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neuraxial blocks Flashcards

1
Q

ID these structures

A
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2
Q

ID atlas and axis on cervical vertebrae

A
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3
Q

what kind of curves are found on the vertebral column (2 types)

A

cervical and lumbar lordosis
thoracic and sacral kyphosis

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4
Q

how many vertebrae

A

33 (7 c, 12 t, 5 l, 5s, 4c)

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5
Q

outline these structures
pedicle
superior articular process
transverse process
spinous process
inferior articular process
vertebral body

A
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6
Q

atlas (C1) anatomy
lateral masses
transverse foramen
anterior tubercle
anterior arch
superior articular faucet
posterior arch
posterior tubercle

A
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7
Q

axis (C2) anatomy
odontoid process (dens)
vertebral body
superior articular facet joint
lamina
spinous process

A
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8
Q

ID these two structures

A
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9
Q

the spinal nerves exit the vertebral column via the

A

vertebral foramina

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10
Q

ID the facet joint

A
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11
Q

ID these critical land marks

A
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12
Q

another name for tuffiers line (L4)

A

intercristal line

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13
Q

in infants up to 1 year, tuffiers (intercristal) line correlates with

A

L5-S1

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14
Q

sacral hiatus
coincides with
results from
is covered by
provides entry point to

A

coincides with S5
results from incomplete fusion of laminae at S5 and sometimes S4
is covered by sacrococcygeal ligament
provides entry point to epidural space, which is useful in pediatrics

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15
Q

sacral cornua
what is it
what does it result from

A

bony nodules that flank the sacral hiatus
results from incomplete development of facets

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16
Q

ID these structures

A
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16
Q

ID these structures

A
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17
Q

conus medullaris
its where ______ ends
adults: ends at
infants:

A

where the spinal cord ends
adults: L1-2
Infants: L3

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18
Q

cauda equina
comprised of
located at

A

bundle of spinal nerves extending from conus medullaris to dural sac
comprised of nerves and nerve roots from L2-S5 nerve pairs and coccygeal nerve

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19
Q

dural sac
significance
adults:
infants:

A

subarachnoid space that terminates at dural sac
adult: S2
infant: S3

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20
Q

filum terminae
continuation of
extends from
anchors
internal portion extends from
external portion extends from

A

continue of pia mater caudal to conus medullaris that extends from conus medullaris too coccyx
anchors spinal cords to coccyx
internal portion extends from conus medullaris to external sac
external portion extends from dural sac to sacrum

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21
Q

ID the 5 ligaments and where theyre located in the SC

A
  1. supraspinous runs most of the length of the spine and joins the tips of the spinous process
  2. interspinous ligament travels adjacent to and joins the spinous processes
  3. ligamentum flavum: 2 that run the length of the spinal canal. they form dorsolateral margins of epidural space. thickest in lumbar region
  4. posterior longitudinal ligament: travels along the posterior surface of the vertebral bodies
  5. anterior longitudinal ligament: attaches to anterior surface of vertebral bodies and runs entire length of the spine. also attaches to annulus fibrosus of intervertebral discs
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22
Q

what ligaments do you pass through during midline approach

A

supraspinous
interspinous
ligamentum flavum

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23
Q

what ligaments do you pass through during paramedian approach

A

ligamentum flavum

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24
Q

for paramedian, you insert the needle

A

15 degrees off midline or
1cm lateral and 1cm inferior to interspace

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25
Q

ID these spaces

A
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26
Q

cranial border of epidural space

A

foramen magnum

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27
Q

caudal border of epidural space

A

sacrococcygeal ligament

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28
Q

anterior border of epidural space

A

posterior longitudinal ligament

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29
Q

lateral border of epidural space

A

vertebral pedicles

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30
Q

posterior borders of epidural space

A

ligamentum flavum
vertebral lamina

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31
Q

LA injection into subdural space will cause

A

high spinal if using epidural dosing, failed spinal if using spinal dosing

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32
Q

target region when performing spinal

A

subarachnoid space because its got all the goodies (CSF, nerve roots, rootlets, SC)

