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Anesthesia subspecialty > Pain & Regional > Flashcards

Pain & Regional Flashcards

1
Q

When to suspect mistakenly subdural injection

A

When subarachnoid or epidural block does not behave as expected. Often the symptoms are variable but classically they are:

  1. minimal or variable motor blockade,
  2. excessive sensory blockade,
  3. excessive sympatholysis.
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2
Q

Size and type of needle that reduces risk of PDPH?

A

Small > 24 G

Pencil point needles (sprite, whitacre)

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3
Q

Diarrhea & orthostatic hypo tension associated with a …. plexus block (T5-12)

A

celiac plexus, which supplies innervation to all the intraabdominal organs, including most of the bowel. hypotension occurs because vasodilation of the splanchnic vessels, increasing venous capacitance

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4
Q

Bilateral lumbar plexus nerve blocks complication … and …

A

ejaculatory mechanism and hypotension caused by vasodilation and lower extremity venous pooling

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5
Q

Risk factors for PDPH includes

A
  • Young age (incidence peaks in the early 20s)
  • Pregnancy
  • History of headaches
  • Smaller gauge (larger bore) cutting needles
  • Greater number of dural punctures
  • Skill of the operator
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6
Q

Antiphosphlipid syndrome patients have elevated PTT, would that be a CI for neuraxial anesthesia?

A

No, the PTT elevated as a result from an inhibitor directed against phospholipid rather than specific coagulation factors and so dose not suggest a bleeding tendency.

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7
Q

If phrenic nerve hit during interscalene blockade, where would you redirect the needle

A

posteriorly

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8
Q

If develops twitching in the sartorius muscle during femoral block, what next step? (you might hit the femoral branch suppling the sartourius and not the main trunk of femoral nerve).

A

Check the patellar twitch.

If a sartorius twitch without patellar twitch is elicited, the needle should be redirected deeper and lateral.

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9
Q

Ilioinguinal block is performed in the transversus abdominis plane between …

A

the internal oblique muscle and the transversus abdominis muscle.

It provides cutaneous sensory innervation to suprapubic abdomen, root of the penis and upper scrotum in males, and the mons pubis and labia majora in females.

It can be targeted on the flank at the axis level between the anterior superior iliac spine and the umbilicus

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10
Q

Treatment of nausea associated with high (T5) spinal block?

A

Atropine

Unopposed parasympathetic (vagal) activity after sympathetic blockade cause increase peristalsis leading to nausea (txt with atropine).

Hypotension exacerbate the nausea and so vasoactive agents (eg
phenylephrine) can be thought

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11
Q

Abteriomedial thigh innervates by … and the Medial lower leg innervated by ….

A

Ant cutaneous
Saphenous nerve

(Both are a branch of femoral)

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12
Q

Innervation of the lower leg (except medial side) by ….

The heel and planter region innervated by ….

A

Sural/peroneal nerve

Tibial nerve

(Both branches of sciatic)

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13
Q

Gabapinta MoA

A

NMDA antagonist On peripheral same as ketamine

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14
Q

Defination of pain accourding to International Ass. for the study of pain? and chronic pain?

A

Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

Chronic pain is the pain without apparent biological value that has persisted beyond the normal tissue healing time usually taken to be 3 months

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15
Q

Pain classified to 2 terms?

A

Nociceptive and Neuropathic

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16
Q

Radical spinal pain?

A

Radical pain describes pain that is referred to LE and caused by stimulation of a spinal nerve.

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17
Q

Lumber spinal pain

A

pain inferior to the tip of the 12 thoracic spinous process and superior to the tip of the first sacral spinous process.

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18
Q

Sacral spinal pain

A

inferior to the first sacral spinous process and superios to the sacrococcygeal joint

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19
Q

Lumbosacral spinal pain?

A

is pain in either lumber or sacral region and constitutes LBP.

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20
Q

Nociceptive or the physiological pain term?

A

activity in peripheral pain neurons is due to ongoing tissue injury (e.g. OA)

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21
Q

Neuropathic pain term?

A

pain in which abnormal function of the nervous system causes ongoing pain or the persistent of pain following injury to nerves system (e.g. PHN, DPN)

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22
Q

RF for developing chronic pain?

A

Age, gender, socioeconomic status, education level, BMI, smoking, physical activity (bending, lifting), repetitive tasks, job dissatisfaction, depression, spinal anatomic variations, imaging abnormalities.

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23
Q

The earliest change in lumber facet joint leading to chronic LBP?

