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Advanced Anesthesia II > Neuraxial Anesthesia Review > Flashcards

Neuraxial Anesthesia Review Flashcards

1
Q

what is the most prominent cervical process

A

c7

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2
Q

what is the inferior tip of scapula

A

t7

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3
Q

what is the supeerior aspect of the iliac crest

A

tuffier’s line (L4)

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4
Q

what is the posterior superior iliac spine

A

s2

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5
Q

what occurs w/epidural spread in OB patients?

A

increase in spread d/t the engorged epidural veins compressing the dura

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6
Q

where does the spinal cord end?

A

L1 - L2

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7
Q

what are we targetting for spinal + epidurals?

A

the nerve roots

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8
Q

what affects the spread during a spinal?

A

the baricity

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9
Q

what affects the spread during an epidural?

A

the volume

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10
Q

spinal vs epidural

A

spinal: single shot, dosage, baricity, patient position
epidural: catheter, volume block

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11
Q

what level do you want for a labor vs c/sx

A 
labor = T10
c/sx = T5/T6
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12
Q

name the absolute contraindications for neuraxial

A
  1. refusal
  2. increased ICP
  3. coagulopathies
  4. severe aortic or mitral stenosis
  5. severe hypovolemia
  6. infection at the injection site
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13
Q

aortic valve stenosis mild

A

jet velocity: < 3
mean gradient: < 25
valve area: > 1.5

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14
Q

aortic valve stenosis moderate

A

jet velocity: 3 - 4
mean gradient: 25 - 50
valve area: 1 - 1.5

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15
Q

aortic valve stenosis severe

A

jet velocity: > 4
mean gradient: > 50
valve area: < 1

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16
Q

aortic valve stenosis critical

A

jet velocity: > 5
mean gradient: > 80
valve area: < 0.7

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17
Q

relative contraindications for neuraxial anesthesia (7)

A
  1. uncooperative
  2. allergy (esters- chloroprocaine, procaine, tetracaine)
  3. anticoagulant or thrombolytic therapy (afibb, DVT, DVT prophylaxis)
  4. pre-existing neuro deficit
  5. chronic HA or backache
  6. severe spinal deformity
  7. valvular stenosis
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18
Q

minimal pre-procedure monitoring

A
  • PIV
  • Suction
  • Airway supplies
  • monitors (EKG, pulse ox, BP, ETCO2)
  • Supportive medications (induction, paralytic, atropine, vasoactive)
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19
Q

what is the most common identifiable interspace

A

L2 - L3

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20
Q

discuss the difference between Tuohy + Crawford needle

A

Both are 9 cm w/1 cm increments

  • Tuohy = curved, easier
  • Crawford = straight, easier to insert, higher rate of dural punctures
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21
Q

What is the distance to ligamentum flavum

A

4 - 6 cm at the lumbar level

Ligamentum –> dura is another 4 mm

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22
Q

what type of grip w/epidural

A

bromage grip to advance through supraspinous ligament, interspinous ligament

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23
Q

how to insert epidural needle

A

bevel cephalad
loss of resistance is the most common method
fill w/2-3 mL of NS

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24
Q

Tuohy + hub =

A

12 cm

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25
Q

Epidural Catheters

A

typically two gauges smaller than the needle
open-ended w/multiport (lower incidence of inadequate analgesia but higher incidence of accidental vein cannula)

1 dash = 1 cm
2 dash = 10 cm
thick line = 12 cm
3 dash = 15

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26
Q

how far to advance epidural catheter?

A

when the thick black mark is flush w/hub, the catheter is flush with the needle tip. slight resistance is noted when the catheter is advanced and the patient might feel a paresthesia

advance 3 - 5 cm past the needle hub

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27
Q

too deep placement of epidural catheter?

A

puncture of dura
pass into an epidural vein
migration into intervertebral foramen

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28
Q

how to remove the needle for an epidural

A

slowly withdraw needle over the catheter

once removed- note the depth of the catheter at the skin (if the depth is < 1 cm to epidural space… replace)

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29
Q

epidural test dosee

A

attach adaptor to the free end
look for blood / csf
aspirate
inject 3 mL of 1.5% lidocaine w/epinephrine 1:200,000

45 mg lido + 15 mcg epi

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30
Q

how do you know if the needle is in the epidural vein

A

> 20% increase in HR and BP

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31
Q

who performed the first spinal anesthetic

A

Augustus bier in 1899

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32
Q

what is specific gravity… water? CSF?

A

the density of a substance compared to the density of water

water = 1
CSF = 1.003 - 1.009
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33
Q

what is baricity

A

the resting position of two fluids w/different specific gravities when mixed in a single container - this helps the potential spread of LA in the subarachnoid space

34
Q

isobaric

A

LA = CSF (i.e. NS)

–> longer effect b/c large volume per area

35
Q

hyperbaric

A

lasts 2 hours
LA > CSF
dextrose

36
Q

hypobaric

A

sterile water

37
Q

what primarily influences the LA level during a spinal

A

baricity, position of patient, drug dose, site of injection

38
Q

secondary influences on the anesthetic level

A 
patient height
pregnant
age
CSF volume
spine curve
drug volume
intra-abdominal pressure
needle direction
39
Q

patient is supine.. where does hyperbaric LA go

A

T4 - T8

40
Q

what is the size of your introducer for a spinal

A

18G

41
Q

size of spinal needle

A

25G (22G if an old person just don’t use introducer)

