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Apex > Neuraxial blocks > Flashcards

Neuraxial blocks Flashcards

1
Q

How many cervical vertebrae are there?

A

7

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2
Q

How many thoracic vertebrae are there?

A

12

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3
Q

How many Lumbar vertebrae are there?

A

5

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4
Q

How many sacral vertebrae are there?

A

5~fused

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5
Q

How many coccygeal vertebrae are there?

A

4~fused

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6
Q

What is the vertebral foramen?

A

Space that contains the spinal cord, nerve roots, and epidural space

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7
Q

What is vertebrae C1 also called?

A

The atlas

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8
Q

What is vertebrae C2 also called?

A

The axis (this vertebrae has the dens!)

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9
Q

What is another name for the facet joint?

A

Zygapophyseal joint

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10
Q

Where is the vertebra prominens?

A

C7

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11
Q

Where is the SPINE of the scapula?

A

T3

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12
Q

Where is the Inferior angle of the scapula?

A

T7

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13
Q

At what level is the rib margin?

A

L1

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14
Q

At what level is the iliac crest?

A

L4

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15
Q

At what level is the posterior iliac spine?

A

S2

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16
Q

What is another name for the intercristal line?

A

Tuffier’s line ~ correlates with L4 vertebra

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17
Q

Where is the sacral hiatus?

A

S5

Covered by the sacrococcygeal ligament

Entry point to the epidural space in pediatrics

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18
Q

What are the sacral Cornu?

A

Bony nodukes that flank the sacral hiatus

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19
Q

Where does the spinal cord end in an adult (aka conus medullaris)?

A

Adult: L1-L2

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20
Q

Where does the spinal cord end in the infant? (Aka conus medullaris)

A

L3

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21
Q

What is the cauda Equina?

A

Bundle of nerve fibers extending from conus medullaris to Duran sac

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22
Q

Where does the Dural sac terminate in the adult?

A

S2

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23
Q

Where does the dural sac terminate in the infant?

A

S3

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24
Q

What is the film terminale?

A

Continuation of pia mater that extends from the conus medullaris to coccyx

Anchors spinal cord to coccyx

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25
Q

What is the order of the five ligaments in the spinal column? From outside in…

A

Supraspinous
Interspinous
Ligamentum flavum
Posterior longitudinal ligament
Anterior longitudinal ligament

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26
Q

What ligaments does the needle pass in the midline approach?

A

Supraspinous
Interspinous
Ligamentum flavum

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27
Q

What ligaments does the needle pass in the paramedical approach?

A

Ligamentum flavum

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28
Q

What are the 3 meninges layers of the spinal cord? From outside in?

A

DAP

Dura
Arachnoid
Pia

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29
Q

What is the cranial border, caudal border, anterior border and posterior border of the epidural space?

A

Cranial (top) foramen magnum
Caudal (bottom): sacrococcygeal ligament
Anterior: posterior longitudinal ligament
Posterior: ligamentum flavum

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30
Q

How does the epidural space affect lipophilic drugs?

A

Acts as a sink reducing bioavailability

(Bupi > Lido > morphine)

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31
Q

What is another name for the epidural veins?

A

Bataan’s plexus

They pass the anterior and lateral regions of the epidural space

**pregnancy and obesity increase intraabdominal pressure and cause engorgement of these vessels

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32
Q

What is the plica mediana dorsalis?

A

Hypothetically…this is a band of tissue that courses b/t the ligamentum flavum and dura mater.

** been considered the culprit for difficult epidural catheter insertion

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33
Q

What is a tough fibrous shield that protects the spinal cord?

A

Dura mater

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34
Q

What is a potential space b/t the dura mater and the arachnoid mater?

A

Subdural space

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35
Q

What is a thin layer of connective tissue that neighbors the dura mater?

A

Arachnoid mater

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36
Q

Which space is deep to the arachnoid mater and contains CSF, nerve roots, and the spinal cord?

A

Subarachnoid space

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37
Q

What is the external covering of the spinal cord?

A

Pia mater.

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38
Q

What does C6 innervate?

A

1st digit (thumb)

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39
Q

What does C7 innervate?

A

2nd and 3rd middle digits

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40
Q

What does C8 innervate?

A

4th and 5th digits

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41
Q

What does T4 innervate?

A

Nipple line

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42
Q

What does T6 innervate?

A

Xiphoid process

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43
Q

What does T10 innervate?

A

Umbilicus

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44
Q

What does T12 innervate?

A

Pubic symphysis

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45
Q

What does L4 innervate?

A

Anterior knee

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46
Q

What sensory level is necessary for an upper abd surgery, c-section, or cystectomy?

A

T4

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47
Q

What sensory level is necessary for a lower abdominal surgery/appendectomy ?

