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Anesthesia Foundations 2 > Neuraxial Blocks - Torabi PP > Flashcards

Neuraxial Blocks - Torabi PP Flashcards

1
Q

What vertebral level corresponds with this landmark: Spine of Scapula

A

T3

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2
Q

What vertebral level corresponds with this landmark: Posterior Superior Iliac Spine

A

S2

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3
Q

What vertebral level corresponds with this landmark: Superior Aspect of Iliac Crest

A

L4

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4
Q

What vertebral level corresponds with this landmark: Vertebra Prominens

A

C7

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5
Q

What vertebral level corresponds with this landmark: Inferior Angle of Scapula

A

T7

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6
Q

What vertebral level corresponds with this landmark: Rib margin 10cm from the midline

A

L1

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7
Q

How many vertebrae are there?

A

33

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8
Q

How many cervical vertebrae?

A

7

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9
Q

How many thoracic vertebrae?

A

12

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10
Q

How many lumbar vertebrae?

A

5

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11
Q

How many sacral vertebrae?

A

5 -fused

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12
Q

How many coccygeal vertebrae?

A

4-fused

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13
Q

Another name for facet joint?

A

Zygapophyseal Joint

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14
Q

What is the intercristal line?

A

AKA Tuffers Line
A horizontal line drawn across the superior aspects of the iliac crests correlates with the L4 vertebra.

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15
Q

The interspace above the intercristal line correlates with?

A

L3-L4

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16
Q

The interspace below the intercristal line correlates with?

A

L4-L5

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17
Q

In infants, up to 1 year, the intercristal line correlates with the?

A

L5-S1 interspace

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18
Q

What is the Sacral Hiatus

A
  • Coincides with S5
  • Covered by sacrococcygeal ligament
  • Provides entry point to epidural space, useful in pediatrics
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19
Q

What is the sacral cornua

A

bony nodules that flank the sacral hiatus

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20
Q

Where is the conus medullaris located in adults and infants?

A

Adult: L1-L2
Infant: L3

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21
Q

What and Where is the cauda equina?

A

Bundle of spinal nerves extending from the conus medullaris to the dural sac.
Nerve and Nerve Roots from L2-S5 nerve pairs and coccygeal nerve

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22
Q

Where does the subarachnoid space terminate? What vertebrae?

A

dural sac
Adult: S2
Infant S3

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23
Q

What anchors the spinal cord to the coccyx?

A

Filum Terminale

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24
Q

What two points is the Filum Terminale fixed at?

A
  1. conus medullaris
  2. coccyx
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25
Q

Describe the location of the supraspinous ligament

A

Runs most of the length of the spine and joins the tips of the spinous processes

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26
Q

Describe the location of the Interspinous Ligament

A

Travels adjacent to and joins the spinous processes

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27
Q

Describe the location of the Ligamentum Flavum

A

2 Flava run the length of the spinal canal
Form the dorsolateral margins of the epidural space

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28
Q

Where is the ligamentum flavum thickest?

A

Lumbar region

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29
Q

Piercing the ligamentum flavum contributes to losing resistance when the needle enters the ____?

A

Epidural Space

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30
Q

Describe the location of the posterior longitudinal ligament?

A

Travels along the posterior surface of the vertebral bodies

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31
Q

Describe the location of the anterior longitudinal ligament

A

It attaches to the anterior surface (tummy side) of the vertebral bodies and extends the entire length of the spine.

It also attaches the annulus fibrosus of the intervertebral discs

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32
Q

During the midline approach, the needle [passes through how many and which ligaments?

A

passes through 3
Supraspinous Ligament
Interspinous Ligament
Ligamentum Flavum

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33
Q

During the paramedian or Taylor approach, how many ligaments does the needle pass, and which ligaments?

A

1 ligament: Ligamentum Flavum

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34
Q

With either approach, midline or paramedian, the needle should NEVER pass through which ligaments?

A

Anterior or Posterior Longitudinal Ligaments

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35
Q

When is the paramedian approach useful?

A

When the interspinous ligament is calcified or when the patient cannot flex their spine

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36
Q

What position can the paramedian approach be performed in?

A

Sitting, lateral, or prone

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37
Q

The paramedian approach involves inserting the needle:

A

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

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38
Q

Name the borders of the epidural space: cranial, caudal, anterior, posterior, lateral

A

Cranial: Foramen Magnum
Caudaul: Sacrococcygeal Ligament
Anterior: Posterior Longitudinal Ligament
Posterior: Ligamentum Flavum, Vertebral Lamina
Lateral: Vertebral Pedicles

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39
Q

Epidural fat acts as a sink for lipophilic drugs, reducing their bioavailability. List these drugs in order of bioavailability in the epidural space: fentanyl, morphine, bupivacaine, lidocaine

A

Bupivacaine > Lidocaine and Fentanyl > Morphine

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40
Q

The group of epidural veins that drain venous blood from the spinal cord is called?

