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Jackie - Summer 6901 > Neuroaxial Blocks, Epidurals & Spinals > Flashcards

Neuroaxial Blocks, Epidurals & Spinals Flashcards

1
Q

What terms match up? 1. Epidural 2. Spinal block 3. SAB (subarachnoid block) 4. Peridural 5. Intrathecal 6. Extradural 7. Caudal

A

1, 4, 6, 7 2, 3, 5

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2
Q

How many curvatures are there in the spine?

A

4

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3
Q

Anterior or posterior curve? 1. Cervical 2. Thoracic 3. Lumbar 4. Sacral

A
  1. Anterior 2. Posterior 3. Anterior 4. Posterior
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4
Q

How many vertebrae are in each category? 1. Cervical 2. Thoracic 3. Lumbar 4. Sacral 5. Coccygeal

A
  1. 7 2. 12 3. 5 4. 5 5. 4
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5
Q

What two types of vertebrae are fused in adults?

A

Sacral and coccygeal

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6
Q

What level does the spinal cord stop from? And what emerges from there?

A

L1 and the cauda equina emerges from there

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7
Q

What level is the line drawn from the lower borders of the scapula?

A

T7

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8
Q

What spinal level is the line is drawn between the iliac crests? And what is the name for this?

A

L4 - Tuffier’s Line

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9
Q

What is the line between the posterior superior iliac spines?

A

S2 - distal extent of the dural sac

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10
Q

What is the term for a baricity greater than the spinal fluid? Hyper or hypobaric?

A

Hyperbaric

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11
Q

What are the 6 common parts of a vertebrae? And how many of each?

A

1 vertebral body 2 pedicles 2 transverse processes 2 laminae 1 spinous process 4 articular processes

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12
Q

What is the function of the 2 pedicles on the vertebra?

A

Notched for nerve roots

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13
Q

What is the function of the transverse processes on the vertebra?

A

Muscle attachments

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14
Q

What is the function of the 4 articular processes on the vertebra?

A

Synovial joints or faucet joints. Enable the spine to bend, move and twist.

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15
Q

What spinous process are more horizontal: Lumbar, cervical or throacic?

A

Lumbar & cervical

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16
Q

What vertebrae laminae are more vertical in orientation?

A

The more caudal vertebra

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17
Q

What vertebrae have shorter and broader spinous processes?

A

Lumbar

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18
Q

What ligament joins the vertebral spines?

A

supraspinous ligament

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19
Q

What ligament extends from the occipital protuberance to the coccyx?

A

supraspinous ligament

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20
Q

What ligament is between the spinous processes?

A

Interspinous ligament

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21
Q

What ligament extends from the foramen magnum to the sacral hiatus and is thickest in the lumbar area?

A

Ligamentum flavum

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22
Q

What three ligaments do you transverse when you are placing an epidural?

A

Supraspinous ligament, transverse ligament, and ligmentum flavum.

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23
Q

When will you know that you are in the epidural space?

A

When you loose resistance after crossing the ligmentum flavum

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24
Q

The epidural space extends from what area to what area?

A

base of the skull to the sacrococcygeal membrane.

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25
Q

The epidural space contains what?

A

epidural veins, fat, lymphatics, arteries, and nerve roots

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26
Q

What is the distance from the surface of the skin to the epidural space?

A

2.5cm to 8cm

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27
Q

What spinal level does the spinal cord extend to in adults and what level in children?

A

Adults: L1 Children: L3

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28
Q

What is the term for the tapered end of the spinal cord?

A

Conus medullaris

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29
Q

What structure anchors the spinal cord to the coccyx?

A

Flium Terminale

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30
Q

What are the nerve roots called that originate from the conus medullaris? And how does the spinal needle affect these nerve roots?

A

Cauda equina (“horses tail”) The spinal needle pushes the nerve roots away

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31
Q

Label these 10 items

A
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32
Q

What are the three meninges from deep to superficial?