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33
Q

how many paired spinal nerves in SC

A

31

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34
Q

ID dorsal, lateral, ventral horn

A
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35
Q

dermatomes:
spinal nerve root C6
cutaneous innervation

A

1st digit (thumb)

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36
Q

dermatomes:
spinal nerve root C7
cutaneous innervation

A

2nd and 3rd digits

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37
Q

dermatomes:
spinal nerve root C8
cutaneous innervation

A

4th and 5th digits

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38
Q

dermatomes:
spinal nerve root T4
cutaneous innervation
surgeries where you need this level of coverage

A

nipple line

upper abdominal surgery
c section
cystectomy

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39
Q

dermatomes:
spinal nerve root T6
cutaneous innervation
surgeries where you need this level of coverage

A

xiphoid process

lower abdominal surgery
appendectomy

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40
Q

dermatomes:
spinal nerve root T10
cutaneous innervation
surgeries where you need this level of coverage

A

umbilicus

total hip
vaginal delivery
TURP

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41
Q

dermatomes:
spinal nerve root T12
cutaneous innervation

A

pubic symphysis

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42
Q

dermatomes:
spinal nerve root L4
cutaneous innervation

A

anterior knee

43
Q

surgeries where you need this level of coverage: L1-L3 (inguinal ligament)

A

LE surgery

44
Q

surgeries where you need this level of coverage: L2-3

A

foot surgery

45
Q

surgeries where you need this level of coverage S2-5

A

hemmrhoidectomy

46
Q

upper thoracic epidural indications
dosing guidelines

A

T2-6 upper thoracic
thoracotomy, TAA, breast surgery
5-10mL LA

47
Q

lower thoracic epidural indications
spread
dosing guidelines (mL LA)

A

T6-L1 lower thoracic (T1-L4 spread)
gastrectomy, esophagectomy, pancreatectomy, hepatic resection
10-20mL LA

48
Q

lumbar epidural indications (2)
insertion, spread
dosing guideliens

A

L2-5 insertion, (T8-S5 spread)
total hip, total knee
20mL LA

49
Q

do thoracic epidurals help decrease PPC’s

A

yeh boi

50
Q

when thoracic epidural is coupled with GA, cardiopulmonary considerations include a higher risk of

A

bradycardia (block of cardioaccelerator nerves T1-4)
HoTN (decreased CO and vasodilation)
changes in aw resistance (increased vagal influence on airways)

51
Q

in the subarachnoid space, the primary site of LA action is on

A

myelinated preganglionic fibers of nerve roots

52
Q

during an epidural, what does the LA have to do to get to the site of action

A

diffuse through dural cuff and leak through intervertebral foramen to enter paravertebral area

53
Q

spinal anesthesia: controllable and non controllable factors that DO affect spread

A

-controllable:
baricity
patient position during and after block placement
dose
site of injection

non controllable:
volume and density of CSF

54
Q

spinal anesthesia: factors that DO NOT affect spread

A

barbotage
increased intra abdominal pressure (coughing, labor)
speed of injection
orientation of bevel
addition of vasoconstrictor
weight
gender

55
Q

epidural anesthesia: controllable and non controllable factors that DO affect spread

A

-controllable:
LA volume (most important)
level of injection (most important procedure related factor)
LA dose

-non controllable:
-pregnancy
-old age

56
Q

epidural anesthesia: factors that DO NOT affect spread

A

additives
direction of needle orifice
speed of injection

57
Q

first, second, third TYPE of fibers blocked in order

A

ANS first (highest block as well)
sensory second (higher than motor block)
motor last