A

Batson’s Plexus

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41
Q

What regions do the epidural veins pass through within the epidural space

A

anterior and lateral regions

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42
Q

Conditions such as obesity and pregnancy increase or decrease the epidural space?

A

Decrease. Increases in intraabdominal pressure cause engorgement of Batson’s plexus. Associated with an increased risk of needle injury or cannulation during neuraxial techniques.

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43
Q

Inadvertent local anesthetic injection into the subdural space will cause?

A

If using epidural dosing: A high spinal

If using spinal dosing: A failed spinal

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44
Q

The subarachnoid space lies deep to the arachnoid mater. Name a few things it contains:

A

CSF, Nerve Roots, Rootlets, and the spinal cord

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45
Q

What is the target area when performing a spinal anesthetic?

A

Subarachnoid Space

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46
Q

The adult spinal cord extends from where to where? And in Children?

A

The medulla oblongata through L1 – L2

Children L3

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47
Q

What is the primary function of the cauda equina?

A

To send and receive messages between the lower limbs and the pelvic organs, which consist of the bladder, the rectum, and internal genital organs.

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48
Q

When does Cauda Equina syndrome usually develop, and how long does it persist?

A

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

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49
Q

What position is caudal anesthesia done in? What landmark do you palpate for?

A

Lateral or prone position

Palpate scaral hiatus and sacral cornua

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50
Q

Absolute contraindications for caudal anesthesia

A

Spina bifida
meningomyelocele of the sacrum
meningitis

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51
Q

Incidence of local anesthetic-induced seizures occurs more frequently following?

A

Caudal epidural

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52
Q

Indications and Advantages of Neuraxial blockade

A

-Indicated for acute and chronic pain, surgery, labor analgesia/anesthesia
-Less nausea, vomiting, urinary retention
-Decreased opioid consumption
-Greater mental alertness
-Blunt stress response to surgery
-Decrease intraoperative blood loss
-Lower thromboembolic events, ileus
-Increase patency of vascular grafts
-Improved respiratory function

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53
Q

In the adult, the Dura sack ends at what vertebrae? In the infant?

A

S2-adult
S3-infant

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54
Q

How much CSF is produced every day, what produces it?

A

500 mL produced every day/25 mLs per hour.

Produced by the choroid plexus in the lateral third and fourth ventricle.

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55
Q

How much CSF is in circulation? I swear.

A

One 25–150 mL

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56
Q

how much CSF in the subarachnoid space?

A

30–80 mL (T – 11 downward)

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57
Q

After CSF is produced in the lateral ventricles, where does it flow next?

A

Through the Foramina of Munro to the third ventricle.

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58
Q

in the third ventricle where does CSF flow next?

A

Through the aqueduct of Sylvius to the fourth ventricle

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59
Q

From the fourth ventricle, where does CSF next?

A

passes through the foramina
of Magendie and Luschka of the fourth ventricle to reach the subarachnoid space of
the brain

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60
Q

About how long does a spinal last that doesn’t have epinephrine added?

A

~2 hours

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61
Q

what are some indications for a high (T4-T6) thoracic epidural

A

Thoracotomy, pectus repair, thoracic, aortic aneurysm repair

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62
Q

What are some indications for a mid thoracic epidural?

A

Upper abdominal surgery such as: esophagectomy, gastrectomy, pancreatectomy, hepatic resection

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63
Q

What are some indications for a lower thoracic epidural?

A

Lower abdominal surgery such as: abdominal aortic aneurysm repair. Colectomy, abdominal peroneal resection

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64
Q

when performing a spinal for a C-section. What dermatome level do we want the spinal to reach?

A

T4 – nipple line

65
Q

what spinal nerve root gives cutaneous innervation to the first digit a.k.a. thumb

66
Q

What spinal nerve root gives cutaneous innervation to the second and third digits?

67
Q

What spinal nerve root gives cutaneous innervation of the fourth and fifth digits

68
Q

What spinal nerve root gives cutaneous innervation across the nipple line?

69
Q

What spinal nerve root gives cutaneous innervation at the xiphoid process?

70
Q

What spinal nerve root gives cutaneous innervation at the umbilicus?

71
Q

What spinal nerve root gives cutaneous innervation at the pubic symphysis?