A

Pia mater, arachnoid mater, and dura mater

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33
Q

What meninges are thin?

A

Pia and arachnoid maters

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34
Q

What meninges are thick?

A

Dura mater

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35
Q

What meninge directly covers the spinal cord?

A

Pia mater

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36
Q

What meninge is spider web-like?

A

Arachnoid mater

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37
Q

What space contains the CSF?

A

Subarachonid space

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38
Q

What meninge is the outer layer that is the consistency of an egg membrane?

A

Dura mater

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39
Q

What area of the spinal cord is supplied by the anterior spinal artery? Is this artery single or paird? And where does this artery arise from?

A

Supplies the anterior 2/3 of the spinal cord.

Single.

Arises from the vertebral artery.

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40
Q

What does the posterior spinal artery supply blood to? Is this single or paired artery? What does this artery arise from?

A

posterior 1/3 of the cord

Paired

Arises from the cerebellar arteries

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41
Q

What is the artery in the spinal cord that aries from the aorta? What does it supply blood to? What level in the spine is this artery found?

A

Artery of Adamkiewicz

Major blood supply to the anterior lower 2/3 of the cord

Between T11 and L3

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42
Q

What is the term for the area between the radicular arteries on the spinal cord? What type of blood flow occurs in these areas? Why is this siginificant during low-flow states? Between which specific arteries does this occur?

A

Watershed zones

Could be a lack of direct blood supply

Could be areas of ischemia

Between cervical radicular artery and thoracic radicular artery or between thoracic radicular artery and radicularis magma

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43
Q

What is another name for radicularis magma? And what does this artery supply blood to?

A

Artery of Adamkiewicz

The lower 2/3 of the spinal cord

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44
Q

Where is the CSF made?

A

Choroid plexus

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45
Q

Where is the CSF absorbed?

A

arachnoid villi

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46
Q

How much (mls) CSF is produced daily?

A

500cc

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47
Q

What is the total volume of the CSF?

A

120-150ml

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48
Q

How much of the CSF (mls) is in the spinal cord?

49
Q

What is the pressure of the CSF when supine (horizontal)?

50
Q

What is the specific gravity of the CSF?

A

1.004-1.009

51
Q

What procedures (7) are neuroaxial blocks useful for?

A

lower abdominal, inguinal, urogenital, rectal and lower extremity, obstetric, acute/chronic pain

52
Q

Can it be used in combination with general anesthesia?

53
Q

Neuroaxial anesthesia (more or less):

  1. nausea/vomiting
  2. urinary retention
  3. narcotic requirement
  4. return to metal alertness
  5. ability to eat, void and ambulate
  6. patient safety
  7. postop analgesia
A
  1. less
  2. less
  3. less
  4. quicker
  5. quicker
  6. improved
  7. better
54
Q

What are some debatable advantages of neuroaxial anesthesia?

A

safer

decreased blood loss

decreased thromboembolic events

decreased post-op ileus

increased cardiac stability

increased respiratory stability

55
Q

Absolute, relative or controversia contraindications?

  1. uncooperative patient
  2. patient refusal
  3. prolonged operation
  4. increased ICP
  5. major blood loss
  6. Mild or moderate stenotic valve lesions
  7. maneuvers that compromise respiration
  8. sepsis, elevated WBC, fever,
  9. Severe hypovolemia
  10. progressive or unstable neurologic disease
  11. infection at the site of injection
  12. severe arotic or mitral stenosis
  13. demylinating lesions
  14. Difficult to discern effects or complications of the block
  15. acute upper respiratory infection
  16. Chronic back pain, headache
  17. Multiple back surgeries
  18. significant coagulopathy (prolonged INR/PT, Plt <80, severe hepatic dysfunction)
  19. severe spinal deformity
  20. heart blocks
  21. full stomach
  22. Patient age
  23. HIV
  24. difficult airway
A
  1. relative
  2. absolute
  3. controversial
  4. absolute
  5. controversial
  6. relative
  7. controversial
  8. relative
  9. absolute
  10. relative
  11. absolute
  12. absolute
  13. relative
  14. relative
  15. controversial
  16. relative
  17. relative
  18. absolute
  19. relative
  20. relative
  21. controversial
  22. relative
  23. relative
  24. controversial
56
Q

