyre larger more rigid needles

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25
Q

describe the bromage grip for epidural placement

A

hand firm support to stabilize needle
attach and secure syringe
passing catheter through needle

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26
Q

name ligaments in order to dura

A 
supraspinous
interspinous
ligamentum flavum
epidural space
dura
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27
Q

what happens if you see a small amount of clear fluid during epidural placement

A

CSF would be a copious amount, so a small amount is ok

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28
Q

how many gauges smaller than the epidural needle is the epidural catheter

A

typically two gauges smaller than a needle

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29
Q

what happens if paresthesias occur during catheter placement

A

stop. if it isn’t persistent, its ok to keep going. theyre not uncommon

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30
Q

how far do you advance the epidural catheter

A

3-5cm past the needle hub

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31
Q

shallow placement of epidural catheter may result in

A

dislodgment of epidural space

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32
Q

too deep placement of epidural catheter may result in

A

puncture of dura
passage into epidural vein
migration through intervertebral foamen

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33
Q

test dose for epidural?

A

first, aspirate
1.5% lidocaine and 1:200,000 epinephrine
inject 3mL which is 45mg lidocaine and 15mcg epinephrine

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34
Q

if needle is in intravascular space during epidural test dose, what do you anticipate seeing

A

increase in HR and BP

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35
Q

what is in hyperbaric solution for a spinal

A

dextrose

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36
Q

what is in hypobaric solution for a spinal

A

sterile water

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37
Q

other factors related to spinal level (not the most important 4) include

A 
patient height
pregnancy
age
CSF volume
curvature of the spine
volume
intra abdominal pressure
needle direction
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38
Q

what is the most dependent area of the spine that hyperbaric solutions mitigate to

A

T4-T8

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39
Q

spinal needles that are not cutting needles (3)

A

whitacre, sprotte, pencan

40
Q

how to utilize a cutting needle to minimize frequency of PDPH

A

rotate it 90 degrees, separates dura a little more and cuts a little less

41
Q

what are the two pops felt during a spinal

A

ligamentum flavum

dura

42
Q

how to do a continuous spinal (and why)

A

provides prolonged surgical anesthesia and postoperative pain management
dura punctured 17 gauge epidural needle
epidural catheter passed through dura than subarachnoid space

43
Q

when to consider a continuous spinal

A

consider when a wet tap occurs during epidural placement

44
Q

describe a two level CSE

A

spinal placed first

epidural catheter placed 1-2 levels above

45
Q

describe a one level CSE

A

placement of epidural needle
spinal needle passed through
small intrathecal dose injected (opioid or smaller dose of LA)
epidural catheter placed

46
Q

goal of CSE

A

relieve pain so mom can deliver

47
Q

additional concerns of CSE include (3)

A

intrathecal opioid effects on fetus
inability to ambulate after receiving narcotics
maternal hypotension and itching

48
Q

potential complications of CSE include (6)

A 
failure to obtain either intrathecal or epidural block
catheter migration
increased spinal level
metallic particles
PDPH
neurologic injury
49
Q

if you use the paramedian approach for a spinal, which ligaments do you not go through

A

the supraspinous and interspinous ligament

50
Q

if youre hitting bone early during insertion of spinal,

A

you are touching the superior crest of spinous process below the interspace. redirect cephalad

51
Q

if youre hitting bone late during insertion of a spinal,

A

needle is touching the inferior surface of the spinous process above the interspace. redirect caudal

52
Q

if paresthesia does not resolve during insertion of spinal

A

remove and reposition

53
Q

if you get frank blood during insertion of a spinal, you are likely in

A

an epidural vein. withdrawal and reposition

54
Q

if you get blood tinged CSF during placement of a spinal,

A

allow CSF to flow for several seconds. when clear, inject medication

55
Q

does LA metabolize in CSF

A

no, this is based on rate of absorption into systemic vasculature.

56
Q

what will addition of vasoconstrictors to neuraxial anesthesia do

A

slow absorption and prolong block

57
Q

esters include (3)

A

procaine, chlorprocaine, tetracaine

58
Q

amides include (4)

A

lidocaine, mepivicaine, ropivicaine, bupivicaine

59
Q

procaine: pKa, percent ionized, percent protein binding, onset, DOA

A 
pKa 8.9 
percent ionized 97 
percent protein binding 6
onset slow
DOA 60-90 minutes
60
Q

chlorprocaine onset, DOA

A

onset fast

DOA 30-60 minutes

61
Q

tetracaine pKa, percent ionized, percent protein binding, onset, DOA

A 
pKa 8.5
percent ionized 93
percent protein binding 94
onset slow
DOA 180-600
62
Q

lidocaine pKa, percent ionized, percent protein binding, onset, DOA

A 
pKa 7.9
percent ionized 76
percent protein binding 64
onset fast
DOA 90-120
63
Q

mepivicaine onset, DOA

A

fast, 120-240

64
Q

ropivicaine onset, DOA

A

slow, 180-600

65
Q

bupivicaine pKa, percent ionized, percent protein binding, onset, DOA

A 
pKa 8.1
percent ionized 83
percent protein binding 95
onset slow
DOA 180-600
66
Q

neuraxial additives: epinephrine
MOA
dose
greater effect with

A

alpha 1 agonist
.1-.2mL of 1:1000 solution can be added to LA’s
greater effect with tetracaine

67
Q

neuraxial additives: phenylephrine MOA, dose, greatest effect with?