72
Q

What spinal nerve root gives cutaneous innervation at the anterior knee?

73
Q

what three nerve roots keep the diaphragm alive?

A

C3 four and five

74
Q

At what dermatome level are all cardio accelerator fibers blocked?

75
Q

list the order of blockade from a spinal

A

Autonomic
Temperature
Pain
Touch
Deep pressure
Motor

76
Q

what are three things you can use to test your sensation/sensory block?

A

Cold spray, ice cubes, alcohol pad

77
Q

What are three things you can use to test your sensory/pain block?

A

Broken end of tongue blade, style of epidural, needle, or blunt needle tip, nerve stimulator.

Test normal area first then test from mid thigh and move upwards

78
Q

What are two ways to test your motor block?

A

Ask the patient to lift their leg or ask the patient to step on the gas

79
Q

what is the site of action of an epidural?

A

Defuses through the Darrell cuff migrating to nerve roots

80
Q

What is the side of action of a spinal?

A

Myelinated pre-ganglionic fibers of spinal nerve roots

81
Q

What gauge is the Tuohy needle used in an epidural?

82
Q

The primary determinant of spread in an epidural is?

A

the volume injected

83
Q

do you expect an autonomic/sympathetic blockade in epidurals?

A

NO, unless you position the patient flat and dose them too high for a C-section.

84
Q

What is baricity?

A

Ratio of the density of the local anesthetic solution to the density of CSF

85
Q

Caution must be used when using a hypobaric local anesthetic solution because?

A

It can rise, causing a more dispersed blockade

86
Q

what are two ways via positioning, you can use baricity to your advantage when performing a spinal for a hemorrhoidectomy?

A

Hyperbaric solution: place patient in sitting position for 15 minutes, then turn prone

Hypobaric solution: jackknife or prone position

87
Q

what is the main determinant of local anesthetic spread for a spinal?

88
Q

what are factors that significantly affect the spread of spinal anesthesia?

A

-Baricity of local anesthetic
-Patient position during an after block
-Dose
-Site of injection

89
Q

What are factors that do not significantly affect the spread of spinal anesthesia?

A

Barbotage
Increased intra-abdominal pressure
Speed of injection
Orientation of needle bevel
Addition of vasoconstrictor
Weight
Gender

90
Q

What is barbotage?

A

The aspiration of injected volume + CSF back into the syringe, followed by re-injection twice with 0.5mL INCREASES WITH EACH ASPIRATED VOLUME.

[the technique of repeatedly withdrawing and re-injecting cerebrospinal fluid (CSF) and local anesthetic solution during the injection process]

91
Q

What are absolute contraindications to neuraxial anesthesia?

A

patient refusal Coagulopathy or bleeding
Increased intracranial pressure Severe aortic or mitral stenosis
Ischemic hypertrophic subaortic stenosis Severe hypovolemia
`Infection at site of injection

92
Q

relative contraindications to neuraxial anesthesia

A

Pre-existing neurological complications Peripheral neuropathy
Sepsis Hypertrophic obstructive cardiomyopathy
Uncooperative patient Severe spinal deformity
`Demyelinating lesions

93
Q

what are some controversial contraindications to neuraxial anesthesia?

A

` prior back surgery
` prolonged operation
` major blood loss
` complicated surgery
` maneuvers that compromise respiration

94
Q

what coag lab values would indicate neuraxial anesthesia should be avoided?

A

Platelets less than 100,000
PT, aPTT, and bleeding time > than 2x normal values

95
Q

What is normal PT values

96
Q

What is normal PTT values

97
Q

Normal Bleeding time

98
Q

When used alone do herbal supplements appear to increase the risk of spinal hematoma?

A

No, but when combined with an anticoagulant risk increases

99
Q

What three herbal supplements should be stopped prior to expected neuraxial anesthesia?

A

Gingki (stop 36 hours)
Garlic (stop 7 days)
Ginseng (stop 34hrs)

100
Q

How many days before a block placement should warfarin be held

100
Q

What anticoagulant class of agents are absolute contraindications to Neuraxial anesthesia?

A

Thrombolytic agents such as TPA, streptokinase, Alteplase, urokinase

101
Q

An epidural catheter can be removed if the INR is less than?

102
Q

What are the neuraxial anesthetic considerations for patients on unfractionated heparin?

A

You can proceed with neuraxial if:
1. Patient has a normal clotting mechanism.
2. Patient is not on other blood thinning drug drugs.

Hold heparin 2 to 4 hours before block.

Hold for one hour after block

After indwelling catheter has been removed hold 2 to 4 hours

103
Q

What are the neuraxial anesthetic considerations for patients on LMW heparin?