Blockade physiology:

  1. Level of motor neuron block compared to sensory
  2. Level of autonomic nerve block compared to sensory
A
  1. 2 levels below
  2. 2 levels above
57
Q

Blockade physiology:

Heavy, light or no mylenation:

  1. motor
  2. sensory
  3. autonomic
A
  1. heavy
  2. non-mylenated
  3. light mylenated
58
Q

Blockade physiology:

Type of fiber:

  1. Autonomic
  2. Sensory
  3. Motor
59
Q

Blockade physiology:

Onset (first, second, last) to effect:

  1. Autonomic
  2. Sensory
  3. Motor
A
  1. First
  2. second
  3. Last
60
Q

Blockade physiology:

Time to recovery (first, second, last):

  1. Autonomic
  2. Sensory
  3. Motor
A
  1. Last
  2. Second
  3. First
61
Q

Spinal/Epidural Cardiovascular effects:

The height of the block affects vasomotor tone how: Increase or decrease?

  1. arterial vasodilation
  2. SVR
  3. Venous pooling
  4. Venous return
  5. Heart rate
A
  1. increased
  2. decreased
  3. increased
  4. decreased
  5. decreased
62
Q

Term for the autonomic blockade: unnoposed parasympathetic (vagal) tone (vs. sympathetic tone)

A

sympathectomy

63
Q

Spinal/Epidural Cardiovascular effects: What level do the sympathetic fibers arise from?

64
Q

Spinal/Epidural Cardiovascular effects: What levels do the cardio acceleratory fibers arise from?

65
Q

Spinal/Epidural Cardiovascular effects:

What is the effect of blocking the cardioaccelerator fibers?

What is this reflex called?

A

unopposed vagal tone and slowing of the heart rate

Bainbridge reflex

66
Q

What are some pulmonary effects of spinal anesthesia?

  1. accessory muscle
  2. intercostal nerve
  3. perception of breathing
  4. vital capacity
  5. effect of phrenic nerve
  6. cough
A
  1. loss of
  2. paralysis
  3. loss - can be scary
  4. small decrease
  5. Rarely paralyzed - apnea may result from brainstem hypoperfusion
  6. Impaired - problem with pts with COPD
67
Q

Effects of spinal anesthesia:

GI:

  1. vagal tone
  2. peristalsis
  3. sphincters
A
  1. unopposed
  2. increased
  3. relaxed
68
Q

Effects fo spinal anesthesia:

  1. thermoregulation
  2. CNS
  3. stress response
A
  1. decreased
  2. depression (some)
  3. decreased (some)
69
Q

Immediate complications of spinal anesthesia: Total spinal

How does this happen?

A

inadvertent dural injections with epidural placement

70
Q

Immediate complications of spinal anesthesia: Total spinal

Onset fast or slow?

71
Q

Immediate complications of spinal anesthesia: Total spinal

What levels does it get to?

A

cervical levels

72
Q

Immediate complications of spinal anesthesia: Total spinal

What are symptoms? (2 neuro, 2 cardiac, 1 GI, 2 resp)

A

agitation, unconsciousness, nausea, hypotension, bradycardia, respiratory insufficiency, apnea

73
Q

Immediate complications of spinal anesthesia: Total spinal

What is treatment? (Actions and meds)

A

ABC’s

Ephedrine, phenylepherine, fluids, move rapidly to epinephrine (300-500mcg)

74
Q

Immediate complications of spinal anesthesia: Cardiac arrest

What is an early symptom?

A

profound bradycardia

75
Q

Immediate complications of spinal anesthesia: Cardiac arrest

What patient population is most at risk?