A

pure alpha agonist slightly more effective than epinephrine
.05-.2mL of 1% solution (.5-2mcg added to LA)
greatest effect with tetracaine

68
Q 
neuraxial additives: clonidine
MOA
contraindicated with?
synergistic with
helps with
A

selective alpha 2 agonist
used when epinephrine is contraindicated
when mixed with lidocaine or bupivicaine, has synergistic effects
the central action appears to help with tourniquet pain

69
Q

most common neuraxial additives include

A

fentanyl

morphine

70
Q

fentanyl as a spinal additive: solubility

A

high lipid solubility. binds directly to lipid elements of spinal cord. less drug available to diffuse systemically.

71
Q

fentanyl as a spinal additive: dosage, onset, DOA

A

provides profound analgesia
12.5-25mcg mixed with LA
onset: 5-10 minutes
DOA: 2-4 hours

72
Q

morphine as a neuraxial additive (spinal OR epidural): solubility

A

highly polarized, not very lipid soluble
drifts freely in CSF
in approx 6-8 hours, will rise to respiratory center

73
Q

morphine as a neuraxial additive (spinal OR epidural): dosage, onset, DOA

A

provides profound analgesia
.1-.25mg mixed with LA
onset 60-90 minutes
DOA approx 24h

74
Q

morphine as a neuraxial additive (spinal OR epidural): adverse effects (3)

A

itching
urinary retention
delayed respiratory depression

75
Q

dexmedetomidine as a neuraxial additive: dosing

A

spinal: 5mcg
epidural: 20-50mcg

76
Q

dexmedetomidine as a neuraxial additive: side effects

A 
profound hypotension (when used in conjunction with an opioid ex: precedex and fentanyl)
prolonged block
77
Q

which fibers are blocked first for neuraxial anesthesia

A

sympathectomy: 1st, preganglionic B fibers. vasodilation=good block aka drop in BP first sign. n/v may follow

78
Q

fiber type: A alpha

function, diameter, myelination, block onset

A

proprioception
6-22
heavy
last

79
Q

fiber type: A beta

function, diameter, myelination, block onset

A

touch, pressure
6-22micrometers
heavy
intermediate

80
Q

fiber type: A gamma

function, diameter, myelination, block onset

A

muscle tone
3-6
heavy
intermediate

81
Q

fiber type: A delta

function, diameter, myelination, block onset

A

pain, cold, temperature, touch
1-5
heavy
intermediate

82
Q

fiber type: B

function, diameter, myelination, block onset

A

preganglionic autonomic vasomotor
<3
light myelination
early block onset

83
Q

fiber type: C sympathetic

function, diameter, myelination, block onset

A

postganglionic vasomotor
.3-1.3
no myelination
early onset

84
Q

fiber type: C dorsal root

function, diameter, myelination, block onset

A

pain, warm and cold temperature, touch
.4-1.2
no myelination
early block onset

85
Q

which fibers follow B fibers and what is the result

A

a delta and C pain fibers and temperature follow B fibers.
unable to discriminate light touch or temeprature
temperature discrimination mirrors sensory loss

86
Q

which are the last fibers to be blocked and what is the result

A

A alpha beta and gamma

touch and proprioception, surgical muscle relaxation, may feel pressure

87
Q

what are the goal nerve fibers for a labor epidural

A

a delta and C fibers so she can still feel contractions

88
Q

evaluation of block

A

assess block q2-3 minutes
frequent assessment of BP and VS
physiologic changes closely resemble block level

89
Q

which dermatome level do you need for labor analgesia

A

T10

90
Q

which dermatome level do you need for a C section

A

T4-T6

91
Q

autonomic blockade is where in relation to sensory block? motor blockade is where in relation to sensory block?

A

autonomic blockade is usually two dermatomes higher than the sensory block
motor blockade is usually two dermatomes lower than the sensory block

92
Q

complications to neuraxial anesthesia

A 
HoTN
intercostal muscle paralysis
apnea/phrenic nerve paralysis
paresthesia
subarachnoid or epidural hematoma
meningitis/epidural abscess
chemical meningitis
n/v
PDPH
93
Q

what may a patient complain about when having a PDPH

A

if i lay down i feel fine, if i sit up I have a HA

94
Q

risk factors for PDPH include

A 
patient needle size and type
patient population (young, female, pregnancy)
95
Q

s/sx of PDPH

A 
bilateral frontal or rtetroorbital or occipital
extends into next
photophobia
nausea
positional
96
Q

PDPH treatment in first 12-24 hours (conservative)

A 
recumbent position
analgesics
fluid administation 
caffeine
stool softeners and soft diet
97
Q

epidural blood patch for PDPH includes

A

injecting 15-20mL autologous blood
below initial puncture site by 1-2 levels
90% will respond to initial therapy

N934 Adv Principles Fa 21 (23 decks)

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