A

T6-T7 (xiphoid process)

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48
Q

What sensory level is necessary for a total hip arthroplasty, Vaginal delivery, or TURP

A

T10

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49
Q

What sensory level is necessary for a lower extremity surgery?

A

L1-L3

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50
Q

What sensory level is necessary for a foot surgery?

A

L2-L3

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51
Q

What sensory level is necessary for a hemorrhoidectomy?

A

S2-S5

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52
Q

What are some controllable factors for spinal anesthesia?

A

Baricity
Patient position
Dose
And Site of injection

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53
Q

What are some controllable factors for epidural anesthesia?

A

Local anesthetic volume (most imp.)
Level of injection
Local anesthetic dose

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54
Q

How does the level of injection affect the spread in epidural anesthesia?

A

Lumbar: cephalon
Midthoracic: both cephalon and caudad
Cervical: caudad

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55
Q

In spinal anesthesia, what is the sensory blockade, what is the autonomic blockage and what is the motor blockade?

A

Sensory: usually 2 dermatomes ABOVE motor

Autonomic: usually 2-6 dermatomes ABOVE sensory

Motor: usually 2 dermatomes BELOW sensory

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56
Q

In epidural anesthesia, what is the sensory blockade, what is the ANS blockade, and what is the motor blockade?

A

Sensory and ANS are 2-4 dermatomes ABOVE motor

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57
Q

What is the first sensory modality blocker? What is the second? What is the last?

A

1st: sense of temperature
2nd: pain
3rd: sense of light touch or pressure

58
Q

Where is the primary site of action of a spinal anesthetic?

A

In the subarachnoid space ~ myelinated preganglionic fibers of the spinal nerve roots

59
Q

For a spinal anesthetic, what is the dose of bupivaciane at the T10 level and what is the dose at the T4 level?

A

T10: 10-15mg
T4: 12-20 mg

60
Q

For a spinal anesthetic, what is the dose of Levobupivacaine at the T10 level and what is the dose at the T4 level?

A

T10: 10-15 mg
T4: 12-20 mg

61
Q

For a spinal anesthetic, what is the dose of ropivacaine at the T10 level and what is the dose at the T4 level?

A

T10: 12-18mg
T4: 18-25 mg

62
Q

For a spinal anesthetic, what is the dose of Chloroprocaine 3% at the T10 level and what is the dose at the T4 level?

A

T10: 30-40 mg
T4: 40-60 mg

63
Q

For a spinal anesthetic, what is the dose of tetracaine at the T10 level and what is the dose at the T4 level?

A

T10: 6-10 mg
T4: 12-16 mg

64
Q

What is the initial dose per segment to be blocked in an epidural?

A

1-2 mL per segment

65
Q

What is a “top up” dose?

A

50-75%

66
Q

What is the difference b/t specific gravity and baricity?

A

Both are the density of a substance relative to a substance

Specific gravity = water
Baricity = CSF

67
Q

What is an isobaric solution?

A

Baricity is similar to CSF

68
Q

What is a hyperbaric solution?

A

Baricity is greater ~ higher density > 1

Dextrose is added to increase Baricity

69
Q

What is a hypobaric solution?

A

Baricity is lower ~ lesser density < 1

Water is added to reduce Baricity

70
Q

Which is the only solution that is hyperbaric in water?

A

Procaine 10% in water (there are a lot of molecules in procaine)

71
Q

What are the highest points of lordosis in the supine position?

A

L3
C5

72
Q

What are the high points of kyphosis in the supine position?

A

T5-T7 and S2

73
Q

What can occur if you have unloading of the ventricular mechanoreceptors?

A

Activation of the Bezold-Jarisch reflex (this can lead to asystole with spinal anesthesia

74
Q

How does neuraxial anesthesia affect the resp system?

A

Accessory muscle function is reduced. ~this can reduce pulmonary reserve.

75
Q

What is usually the culprit if a patient becomes apneic with neuraxial anesthesia?

A

Brainstem hypoperfusion.

76
Q

How does neuraxial anesthesia affect the CNS?

A

Reduces sensory input to the reticular activating system ~ causes drowsiness

77
Q

How does neuraxial anesthesia affect the Neuro endocrine system?

A

Inhibits afferent traffic and diminishes the stress response

78
Q

How does neuraxial anesthesia affect the GI system?

A

Relaxes sphincters and increases peristalsis

79
Q

What do opioids NOT cause in spinal or epidural anesthesia?

A

Sympathectomy
Skeletal muscle weakness
Changes in proprioception

80
Q

What are some traits about hydrophilic drugs administered in the intrathecal/epidural administration?

A

Spread: extensive (more rostral spread)
Wider band of analgesia
Site of action: rexed laminae II and 3
Onset: 30 mins
Duration: 6-24 hours
**resp depression (early < 6 hrs; late > 6 hrs)
N&V: increased
Pruritus: increased

81
Q

What are some traits about lipophilic drugs that are administered in the epidural and spinal space?