A

young, healthy people

76
Q

Immediate complications of spinal anesthesia: Cardiac arrest

What type of block does it arise from?

A

high sympathetic block

77
Q

Immediate complications of spinal anesthesia: Cardiac arrest

Why does it occur?

A

vagal responses to decreased preload

78
Q

Immediate complications of spinal anesthesia: Cardiac arrest

What type of treatment is necessary?

A

Rapid, agressive treatment of bradycardia and hypotension (epinepherine 300-500mcg)

79
Q

Immediate complications of spinal anesthesia: GI complications

Incidence of nausea and vomiting

A

25%

about 100% for c-section

80
Q

Immediate complications of spinal anesthesia: GI complications

A

unopposed vagal tone, increased peristalsis, relaxed sphincters

81
Q

Immediate complications of spinal anesthesia: GI complications

What is a good antiemetic that is not usually used for an antiemetic?

82
Q

Immediate complications of spinal anesthesia: intravenous injection/local toxicity

What should you do prior to injection?

83
Q

Immediate complications of spinal anesthesia: intravenous injection/local toxicity

What should you do prior to giving the entire epidural injection?

A

Give a test dose

84
Q

Immediate complications of spinal anesthesia: intravenous injection/local toxicity

Lidocaine toxicity will manifest how?

A

CNS toxiticy (tingling, strange taste - copper pennies/metalic, visual disturbances, ringing in the ears)

85
Q

Immediate complications of spinal anesthesia: intravenous injection/local toxicity

Marcaine (bupivicaine) toxicity will manifest how? How do you treat?

A

Cardiac toxicity (ventricular arrhythmias)

Treat with lipid rescue - because lipid soluable

86
Q

Immediate complications of spinal anesthesia: intravenous injection/local toxicity

What is the med dose and % for lipid rescue? what is the bolus rate? How often do you repeat the boluses? Until what dose is reached?

What is the infusion rate? Continue until when? When would you increase the infusion? What would you increase the infusion to?

What is the maximum dose?

A

intralipid 20%

Bolus: 1.5ml/kg over 1 min

Repeat boluses every 3-5 minutes

until 3ml/kg

Infusion: 0.25ml/kg/min

continue until hemodynamic stability has been restored

Increase rate if BP drops - to 0.5ml/kg/min

Maximum dose: 8ml/kg

87
Q

Delayed complications of spinal anesthesia:

What is the most common complication of SAB?

A

Post dural puncture headache (PDPH)

88
Q

Delayed complications of spinal anesthesia:

What is the cause of PDPH?

A

Leakage of CSF through dural hole - CSF pressure falls and brainstem drops into the foramen magnum

89
Q

Delayed complications of spinal anesthesia: PDPH

What needle gauge do you want to use?

A

high gauge - small needle

17g touhy - 80%

29g sprotte - 1%

90
Q

Delayed complications of spinal anesthesia: PDPH

What direction do you want the bevel?

A

Keep parallel to fibers to avoid cutting - bevel to the side

91
Q

Delayed complications of spinal anesthesia: PDPH

What patient population has the highest incidence?

What patient population has the lowest incidence?

A

pregnant, young females - 20%

elderly males - <5%

92
Q

Delayed complications of spinal anesthesia: PDPH

What is the hallmark symptom? What are the characterisitics? What is the onset time?

A

POSITIONAL HEADACHE

headache behind the eyes moving posteriorly to occiput and extending to the neck and shoulders.

Throbbing or constant and associated with photophobia and nausea

Onset: 12-72 hours following the procedure

93
Q

Delayed complications of spinal anesthesia: PDPH

What are the 5 interventions to treat a PDPH?

A

Recumbant positioning

analgesics

fluid

caffeine

blood patch

94
Q

Delayed complications of spinal anesthesia: PDPH

How much blood is needed for a blood patch?