42
Q

name the types of spinal needles

A

cutting vs. pencil point

Gertie Marx (26G)
Sprotte (25G) PP
Whitacre (25G) PP
Quinke (25G) Cutting

43
Q

what are the two pops of a spinal

A

ligamentum flavum

dura

44
Q

what is a continuous spinal

A
  • dura punctured w/17G epidural needle
  • an epidural catheter is placed through the dura into subarachnoid space
  • small incremental doses of local are given until the desired level achieved (total dose to achieve the desired level is the same)
45
Q

CSE

A

Two Step: spinal first (usually just narcotics), epidural placed 1 - 2 levels above
One Step: epidural needle placed, spinal through the epidural needle, intrathecal dose given, catheter placed

46
Q

CSE concerns

A
  • intrathecal effects on fetus
  • cannot ambulate post narcotics
  • maternal hypotension + itching
  • catheter migration
  • high spinal
  • metallic particles
  • PDPH
  • neuro injury
47
Q

paramedian approach

A

used when patient cannot flex spine

  • history of spine surgery, RA, hip or upper leg trauma
  • 1 cm lateral and 1 cm caudal to spinous process
  • advance needle toward midline, pass through paraspinous muscles to ligamentum
48
Q

paramedian passes through what muscles

A

erector spinae

-ileocostalis, spinalis, longissimus

49
Q

hit bone early

A

redirect cephalad

touching the superior crest of spinous process below inteerspace

50
Q

hit bone late

A

needle touching inferior surface of the spinous process above interspace

redirect caudal

51
Q

blood in catheter?

A

text book answer - withdraw and go one level above

52
Q

absence of CSF

A

reinseert stylet
advance 1 - 2 mm
aspirate

esp. important to advance another mm w/pencil point needles

53
Q

blood tinged vs frank blood

A

blood-tinged.. just wait a few seconds to see if it clears

frank blood - epidural vein so withdrawal

54
Q

how is LA metabolized

A

absorbed into plasma
metabolized via properties
ester = non specific plasma esterases
amide = liver

55
Q

procaine

A 
ester
pka = 8.9
ionized = 97
protein binding = 6
slow onset
DOA = 60 - 90m
56
Q

chloroprocaine

A

ester
fast onset
DOA = 30 - 60m

57
Q

tetracaine

A 
ester
pka = 8.5
ionized = 93
protein binding = 94
slow onset
DOA = 180 - 600m
58
Q

lidocaine

A 
amide
7.9
76 ionized
64 protein
fast onset
DOA = 90 - 120
59
Q

mepivicaine

A

fast onset, 120-240 DOA

60
Q

ropivacaine

A

slow onset

DOA 180 - 600m

61
Q

bupivacaine

A 
8.1
83 ionized
95 protein
slow onset
DOA 180 - 600
62
Q

epinephrine

A

alpha 1 agonist
0.1 - 0.2 mL of 1:1000 solution
greatest effect w/tetracaine

63
Q

phenylephrine

A

more effective than epi

0.05 - 0.2 mL of 1% solution (0.5 - 2 mcg)

64
Q

clonidine

A

helps w/tourniquet pain

65
Q

fentanyl characteristics

A

by nature, preservative free
highly lipid soluble
binds directly to the lipid elements of the spinal cord
less drug to diffuse systemically

66
Q

morphine characteristics

A

duramorph
highly polarized, not very lipid soluble so hangs out in CSF for hours

6-8 hours rises to respiratory center

67
Q

fentanyl dosing

A

12.5 - 15 mcg
onset = 5 - 10m
DOA = 2 - 4 hours

68
Q

morphine dosing

A

0.1 - 0.25 mg (100 mcg for a c/sx)
onset = 60 - 90m
DOA = 24h

69
Q

dexmedotomidine

A

alpha 2 agonist
do not mix w/fentanyl

spinal = 5 mcg
epidural = 20 - 50 mcg

great for a one-sided spinal

70
Q

precedex side effects

A 
profound hypotension if you add an opioid with it
prolonged block (4h spinal)
71
Q

a-alpha fibers

A

function = proprioceeption, motor
diameter = 6 - 22 um
heavy myelination
last to block

72
Q

a-beta fibers

A

touch, pressure
diameter = 6 - 22um
heavy myelination
intermediate block

73
Q

a-gamma fibers

A

muscle tone
3 - 6 um
heavy myelination, inteermediate block

74
Q

a-delta

A

pain, cold temp, touch
1 - 5 um
heavy myelin, intermediate block

75
Q

type B fibers

A

preganglionic autonomic vasomotor
< 3 um
light myelination, early block

76
Q

type C fibers

A

sympathetic - postganglionic vasomotor - .3 - 1.3 - early onset
dorsal root - pain, temp, touch - .4 - 1.2 - early onset

NO MYELINATION

77
Q

WHAT IS THE CARDIAC ACCELERATOR FIBERS

A

T4

78
Q

how to evaluate block?

A

(B FIBERS) sympathectomy 1st
a-delta, c fibers next (light touch, temperature)
a-alpha, a-beta, a-gamma last (touch, proprioception, muscle relaxation)

79
Q

what is the easiest way to assess level changes

A

sensory

T4 = nipples
T 10 = bellybutton

c-section we want T4 - T6

80
Q

autonomic blockade

A

two dermatomes higher than sensory block

motor is two levels below

81
Q

post-dural puncture headache

A

dura compromise
RF = needle size, type, younger, female, pregnant
S/S = bilateral frontal or retroorbital or occipital extending to neck, photophobia, nausea, positional

82
Q

PDPH treatment

A

conservative for the first 12 - 24h
-recumbent, analgesics, fluid, caffeine, stool softener, soft diet

BLOOD PATCH
-15 - 20 mL blood, place BELOW puncture site (1 - 2 levels)

Advanced Anesthesia II (9 decks)

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