Neuraxial Technique - E1 Flashcards
What are the 6 reasons we should be set up to do a GETA w/ every neuraxial case?
- Failed block
- High Spinal - knock out resp. drive
- LAST - cardiac arrest/seizures
- Anaphylaxis
- Severe CV collapse
- Case exceeds duration of LA
Spinal Block
Kit Contents Spinal
- 3.5’’ styleted needle
- Introducer
- LA (skin, SAB)
- Betadine Prep
- Sterile drapes
- needles (22g for skin, 18g)
- filter needle - to draw up SA LA
- gauze
- also need sterile gloves, hats, mask
SAB
Why is the needle styleted?
To avoid microclots - the spinal needle is so small if it clots then you can’t push med in
Why does the spinal kit have an introducer needle?
so the spinal needle does not bend
SAB
What is the LA used for skin numbing?
1%
SAB
What is the volume of med we inject w/ a spinal?
2 mL
SAB
What are the cutting needles & when would we use them?
- Quincke
- Pitkin
- use if it is all we have - they cause PDPH
SAB
What are the non-cutting needles?
- Sprotte
- Whitacre
- Pencan
- Green
- Gertie Marx
SAB
What are 3 advantages of using a pencil-point tip needle?
- they drag fewer contaminants into subnormal tissue
- click or pop can be sensed
- less risk of PDPH
How often should we take v/s w/ neuraxial blocks?
Q 3-5 min
SAB
When will you see a swirl in your syringe?
If you are using a hyperbaric LA (mixed w/ dextrose) & you aspirate CSF
SAB
When would we use a pelvic tilt?
- in OB pts w/ a pillow to prevent HoTN caused by compression of the vena cava
SAB
If the pt starts to tell you their hand is getting numb, what are we concerned for??
High migration of the LA
SAB
Common Problems
- lack of free flow CSF
- resistance w/ injection
- No swirl
- Paresthesia - hard stop!
- blood instead of CSF
- No block - check expiration
- Partial block - give pain meds
Epidural
Epidural Kit Contents
- sterile prep/drapes
- LA
- Tuohy needle - 17/18g
- Needles (22g & 18g)
- 3ml, 5ml, 20ml syringes
- filter needle
- line filter
- LOR syringe
- epidural cath
Epidural
What LA is in the kits?
- 1% Lido - skin
- 1.5% Lido (15mg/kg) w/ 1:200,000 Epinephrine
Epidural needles
Tuohy
- most curvature (30 degrees)
- blunt tip less likely to puncture SA space
Epidural needles
Hustead Curvature
15 degrees
Epidural needles
When do we use the Crawford needle?
- catheter placement difficult
- steep angle (thoracic)
* has 0 degrees curvature
Epidural Needles
Weiss Curvature
15 degree curve
* has wings
Is the epidural needle styleted? What size is it?
- yes
- 17-18g
What size should the epidural cath be compared to needle?
2 gauges smaller
How many cm of the epidural cath should be in the epidural space?
3-5cm
Epidural Catheter
Multi-orifice cath
mutliple holes down the catheter length
* lower incidence of inadequate anesthesia - better spread
* most common one used
* higher incidence of inadvertent intravascular placement
Epidural Block
Determining Distance in cm
- measure skin to epidural space
- needle length is 9cm (subtract the visible cm from skin)
- 9cm needle - 4cm visible = 5cm from skin to epidural space - Skin Marking
- cath should be secured @ 10cm at the skin = 5cm from skin to epidural, 5cm in epidural space
Epidural Block
What are potential concerns w/ lumbar tattoos?
What is the recommendation?
- ink could be carried into the spine - leading to chemical arachnoiditis
- Paramedian approach
Epidural Block
What direction should the epidural tip be?
Up - opening cephalad
What is the test dose for an epidural catheter?
- 3 mL of 1.5% Lidocaine w/ epi (1:200,000)
- 1.5% = 15mg/mL = 45mg
- 1:200,000 = 5mcg/mL
Epidural Catheter
What important #s do we need to record?
- depth to epidural space (LOR)
- Catheter marking @ skin - 10cm
- Cath depth/length in epidural space (#cm in space)
What are the 2 ways to identify the epidural space?
- LOR syringe w/ saline (could do air or both)
- Hanging drop method - don’t use anymore
Epidural
What are the symptoms of accidental IV placement?
- HR increase by >20%
- Tinnitus
- metallic taste in mouth - first one usually
- circumoral numbness
- in pts on heart meds - BP increase of >20mmHg = IV placement
Epidural
What are the symptoms of accidental spinal injection?
- dense motor block w/i 5 min of test dose
- pt says feet are numb
When should we give the Epidural test dose in pregnant women?
After a contraction = clearer results
Epidural Dosing
1st dose
1-2mL/segment
* Epidural placed L4/L5 - need T10 blocked = 6 segments
* 6-12mL
Epidural Dosing
Top-up Dose
- give before “two-segment regression”
- give 1/2 - 3/4 of initial dose
- could also start drip
Top-Up times
Lidocaine
60 min from initial
Top-up Times
2-Chloroprocaine
45 min from initial dose
Top-up Times
Mepivacaine
60 min from initial dose
Top-up Times
Bupivacaine & Ropivacaine
120 min from initial dose
Epidural
Common Problems
- CSF “wet tap” (through dura)
- Paresthesia
- can’t thread catheter (PLICA)
- Aspirate blood
- Positive Test dose
- False positive test dose - OB contractions
