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Advanced Principles 2 > Neuraxial Review Part 1 > Flashcards

Neuraxial Review Part 1 Flashcards

1
Q

The anatomic landmark for spinal insertion is

A

Tuffier’s line

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2
Q

A spinal is based on

A

dosage
baricity
patient position influences block level

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3
Q

An epidural is a _____ block

A

volume block (volume determines level)

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4
Q

Absolute contraindications to neuraxial technique include:

A 
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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5
Q

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

A

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

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6
Q

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

A

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

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7
Q

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

A

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

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8
Q

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

A

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

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9
Q

Relative contraindications for neuraxial technique include

A

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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10
Q

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

A

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

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11
Q

Pre-procedure considerations for neuraxial include

A

versed
NPO status
consider fluid bolus administration

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12
Q

Pre-procedure monitoring includes:

A 
patent peripheral IV
suction
airway supplies
ECG, BP, pulse ox, possibly oxygen
supportive meds: induction agent, paralytic, atropine, vasoactive meds
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13
Q

The following landmarks should be palpated for neuraxial technique

A

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

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14
Q

Describe the Tuohy needle

A

pronounced curve
easier for novices
directional placement of catheter

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15
Q

Describe the Crawford needle.

A

is not curved
easier to insert
higher rate of dural punctures

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16
Q

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

A

4-6 cm

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17
Q

The ligaments that are transversed include

A

supraspinous ligament
interspinous ligament
ligamentum flavum

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18
Q

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

A 
loss of resistance
hanging drop (more pronounced at thoracic levels)
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19
Q

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

A

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

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20
Q

Multiport epidural catheter considerations include

A

lower incidence of inadequate analgesia

higher incidence of accidental vein cannula

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21
Q

The epidural catheter should be advanced _________ past the needle hub

A

3-5 cm past the needle hub

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22
Q

Shallow displacement of the epidural catheter may result in

A

dislodgement from epidural space

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23
Q

Too deep placement of the epidural catheter may result in

A

puncture of dura
passage into epidural vein
migration through intervertebral foramen

24
Q

When placing an epidural, you should NEVER attempt to

A

withdrawal the catheter through the needle- sheering will be created

25
Q

An appropriate test dose of an epidural catheter is

A

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

26
Q

If the needle is placed in the intravascular space,

A

20% increase in HR & BP

27
Q

The first spinal was placed in

A

1899

28
Q

The specific gravity describes the

A

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

29
Q

Baricity is the

A

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

30
Q

The types of baricity include

A

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

31
Q

Factors that influence local anesthetic level include

A

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

32
Q

Hyperbaric solutions mitigate to the

A

most dependent areas of the spine

T4-T8

33
Q

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

A

25 gauge

34
Q

The following are examples of pencil point needles:

A

Gertie Marx
Sprotte
Whitacre

35
Q

The following are examples of cutting needles

A

Quincke

36
Q

A continuous spinal can be considered when

A

a “wet tap” occurs during epidural placement

-small incremental doses of LA are given until desired level achieved

37
Q

A combined spinal epidural can be placed

A

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

38
Q

Concerns of a combined spinal epidural include

A

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

39
Q

Potential complications of combined spinal epidurals include

A 
failure to obtain either intrathecal or epidural block
catheter migration
increased spinal level
metallic particles
PDPH
neurologic injury
40
Q

The paramedian approach can be used when

A

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

41
Q

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

A

redirect cephalad

42
Q

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

A

redirect caudad

43
Q

Describe what to do if the patient experiences a parasthesia.

A

stop- if it resolves, continue

if it does not, remove and reposition

44
Q

If there is blood in the catheter,

A

withdrawal the catheter and replace

45
Q

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

A

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

46
Q

If you have blood-tinged CSF

A

frank blood- withdrawal and reposition

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

47
Q

Adding _______ to LA will slow absorption and prolong block

A

vasoconstrictors

48
Q

Describe the onset of nerve blockade.

A 
B
A delta & C pain fibers
A gamma
A beta
A alpha
49
Q

The cardioaccelerator fibers are located at

A

T4

50
Q

A delta & C fibers are responsible for

A

light touch, temperature, sensory loss

51
Q

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

A

touch and proprioception
surgical muscle relaxation
may feel pressure

52
Q

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

A

autonomic
sensory
motor block is two levels below sensory block

53
Q

Complications of neuraxial technique include

A 
hypotension
intercostal muscle paralysis
apnea/phrenic nerve paralysis
paresthesia
subarachnoid or epidural hematoma
meningitis/epidural abscess
chemical meningitis
nausea & vomiting
post dural puncture headache
54
Q

Risk factors for PDPH include

A 
needle size & type
patient population (younger, female & pregnancy)
55
Q

Signs & symptoms of PDPH include

A

headache
photophobia
nausea
can be positional

56
Q

Treatment for PDPH includes

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

Advanced Principles 2 (42 decks)

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