58
Q

spinal: sensory block is how many dermatomes above motor block

A

2

59
Q

spinal: autonomic block is how many dermatomes above sensory blok

A

2-6

60
Q

epidural: sensory and ANS are how many dermatomes above motor block

A

2-4

61
Q

is there an autonomic differential blockade with epidural anesthesia

A

no

62
Q

monitoring sensory block: first, second, last things to go

A

first: temperature (alcohol pad)
second: pain (pinprick)
last: sense of touch or pressure

63
Q

monitoring motor block: modified bromage scale (only for lumbosacral nerves)

A

0= no motor block
1=patient cannot raise extended but can move knee and feet
2= cannot raise extended leg or move knee but can move feet
3=complete motor block (cannot move knee, leg, feet)

64
Q

A alpha
myelination
function
diameter
velocity
block onset

A

myelination: heavy
function: skeletal muscle: motor proprioception
diameter: 12-20
velocity: +++++
block onset: 4th

65
Q

A beta
myelination
function
diameter
velocity
block onset

A

myelination: heavy
function: touch, pressure
diameter: 5-12
velocity: ++++
block onset: 4th

66
Q

A gamma
myelination
function
diameter
velocity
block onset

A

myelination: medium
function: skeletal muscle- tone
diameter: 3-6
velocity: +++
block onset: third

67
Q

A delta
myelination
function
diameter
velocity
block onset

A

myelination: medium
function: fast pain, temp, touch
diameter: 2-5
velocity: +++
block onset: 3rd

68
Q

B
myelination
function
diameter
velocity
block onset

A

myelination: light
function: preganglionic ANS fibers
diameter: 3
velocity: ++
block onset: first

69
Q

C sympathetic
myelination
function
diameter
velocity
block onset

A

myelination: 0
function: postganglionic fibers
diameter: .3-1.3
velocity: +
block onset: second

70
Q

C dorsal root
myelination
function
diameter
velocity
block onset

A

myelination: 0
function: slow pain, temp, touch
diameter: .4-1.2
velocity: +
block onset: second

71
Q

bupivicaine 0.5-0.75% spinal dose dose to get to
T10
T4
onset

A

T10: 10-15mg
T4: 12-20mg
onset 4-8m

72
Q

levobucaine 0.5% (no dextrose)
spinal dose dose to get to
T10
T4
onset

A

T10: 10-15mg
T4: 12-20mg
onset 4-8m

73
Q

ropivicaine 0.5-1% (with or without dextrose) spinal dose dose to get to
T10
T4
onset

A

T10: 12-18mg
T4: 18-25mg
onset 3-8m

74
Q

2- chlorprocaine 3% (with or without dextrose) spinal dose dose to get to
T10
T4
onset

A

T10: 30-40mg
T4: 40-60mg
onset 2-4m

75
Q

tetracaine 0.5-1% (with dextrose) spinal dose dose to get to
T10
T4
onset

A

T10: 6-10mg
T4: 12-16mg
onset 3-5m

76
Q

initial volume dosing for epidural

A

1-2mL for very level to be blocked

77
Q

top off epidural dosing

A

50-75% of original dose and should be administered before recession of 2 dermatomes

78
Q

drug for epidural: chlorprocaine
concentration
onset
DOA

A

concentration 3%
onset: 5-15m
DOA: 30-90m

79
Q

drug for epidural: lidocaine
concentration
onset
DOA

A

concentration 2%
onset 10-20m
DOA 60-120m

80
Q

drug for epidural: ropivicaine
concentration
onset
DOA

A

concentration: 0.1-0.75%
onset: 15-20m
DOA: 140-220m

81
Q

drug for epidural: bupivacaine
concentration
onset
DOA

A

concentration: 0.0625-0.5%
onset: 15-20m
DOA: 160-220m

82
Q

drug for epidural: levobupivacaine
concentration
onset
DOA

A

concentration: 0.0625-0.5%
onset: 15-20m
DOA: 150-225m

83
Q

water
density
SG
baricity

A

density: 0.9933
SG: 1
basicity: 0.9930 (in r/t CSF)