A

Synovitis

progresses to degeneration of articular surface, capsular laxity and sublaxation, and finally enlargement of articular process (facet hypertrophy).

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24
Q

What is acute radical spainl pain typically caused by?

A

Herniated nucleus pulposus (HNP)

which is the internal disruption of the annulus causing some degree of the gelatinous central nucleus pulposus to extend beyond the disk margin as a disk herniation and when it extend to adjacent area to the spinal nerve, it causes an intense inflammatory rxn.

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25
Q

What is chronic radical spinal pain typically caused by?

A

subsequent surgical intervention that caused scaring around the nerve or other reversible causes of nerve root compression that warrant investigation.

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26
Q

Low back pain;

  • Lumbosacral pain
  • Radical pain
  • Neurogenic claudication
A
  • Internal disk disruption -/+ facet arthropathy
  • herniated nucleus pulposus -/+ Foraminal stenosis
  • Central canal stenosis
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27
Q

Neuropathic pain characteristics:

  • Spontenous pain ->
  • Hyperalgesia ->
  • Allodynia ->
A
  • Spontenous pain -> occur without stimulus (sudden lacinating psin as with PHN)
  • Hyperalgesia -> exaggerated pain response to normally mild noxious stimulus (light pinprick leading to extrene, prolonged pain).
  • Allodynia -> painful respose to a normally non-nocious stimulus (light touch causing pain)
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28
Q

Neuropathic pain it is believed raised when ….

A

normal protective physiological system of nervous system that produce sensitization of the peripheral and central nervous system that afford protection during the healing process

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29
Q

Common forms of neuropathic pain are

A

DNP, PHN, CRPS

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30
Q

Common Pain Syndromes?

A

LBP
Neuropathic (DNP, PHN, CRPS)
Musculskletal (Fibromyalgia, myofascial pain syndrome) cancer related pain.

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31
Q

CRPS develops as localized pain disorder within … weeks following a .. and characterized of neuropathic pain associated with …

A

4-6 weeks following trauma to an extremity. neuropathic pain associated with dysfunctional SNS (swelling, edema, temp asymmetry, erythema compared to contralateral limb).

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32
Q

Diagnostic criteria for CRPS?

A

1) continuing pain disproportionate to any inciting event.
2) 1 symptoms in 3/4 following categories
- sensory; hypersethesia/allodynia
- Vasomotor: temp asymetry/skin color changes
- sudomotor/edema: asymmetrical edema/sweating
- Motor/trophic: decreased ROM or dysfunction. or trophic changes (hair, nail, skin).
3) one sign (PE) in 2 or more of the categories above.
4) no other diagnosis explains S&S

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33
Q

S/E of TCA?

A

dry mouth, urinary retention, and worsens preexisting heart block.

34
Q

Pain sensation can be divided into somatic pain and visceral pain. Somatic pain is ….

A

Somatic pain is direct nociception of pain stimuli in the skin, subcutaneous tissue, and muscle

35
Q

Visceral pain describes the ….

A

sensation of the internal organs. In the abdomen, many organs are innervated through nerve fibers whose axons run through the celiac plexus and splanchnic nerves and synapse at the sympathetic chain before entry into the spinal cord. Meanwhile, the sensory nerves of the distal sigmoid and beyond follow parasympathetic nerves back to the central nervous system.

36
Q

Visceral pain is subcategorized into true visceral pain and parietal pain.

A

True visceral pain is nonspecific and dull; often concentrated at the midline.

Parietal pain, clinically called referred pain, is usually localized to a site distal from the stimulus of origin. This is likely due to embryological migration and convergence of tissue. (Manifests when visceral afferent fibers activate somatic nerves in the dorsal column of the spinal cord)

37
Q

Inflammatory pain refers to pain ….

It is characterized as a …, …., ….

A

following tissue injury but with no neural injury.

dull, aching, and poorly localized pain.

38
Q

Myofascial pain is characterized by …

A

the presence of loci of hypersensitivity within a tender, taut, palpable band of muscle called a trigger point.

39
Q

Neuropathic pain is characterized by …, …, …

A

Neuropathic pain is characterized by burning, shooting, tingling pain, often caused by a stimulus that would not usually cause pain.

40
Q

First-order neurons secrete .. in the dorsal horn as a chemical mediator of pain signaling.

The … tract serves as the second-order neuron to transmit pain signals from the … to the ….

Third-order neurons transmit pain signals from the … to the … in the brain.