A

If on a once-daily prophylactic dose hold for 12 hours

If on a therapeutic dose twice daily, hold for 24 hours

Before removing indwelling catheter hold 12 hours

After indwelling catheter has been removed hold two hours

104
Q

Do you need to hold neuraxial anesthesia if patient is taking NSAIDs?

A

No, as long as patient has a normal cloudy mechanism and isn’t on any other blood thinning agents

105
Q

How many days before neuraxial block placement should Clopidogrel be held?

A

Seven days

106
Q

What are three types of neuraxial infections?

A

Septic/aseptic meningitis
Epidural abscess
Arachnoiditis

107
Q

What are some risk factors that increase the risk of infection during neuraxial anesthesia?

A

Breaking aseptic technique
Psoriasis
Diabetes
HIV, immuno suppression
Steroid therapy
Herpes

108
Q

What are “must do’s” for aseptic technique

A

Wash hands for 20 seconds
Surgical cap for provider and patient
Mask which covers both nose and mouth
No ID tags in field
Sterile prep and drape

109
Q

Systemic effects of neuraxial anesthesia

A

Vasodilate arterial and Venus vessels (hypotension, bradycardia) Accessory muscle function is decreased
Impairment of intercostal muscle(impaired ability to cough) Loss of proprioceptive input from chest (dyspnea)
Reduces sensory input to the reticular activating system(drowsiness) Inhibits afferent pathways(decreased stress response)

110
Q

Intraoperative risks of neuraxial anesthesia?

A

Inability to obtain adequate anesthesia
Paresthesia
Hypotension
Dyspnea
High or total spinal
Nausea and vomiting
Allergic reactions

111
Q

What patient population is more likely to have an unexpected cardiac arrest following neuraxial anesthesia?

A

Young healthy patients due to increased basal vagel tone

112
Q

Sub arachnoid block, cardiac arrest can occur______ minutes after insertion

113
Q

Strategies to prevent and treat spinal anesthesia-induced hypotension (SIH)

A

Crystalloid/collide Solutions 15mL/kg, or 500-1000mL, 15 min before procedure
Vasopressors
Positioning
5 – HT3 antagonists (zofran)

114
Q

Post operative risks of neuraxial anesthesia?

A

Wet Tap: PDPH
Sepsis
Neurological problems
Backache
Hematoma

115
Q

What is the definition of a high spinal?

A

Spread of local anesthetic block affecting the spinal nerves above T4. Effects will depend on the nerves involved, except bradycardia and shortness of breath.

116
Q

What is the definition of a total spinal?

A

Intracranial spread of local anesthetic, resulting in loss of consciousness

117
Q

Cardiovascular effects of neuraxial anesthesia

A

Decreased stroke volume via decreased venous return Decrease heart rate if cardio accelerator fibers T1 – T4 are blocked
`Bezold-Jarisch reflex: vagal afferent stimulation in response to noxious ventricular stimuli (aka drop in preload/ventricle pressure)

118
Q

What dose of epinephrine can be added to local anesthetic for a subarachnoid block?

A

0.1–0.2 mg

119
Q

What morphine dose can be added to enhance the quality of a subarachnoid block

A

0.1–0.25 mg

120
Q

What fentanyl dose can be added to enhance the quality of a subarachnoid block?

A

10–25mcg

121
Q

What ocular and facial complication can occur if local anesthetic spread spreads to head and neck?

A

Horner syndrome (ptosis, miosis, and anhidrosis, enophthalmos)

122
Q

What auditory complication can occur from postural puncture, leaks or large volumes of epidural injection?

A

Transient hearing loss and retinal hemorrhage by changes in CSF pressure

123
Q

What is the site of action of opioids when added to neuraxial anesthesia?

A

Substantia gelatinosa, rexed lamina II

124
Q

How do vasoconstrictors prolong the action of local anesthetics in neuraxial anesthesia?

A

Vasoconstriction keeps the local anesthetic in contact with nerve fibers longer

125
Q

What baricity and % Bupivacaine is commonly used for subarachnoid block?

A

Bupivacaine 0.75% with Dextrose 8.25% which is hyperbaric

126
Q

What is the average distance from skin to epidural space in an average adult?

127
Q

What is the average distance from skin to epidural space in an obese adult?

128
Q

What is the average distance from skin to epidural space in a thin adult?

129
Q

In what order, through what structures, does the needle pass during epidural placement?

A

Skin
Subcutaneous fat
Supraspinous ligament
Interspinous ligament
ligamentum flavum
Epidural space

130
Q

What is Batson’s plexus?