84
Q

CSF
density
SG
baricity

A

density: 1.003
SG: 1.002-1.009
baricity: 1

85
Q

basicity of procaine 10% in water

A

hyperbaric. (because theres so many molecules in a 10% solution)

86
Q

primary mechanism of anesthetic blockade when neuraxial anesthesia causes sympathectomy

A

preganglionic B fingers in sympathetic chain

87
Q

how neuraxial anesthesia affects the following CV parameters:
peload
afterload
CO
HR

A

preload decreased d/t sympathectomy
afterload decreased d/t sympathecctomy
CO variable (decreased VR that lowers CO but also decreased SVR to help CO)
HR variable: decreased VR which activates Bezold Jarisch reflex (unloading from mechanoreceptors) which decreases HR/can cause asystole.
reverse Bainbridge reflex-unloading of stretch receptors in SA

88
Q

apnea r/t neuraxial anesthesia

A

-not the result of phrenic nerve paralysis or high concentrations of LA in CSF.
-its usually a result of brainstem hypo perfusion

89
Q

neuraxial anesthesia and accessory respiratory muscle function

A

decreased fx of accessory muscles which has no effect on a healthy person but does have an effect on people who have COPD or so. so, if this comes up on the exam, YES neuraxial anesthesia does have an effect on resp mechanics (insp AND exp)

90
Q

CNS and neuraxial anesthesia

A

decreased perfusion to RAS which can cause drowsiness

91
Q

GI and neuraxial anesthesia

A

neuraxial LA’s decrease SNS tone and increases PSNS which relaxes sphincters and causes peristalsis

92
Q

kidneys, liver, and neuraxial anesthesia

A

so long as SBP is maintained, hepatic and renal BF and function are not altered

93
Q

neuraxial opioids inhibit pain transmission via
(where)
(how)

A

substantia gelatinosa (rexed lamina 2 in dorsal horn)
decreased cAMP, decreased Ca conductance, increased K conductance.

94
Q

neuraxial opioids do NOT cause (3)

A

sympathectomy
skeletal muscle weakness
changes in proprioception

95
Q

list of opioids we use in neuraxial space from most lipophilic to most hydrophilic

A

sufentanil > fentanyl > meperidine > hydromorphone > morphine

96
Q

which opioids (hydrophilic v lipophilic) stay in neuraxial space longer and which diffuses out?

A

hydrophilic stays in CSF for longer time periods
lipophilic doesn’t stay in CSF for a long time and diffuses out into periphery

97
Q

which opioids (hydrophilic v lipophilic) have extensive versus minimal spread

A

hydrophilic: extensive, wide band of analgesia, more rostral spread towards brain

lipophillic: minimal, narrow band of analgesia, less rostral spread

98
Q

site of action of neuraxial opioids (hydrophilic v lipophilic)

A

rexed lamina 2&3
also systemic for lipophilic

99
Q

onset and DOA of hydrophilic neuraxial opioids

A

onset: delayed (30-60m)
DOA: longer (6-24h)

100
Q

onset and DOA of lipophilic neuraxial opioids

A

onset: fast (5-10m)
DOA: shorter (2-4h)

101
Q

which opioids (lipophilic versus hydrophilic) have a higher incidence of n/v and pruritis

A

hydrophilic has higher incidence

102
Q

sufentanil
intrathecal dose
epidural dose

A

intrathecal dose: 5-10mcg
epidural dose: 25-50mcg

103
Q

fentanyl
intrathecal dose
epidural dose

A

intrathecal dose: 10-20mcg
epidural dose 50-100mcg

104
Q

hydromorphone
intrathecal dose
epidural dose

A

intrathecal dose: NO hoe
epidural dose: .5-1mg

105
Q

meperidine
intrathecal dose
epidural dose

A

intrathecal dose 10mg
epidural dose 25-50mg

106
Q

morphine
intrathecal dose
epidural dose

A

intrathecal dose 0.25-0.3mg
epidural dose 2-5mg

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