Neuraxial Review Part 1 Flashcards by Hannah Garrison

The anatomic landmark for spinal insertion is

Tuffier’s line

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A spinal is based on

dosage
baricity
patient position influences block level

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An epidural is a _____ block

volume block (volume determines level)

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Absolute contraindications to neuraxial technique include:

patient refusal
increased ICP
coagulopathy or bleeding diathesis 
severe hypovolemia
infection at the injection site
severe aortic or mitral valve stenosis

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Describe the jet velocity, mean gradient, and valve area for mild aortic valve stenosis.

jet velocity: <3.0
mean gradient: <25
Valve area: >1.5

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Describe the jet velocity, mean gradient, and valve area for moderate aortic valve stenosis.

jet velocity: 3.0-4.0
mean gradient: 25-50
valve area: 1.0-1.5

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Describe the jet velocity, mean gradient, and valve area for severe aortic stenosis.

jet velocity: >4.0
mean gradient: >50
valve area: <1.0

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Describe the jet velocity, mean gradient, and valve area for critical aortic valve stenosis.

jet velocity: >5.0
mean gradient: >80
Valve area: <0.7

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Relative contraindications for neuraxial technique include

uncooperative patient- inability to communicate/obtained informed consent or unable to assist
local anesthetic allergy
patient on anticoagulant or thrombolytic therapy
preexisting neurologic deficit
chronic headache or backache
severe spinal deformity
valvular stenosis

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The relative contraindication of anticoagulant and thrombolytic therapy is inclusive of patients with comorbidities such as

atrial fibrillation
previous DVT
or postsurgical administration for initiation of DVT prophylaxis

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Pre-procedure considerations for neuraxial include

versed
NPO status
consider fluid bolus administration

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Pre-procedure monitoring includes:

patent peripheral IV
suction
airway supplies
ECG, BP, pulse ox, possibly oxygen
supportive meds: induction agent, paralytic, atropine, vasoactive meds

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The following landmarks should be palpated for neuraxial technique

iliac crests
spinous processes of lumbar vertebrae
L2-L3 interspace is most common (examine one level above & below target)

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Describe the Tuohy needle

pronounced curve
easier for novices
directional placement of catheter

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Describe the Crawford needle.

is not curved
easier to insert
higher rate of dural punctures

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The standard depth of insertion at the lumbar level for an epidural is

4-6 cm

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The ligaments that are transversed include

supraspinous ligament
interspinous ligament
ligamentum flavum

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The two type of techniques to discern that you are in the epidural space include

loss of resistance
hanging drop (more pronounced at thoracic levels)

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Describe the following markings on the epidural catheter:
dashed lines
two-dashed lines
thick line

dashed lines= 1 cm
two-dashed lines= 10 cm
thick line= 12 cm

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Multiport epidural catheter considerations include

lower incidence of inadequate analgesia

higher incidence of accidental vein cannula

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The epidural catheter should be advanced _________ past the needle hub

3-5 cm past the needle hub

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Shallow displacement of the epidural catheter may result in

dislodgement from epidural space

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Too deep placement of the epidural catheter may result in

puncture of dura
passage into epidural vein
migration through intervertebral foramen

When placing an epidural, you should NEVER attempt to

withdrawal the catheter through the needle- sheering will be created

An appropriate test dose of an epidural catheter is

3 mL of 1.5% lidocaine with epinephrine 1:200,000 45 mg of lidocaine 15 mcg of epinephrine

If the needle is placed in the intravascular space,

20% increase in HR & BP

The first spinal was placed in

1899

The specific gravity describes the

density of a substance compared to the density of water SG water= 1.0 SG CSF= 1.003-1.009

Baricity is the

resting position of two fluids with different specific gravity when mixed in a single container- this helps determine the potential spread of LA in the SAH

The types of baricity include

isobaric- same, NS or CSF hyperbaric- heavier (more dense than CSF), dextrose hypobaric- LA is lighter than CSF, sterile water

Factors that influence local anesthetic level include

Most important: baricity, position of the patient drug dosage, site of injection other: patient height, pregnancy, age, CSF volume, curvature of the spine, drug volume, intra-abdominal pressure, needle direction

Hyperbaric solutions mitigate to the

most dependent areas of the spine | T4-T8

When using a _____ spinal needle or smaller, first place an introducer

25 gauge

The following are examples of pencil point needles:

Gertie Marx Sprotte Whitacre

The following are examples of cutting needles

Quincke

A continuous spinal can be considered when

a "wet tap" occurs during epidural placement | -small incremental doses of LA are given until desired level achieved

A combined spinal epidural can be placed

two-level- spinal placed first, epidural catheter placed 1-2 levels above one-level- placement of epidural needle, spinal needle passed through, small intrathecal dose injected, epidural catheter placed

Concerns of a combined spinal epidural include

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

Potential complications of combined spinal epidurals include

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

The paramedian approach can be used when

patient cannot flex spine- hx of previous spine surgery, RRA or hip or upper leg trauma will not pass through supraspinous or interspinous ligaments

When the needle touches the superior crest of spinous process below the interspace or you have early contact

redirect cephalad

When the needle touches the inferior surface of the spinous process above the interspace or you have late contact,

redirect caudad

Describe what to do if the patient experiences a parasthesia.

stop- if it resolves, continue | if it does not, remove and reposition

If there is blood in the catheter,

withdrawal the catheter and replace

If you have absence of CSF, no paresthesia, and no bone then it is possible that

the dura was transversed- remove stylet and attach syringe gently aspirate as you slowly withdrawal needle may get CSF as needle tip is withdrawn in to subarachnoid space

If you have blood-tinged CSF

frank blood- withdrawal and reposition | blood-tinged CSF- allows CSF to flow for several seconds and if it clears aspirate & inject

Adding _______ to LA will slow absorption and prolong block

vasoconstrictors

Describe the onset of nerve blockade.

``` B A delta & C pain fibers A gamma A beta A alpha ```

The cardioaccelerator fibers are located at

A delta & C fibers are responsible for

light touch, temperature, sensory loss

A alpha, a beta, and a gamma are responsible for

touch and proprioception surgical muscle relaxation may feel pressure

The ______ blockade is two dermatome levels higher than level of ____ block

autonomic sensory motor block is two levels below sensory block

Complications of neuraxial technique include

``` hypotension intercostal muscle paralysis apnea/phrenic nerve paralysis paresthesia subarachnoid or epidural hematoma meningitis/epidural abscess chemical meningitis nausea & vomiting post dural puncture headache ```

Risk factors for PDPH include

``` needle size & type patient population (younger, female & pregnancy) ```

Signs & symptoms of PDPH include

headache photophobia nausea can be positional

Treatment for PDPH includes

``` recumbent position analgesics fluid administration caffeine stool softeners and soft diet epidural blood patch ```