A

Venous plexus within the epidural space. Obesity and pregnancy make them more engorged.

131
Q

What is the most common needle tip for spinal?

A

25G whitacre

132
Q

What is the most common needle for epidurals?

133
Q

What percent lidocaine do we use for our skin wheal?

134
Q

What is our test dose of lidocaine and epi for an epidural?

A

~3mL of 1.5% lido (15mg/mL) with 1:200,000 epi (5mcg/mL)

135
Q

If an epidural catheter must be withdrawn while the needle remains in place. how do you remove?

A

Carefully withdraw both together

136
Q

Catheter insertion on me tip should be how many centimeters?

137
Q

Is epidural local anesthetic spread more or less in the elderly?

A

3 to 4 times greater in elderly limit local anesthetic volume amt per segment

138
Q

Is epidural spread more or less in pregnancy?

A

More limit local anesthetic volume amount per segment

139
Q

What are some side effects of neuraxial opioids

A

Most common
Respiratory depression
Urinary retention most common among young males
Nausea vomiting

140
Q

How would you manage a patchy epidural block or inadequate block?

A

Reposition the patient with the UNblocked side down (dependent) or by administration of a more local anesthetic solution.

141
Q

What tattoo pigment is associated with the highest incidence of reactions?

142
Q

What signs and symptoms might you see if you inadvertently injected your epidural anesthetic into vasculature?

A

Restlessness, dizziness, tinnitus, perioral paresthesia, difficulty speaking, seizures, loss of consciousness

143
Q

What signs and symptoms might you see if you inadvertently injected your epidural anesthetic into the subarachnoid space (aka spinal)?

A

agitation, profound hypotension, bradycardia, dyspnea, inability to speak, LOC, T1-4 Blockade

144
Q

What should you do if the epidural catheter tip breaks off during removal?

A

Inform patient, document in chart.
If pt asymptomatic - leave in
If symptomatic - order MRI and consult neurosurg

145
Q

What are some complications of a Combined Spinal Epidural (CSE) block

A

Failure to obtain a subarachnoid or epidural block Catheter migration
Increased spinal level after epidural admin Metallic particles when spinal needle enters epidural needle
PDPH Infection
`Neurologic Injury

146
Q

What physiologically occurs that causes a post-dural puncture headache?

A

Decrease in CSF volume and pressure in subarachnoid space, meninges stretched.

147
Q

What are some factors that increase the incidence of PDPH?

A

Large, non-pencil point needle Cutting needle bevel direction (perpendicular) to long axis of meninges
Multiple punctures Female
`Age less than 40

148
Q

When does a PDPH usually occur? What are some S/S?

A

Within several hours to 1-2 days postop

Headache: mild to incapacitating. Positional, relieved when pt is lying down.
N/V
Appetite loss
Blurred vision, photophobia
Plugged ears sensation, loss of hearing acuity, tinnitus
Vertigo
Depression

149
Q

What are two factors that do not effect the risk of PDPH

A

Early ambulation
Continuous spinal catheter, if placed after spinal block

150
Q

Conservative treatments for PDPH

A

horizontal positioning
adequate hydration
oral analgesics
IV Caffeine (500mg)
Oral Caffeine (300mg)
Theophylline: 150mg q12hours
Sphenopalatine Ganglion Block (SPG)

151
Q

What are the steps to performing a sphenopalatine ganglion block

A
  1. Soak long cotton tupped applicator in 1-4% lidocaine or 0.5% bupivacaine
  2. Place pt in sniffing position
  3. Insert applicator into each nare toward middle turbinate
  4. Stop when you hit the posterior wall of nasopharynx
  5. Leave applicator in for 5-10min
152
Q

What is the definitive tx for a PDPH? How does it work?

A

Epidural blood patch

Works by helping clot formation to seal dura and increase CSF pressure

153
Q

How quickly does an epidural blood patch work?

A

Relief is usually instantaneous

154
Q

Can you repeat an epidural blood patch?

A

yes, may try again in 24 hours.

2 failed blood patches -> seek alt diagnosis

155
Q

Where do you insert your needle for an epidural blood patch?

A

At the same level or 1 level below the level of the lowest initial needle insertion

156
Q

Where do you obtain blood for a epidural blood patch?

A

20mL patient’s venous blood from a PIV or 1 time AC blood draw

157
Q

When do you stop injecting the blood in an epidural blood patch?

A

Proceed until pt senses pressure in back, butt, or legs (~12-15mL usually)

158
Q

How long should the pt remain supine after an epidural blood patch?

A

30min-1hour after procedure

Anesthesia Foundations 2 (12 decks)

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