A

Spread: stays in CSF for shorter period of time (less rostral spread)
Narrow band of analgesia
Site of action: rexed laminae 2 and 3/systemic
Onset: 5-10 mins
Duration: 2-4 hours
Resp depression: early
N&V: less
Pruritus: less

82
Q

What is the intrathecal dose and epidural dose of sufentanil?

A

Intrathecal: 5-10 mcg
Epidural: 25-50 mcg

83
Q

What is the intrathecal dose and epidural dose of fentanyl?

A

Intrathecal: 10-20 mcg
Epidural: 50-100 mcg

84
Q

What is the intrathecal dose and epidural dose of hydromorphone?

A

Intrathecal: ~
Epidural: 0.5-1 mg

85
Q

What is the intrathecal dose and epidural dose of meperidine?

A

Intrathecal: 10 mg
Epidural: 25-50 mg

86
Q

What is the intrathecal dose and epidural dose of morphine?

A

Intrathecal: 0.25 - 0.30 mg
Epidural: 2-5 mg

87
Q

What is the most common side effect of neuraxial opioid administration?

A

Pruritus

Then resp depression > urinary retention > N&V

88
Q

Why do opioids cause Pruritus?

A

Stimulation of opioid receptors in the Trigeminal nucleus

**must be treated with an opioid antagonist, such as naloxone

89
Q

How does neuraxial opioids cause urinary retention?

A

Inhibition of sacral parasympathetic tone ~ bladder detrusor muscle relaxation and urinary sphincter muscle contraction

90
Q

How do opioids cause N&V?

A

Activation of opioid receptors in the area posted a of the medulla and vestibular apparatus

91
Q

What can epidural morphine reactivate?

A

Herpes

92
Q

Which local anesthetic reduces the efficacy of epidural opioids?

A

2-Chloroprocaine

93
Q

What is ALWAYS an absolute contraindication to neuraxial anesthesia?

A

Patient refusal

94
Q

At what platelet count would a neuraxial technique be contraindicated?

A

<100,000

95
Q

Which anesthetic technique is preferred for a patient with MS?

A

Epidural is relatively safe, but intrathecal may exacerbate symptoms

96
Q

What 3 vascular lesions are generally considered contraindications for neuraxial anesthesia?

A

Severe Aprtic stenosis
Severe Mitral stenosis
Hypertrophic cardiomyopathy

97
Q

What is an example of a cutting needle?

A

Quincke

(Requires less force)

98
Q

What are two examples of a pencil point needle?

A

Sprotte
Whitacre

99
Q

What are the pros of a cutting needle? What are the cons?

A

Pros: requires less force

Cons: higher risk of PDPH, less tactile feel, needle more easily deflected, more likely to injure nerve roots

100
Q

What are the pros of a pencil point? What are the cons?

A

Pros: lower risk of PDPH, more tactile feel, needle less likely to deflect, less likely to injure nerve roots

Cons: requires more force

101
Q

How are epidural needles differed?

A

By the amount of curvature at the needle tip

Needle angle increases in alphabetical order

Crawford ~ 0
Hustead ~ 15
Tuohy ~ 30 degrees

102
Q

How deep is the epidural space in most adults?

A

3-5 cm from the skin.

103
Q

What are absolute contraindications to caudal anesthesia?

A

Spina bifida
Meningomyelocele of the sacrum
Meningitis

104
Q

What are the two landmarks for a caudal anesthetic?

A

Posterior superior iliac spines and the sacral hiatus

105
Q

What is the dose for a caudal anesthetic that goes to the sacral height?

A

Peds: 0.5 mL/kg

Adult: 12-15 mL

106
Q

What is the dose for a caudal anesthetic that goes from the sacral to low thoracic (~T10)?

A

Peds: 1 mL/kg

Adults: 20-30 mL

107
Q

What is the dose for a caudal anesthetic that goes from sacral to mid thoracic?

A

Peds: 1.25 mL/kg (this should be avoided though)

108
Q

What are some common pediatric procedures where a causal is useful?

A

Circumcision
Hypospadias repair
Anal surgery
Inguinal hernia
Low thoracic surgery

109
Q

What are the presenting symptoms of an epidural hematoma?

A

Lower extremity weakness
Numbness
Low back pain
Bowel and bladder dysfunction

110
Q

If a patient has an epidural hematoma, how soon should surgical decompression be initiated?

A

Within 8 hours!!

111
Q

How long should you hold COX-1 inhibitors prior to neuraxial block?

A

Examples: asa, NSAID

Management: none of labs look ok.

112
Q

How long should you hold a glycoprotein IIb/IIIw antagonist?