95
Q

Delayed complications of spinal anesthesia: PDPH

What level do you put the blood patch?

A

One level below the leak

96
Q

Delayed complications of spinal anesthesia: PDPH

How long does relief take with a blood patch?

97
Q

Delayed complications of spinal anesthesia: GI

Is there increased or decreased peristalsis with a sympathetic blockade? What if the patient has a bowel obstruction?

A

Increased peristalsis

Contraindicated in a bowel obstruction

98
Q

Delayed complications of spinal anesthesia: Urinary

What complication can happen in the urinary tract?

A

Urinary retention

99
Q

Delayed complications of spinal anesthesia: Endocrine

What happens with the stress response?

100
Q

Delayed complications of spinal anesthesia: Bachache

What causes backache? How can you treat this?

A

Profound skeletal muscle relaxation with SAB, positioning in litotomy may cause ligament strain

Treat with reassurance, rest - (or resume reasonable activities of daily leaving), heat, and mild analgesics.

101
Q

Delayed complications of spinal anesthesia: paralysis

What is the incidence of paralysis - frequent or rare? What is the etiology (three categories)?

A

Rare

Direct: needle trauma, surgical positioning

Toxic: chemical (betadine/chlorahexidine), virus, bacteria

Ischemic: hematoma (in watershed zones)

102
Q

Transient neurological symptoms:

What are some transient neurological symptoms of spinal anesthesia? What is the etiology? How long do symptoms last? What are risk factors?

A

pain or dysthesia in the buttocks, thighs, or lower limbs

radicular irritation

Symptoms usually resolve in 1 week

Risk factors: lidocaine, lithotomy, obesity

103
Q

What is cauda equina syndrome?

A

Neurotoxicity

104
Q

Cauda Equina Syndrome: What are possible factors?

A

Multiple attempts, parathesia, microcatheters, 5% lidocaine

105
Q

Cauda Equina Syndrome: What are symptoms?

A

Bowel and bladder dysfunction, paresis fo the legs, patchy sensory deficits

106
Q

Menningitis and arachnoiditis: How does this occur? List 4

A
  1. Contamination of equipment - virtually elimated with disposables
  2. insertion technique,
  3. catheter (coring of epidermis - use stylet in needles),
  4. glass particles (use filtered needle)
107
Q

Epidural hematoma: What increases the risk of epidural hematoma?

A

use of LMWH

108
Q

Epidural hematoma: What happens to the spinal cord with an epidural hematoma?

A

Mass effect - direct pressure and ischemia of the spinal cord

109
Q

Epidural hematoma: What are symptoms of an epidural hematoma?

A

Sharp back and leg pain - progression of numbness and motor weakness. With or without sphincter dysfunction

110
Q

Epidural hematoma: What diagnostic technique needs to be done immediately?

111
Q

Epidural hematoma: What is the treatment of an epidural hematoma? and how soon does it need to be done?

A

Evacuation within 6 hours?

112
Q

Epidural abscess: What are the symptoms of an epidural abscess?

A

back pain with fever following epidural anesthesia

113
Q

Epidural abscess: What is the treatment for an epidural abscess?

A

Antibiotics and surgical decompression

114
Q

Epidural abscess: What can you do to prevent an epidural abscess?

A

Sterile technique and remove the catheter after 96 hours

115
Q

What is the invisible line called that goes above the iliac crests? What vertebrae does this intersect?

A

Tuffier’s line

L4

116
Q

When inserting a neuroaxial block, what does the dominant hand do? What does the nondominant hand do?

A

Dominant: drives the needle

Non-dominant: braces against the back

117
Q

When do you aspiriate when injecting for a spinal?

What are you looking for when you aspiriate?

A

Aspirate at the beginning, mid and post (personal preference)

“swirl” of the CSF - to make sure it got into the CSF

118
Q

What is the paramedian technique?

A

Approaching the spinal column 1 inch from midline

Jackie - Summer 6901 (3 decks)

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