A

First-order neurons secrete substance P in the dorsal horn as a chemical mediator of pain signaling.

The contralateral spinothalamic tract serves as the second-order neuron to transmit pain signals from the dorsal horn to the thalamus.

Third-order neurons transmit pain signals from the thalamus to the postcentral gyrus in the brain.

41
Q

Central inhibition of pain stimulus occurs via the descending pathways from the … and ….

A

periaqueductal gray

alpha-2 receptor agonism

42
Q

Hypersthesia vs hyperalgesia vs allodynia

A

Hyperesthesia (“increased feeling”) is defined as increased sensitivity to stimulation, excluding the special senses.

Hyperalgesia and Allodynia are a type of hyperesthesia.

Hyperalgesia (“increased pain”) is an increased response to a stimulus which is normally painful.

Allodynia (“other pain”) is pain due to a stimulus which does not normally provoke pain.

43
Q

Pregabalin is a GABAergic anticonvulsant and depressant of the central nervous system used commonly to treat neuropathic pain syndromes. Its mechanism of action is by …..

A

binding to α2δ subunit-containing voltage-gated calcium channels and preventing the release of nociceptive neurotransmitters

44
Q

Complex regional pain syndrome type 1 vs type 2?

A

2 types according to the inciting event.

Type I (formerly known as reflex sympathetic dystrophy or RSD) is usually caused by a trivial injury, sprain, crush injury, or burn.

Type II (formerly known as causalgia) is caused by a traumatic injury to a major nerve trunk such as significant orthopedic trauma, gunshot injuries, or knife wounds.

45
Q

The tip of scapula at which vertebral level

A

T7

46
Q

…. blocks are an effective method for first-stage labor analgesia.

….. block helps relieve pain during the second stage of labor

Epidural effective covering pain for stage 1 and 2 labor.

A

Lumbar sympathetic (T10 to L1 block relieve the pain of contractions and cervical dilation).

Pudendal nerve (S2-S4 spinal segment coverage is needed to relieve the pain of vaginal and perineal distention).

47
Q

Why Spinal anelgesia not commonly employed

A

Spinal analgesia is effective for covering pain in the first and second stages of labor. It may affect the ability for the mother to push during delivery, thus it is not commonly employed but may be used as a low-dose rescue technique near the time of delivery.

48
Q

When dose the INR peaks after donor hepatectomy and why do you care? (if your acute pain service).

A

INR increases following donor hepatectomy, peaking on POD 1-3, which should be considered prior to thoracic epidural catheter.

49
Q

The superior aspect of illicit crest at vertebral level …

A

L4

The posterior aspect of it at S2

50
Q

Selective tibial block result into…

A

Planter surface foot anesthesia

51
Q

Interspace btw 1st and 2nd toe innervated by …

A

Deep peroneal L4-L5

52
Q

The medial surface of leg below knee innervated by …

A

Saphenous (branch of femoral) nerve

53
Q

The posterior and lateral leg below knee innervated by …

A

Suraj nerve (branch of tibias)

54
Q

The saiatica and popliteal block will miss which nerve …

A

The saphenous nerve and therefore ptn will feel the medial aspect of leg (medial leg and ankle and foot)

55
Q

The median nerve is ….. to brachial artery at the AC fossa.

A

Medial to the artery (landmark for medial N block, and a consideration when placing brachial line)

56
Q

The brachial pluxes pass in between 2 scalene muscles which also the location for …. block?

A

Between anterior and middle scalene muscle

Interscalene block

57
Q

Musculocutaneous drived from …. and supplies …

A

C5, 6, 7

Lateral forearm

58
Q

The Coeliac/solar plexus located at … and supplies sympathetic to …

A

L1

Forgut (Stomach, oesophagus, deudenum), liver, kidney, spleen, pancreas and GB

Blocking this pluxes at this site will also block the alongside sympathetic nerves treating vescieal pain

59
Q

Stellate ganglion located at … and injection site target for block at ….

A

C7

C6 chassaiganc tubercle

Blocking it causes unopposed parasympathetic sx (Horner’s syndrome; vasodilation, flushing and nasal stuffiness and increases biles ipsilateral side).

60
Q

What is the medial branch block? What nerve targeted ?

A

Blocking the pain from facet joint causing the back pain

Medial branch of posterior division of spinal nerve (which supplies the facet joint).

61
Q

What supplies the facet joint and upon it it’s the block name?

A

Median branch of the posterior spinal nerve.