A

Example: tirofiban, eptifibatide, abciximab

Management:
Before block: hold tirofiban and eptifibatide 4-8 hrs; hold abciximab 24-48 hours

(Contraindicated within 4 weeks of surgery)

113
Q

How long should you hold a thienopyridine derivative?

A

Examples: clopidogrel, prasugrel, ticlopidine

Before block:
5-7 days with Clopidogrel
7-10 days with prasugrel
10 day hold ticlopidine

114
Q

How long should you hold heparin for a neuraxial block!?

A

Before block:
Low dose (5,000) ~ hold 4-6 hours
Higher dose (< 20,000) ~ hold 12 hr
Therapeutic dose (>20,000) ~ hold 24

May restart heparin after 1 hour

115
Q

How long should you hold heparin after removal of neuraxial catheter?

A

SubQ ~ hold 4-6 hours
IV ~ hold 4-6 hours after IV infusion discontinued.

(After catheter removal ~ restart in 1 hour)

116
Q

How long should you hold low molecular weight heparin (lovenox) for neuraxial anesthesia?

A

Before block placement:
Prophylactic: hold for 12 hours
Therapeutic dose: hold for 24 hours

(After block placed, delay first dose by 12 hours after block)

117
Q

How long should you wait for catheter removal with a patient on low molecular heparin (lovenox)

A

Catheter removal:
Remove before lovenox if possible or delay first dose 4 hours after removal

Otherwise remove 12 hours after last dose and HOLD next dose for at least 4 hours

118
Q

How long should you hold for a patient taking warfarin requesting neuraxial anesthesia?

A

Before block
Hold: 5 days

Catheter removal: wait until INR < 1.5

119
Q

How long should you hold for a patient taking oral anti-factor 10a agents requesting neuraxial anesthesia?

A

Before block:
72 hrs (3 days)

Catheter removal: must wait 6 hrs prior to first postoperative dose

120
Q

What is an ABSOLUTE contraindication to neuraxial anesthesia?

A

Thrombolytic agents

121
Q

What causes a post-dural puncture headache?

A

As CSF pressure is lost, cerebral vessels dilate, the brain stem sags into the foramen magnum and stretches the meninges and pulls on the tentorium

122
Q

What are some patient factors that increase the risk for PDPH?

A

Younger
Female
Pregnancy

123
Q

What are some practitioner factors?

A

Cutting tip needle
Larger diameter needle
Using air for LOR
Needle PERPENDICULAR instead of parallel

124
Q

What is the treatment for PDPH?

A

Bed rest
NSAIDs
Caffeine
Epidural blood patch (the DEFINITE treatment)
Sphenopalatine ganglion block

125
Q

What is the most common side effects following epidrual blood patch?

A

Backache and radicular pain

126
Q

What are the two routes by which an infectious organism can reach the CSF?

A

Failure of aseptic technique
Bacteria in the patient’s blood at the time of SAB

127
Q

What is the most common bacteria for post-spinal meningitis?

A

Streptococcus

128
Q

What is the MOST effective way to prevent post-spinal bacterial meningitis?

A

Alcohol and chlorhexidine

129
Q

What is cauda equina syndrome?

A

Neurotoxicity as result to high concentrations of local anesthetic

130
Q

What factors increase the risk of cauda equina syndrome?

A

5% lido
Spinal microcatheters

131
Q

What are the signs and symptoms of cauda equina syndrome?

A

Bladder and bowel dysfunction
Weakness
Sensory deficits
Paralysis

Treatment: supportive

132
Q

What is transient a Neurological Symptom?

A

Usually develops because of patient positioning, stretching of the sciatic nerve, myofascial strain, and/or muscle spasm

133
Q

What factors increase the risk of transient neurological symptoms?

A

Lidocaine, lithotomy, ambulatory surgery, and knee arthroscopy

134
Q

What are some signs and symptoms of transient neurological symptoms?

A

Severe back and butt pain that radiates to both legs

Develops within 6-36 hours and lasts 1-7 days

135
Q

What is the tx for transient neurological symptoms?

A

NSAIDs
Opioids
Trigger point injections

136
Q

What happens if a neuraxial catheter breaks off?

A

Leave the fragments in the patient, alert the patient, and watch for complications.

137
Q

What do you do if there is blood in the NEEDLE?!

A

Needle was inserted too laterally

Redirect midline

138
Q

What do you do if there is blood in the epidural catheter?

A

Pull the catheter back a little, flush, and repeat procedure till you are unable to aspirate blood and/or not enough catheter remains in the space

139
Q

What do you do for a failed spinal (no anesthesia)

A

If a spinal does not set up in 15-20 mins, it is reasonable to repeat the injection

140
Q

What do you do with a patchy spinal?

A

Do NOT repeat spinal ~ transition to another technique

141
Q

What do you with a unilateral block?

A

Position the patient with the poorly blocked side down and administer several mL of anesthetic ~ if not, consider another technique

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