Medial branch block

62
Q

WHO-3 step analgesic ladder

A

Non-opioid (mild pain); COX2, ASA, Tylenol, Diclofenac, NSAIDs

Weak opioid (mild to moderate); Codine, Tramadol, hydrocodone, dihydrocodine

Sever pain; Morpine, Dilaudid, Methadone, Levirphanol, fentanyl, Oxycodone

63
Q

CRPS 1 vs 2 and their stages?

A

Type I CRPS (90% of CRPS cases) occurs without a definable nerve lesion, while type II occurs with a definable nerve lesion. The pathogenesis is likely due to an injury causing increased sensitivity to sympathetic nerves, an abnormal response to and sensation of pain, and increased neuropeptide release causing burning pain to light touch (allodynia).

Typically, CRPS occurs in 3 stages. Stage 1 includes burning pain, edema, and vasomotor changes in a limb after injury. Stage 2 includes progression of edema, skin thickening, and muscle wasting. Stage 3 is the most severe and includes limited range of motion and bone demineralization on x-ray. Diagnosis can be confirmed by either autonomic testing that measures increased resting sweat output or magnetic resonance imaging that looks for the above changes. The treatment for CRPS is regional sympathetic nerve block or intravenous regional anesthesia. This patient appears to have Stage 3 disease and would benefit from a local nerve block

64
Q

Warfarin antidote/high INR mgmt

A

Patients INR <5 and no clinical evidence of serious bleeding should have their warfarin held for 1 or 2 days and then restarted when the INR is in the therapeutic range. Patients with INR 5-9 and no serious bleeding should have their warfarin held and be given a low dose (1-2.5 mg) of oral vitamin K if there is an increased risk of future bleeding (eg, history of prior bleed). Patients with INR >9 and no serious bleeding should have their warfarin held and be given a higher dose (2.5-5 mg) of oral vitamin K. Patients with serious bleeding, regardless of the INR, should have their warfarin held and receive intravenous vitamin K, FFP, recombinant factor VIIa, or prothrombin complex concentrate

65
Q

Clonidine vs Morphine when administered into epidural?

A

Clonidine is an effective analgesic drug. It has a longer epidural effect duration than morphine. When given in combination with morphine, the analgesic effect is enhanced.

Clonidine does not have the side effects commonly seen with opioids. When clonidine is combined with an opioid, it enhances analgesia and allows for the reduced dosing of the opioid. This further reduces the risk of nausea and vomiting. Several studies have shown that clonidine can reduce the risk of PONV and the mechanism is likely multifactorial, including the previously mentioned reduction on anesthetic requirements as well as a reduction in sympathetic tone and catecholamine release.

However, Clonidine is more likely to produce significant hypotension.

Morphine plus clonidine increases both duration and intensity of the analgesia.

66
Q

Landmark of interscalene block?

A

Needle insertion in interscalene groove at C6 (that is posterior to the clavicle head of SCM and btw anterior and middle scalene muscle).

67
Q

Landmark of infraclaviculqr block?

A

Needle insertion is 2 cm inferior and 2 cm medial to coracoid process

68
Q

Needle insertion for axillary block?

A

Palpate/visualize axillary artery and guide the needle through it -> penetrate through the artery to reach behind the artery where radial nerve is and inject local.

On the way back as drawing out the needle -> once you exit the artery and no blood on aspiration -> inject again to cover the median and ulnar nerves.

69
Q

Musculocutaneous needle insertion landmark?

A

Injection into the belly of the coracobrachialis muscle, which sits just posterior to the biceps

Often combined with axillary block to cover the lateral forearm

70
Q

Ulnar nerve block landmark?

A

At the elbow btw medial epicondyle and olecranon process, medial to the ulnar artery

71
Q

Landmark of radial nerve block?

A

At the elbow btw the brachioradilis and biceps tendon.

It can be done at the wrist in the anatomical snuff box btw brachioradialis and biceps tendon

72
Q

Medial nerve block landmark?

A

At the elbow btw brachial artery at the posterior teres muscle.

Can be done at the wrist; btw palmaris longus and flexor carpi radialis tendon

73
Q

Femoral nerve block landmark?

A

Below inguinal ligament, insert needle lateral to femoral artery at the level of femoral crease.

74
Q

Sciatica nerve block landmark?

A

Classic posterior approach;
A line drawn btw greater trochanter and PSIS. Insert needle 4 cm distal to the midpoint of these landmarks

Parasacral approach;
Line drawn btw ischial tuberosity and PSIS. Insert needle 6cm caudal to PSIS on drawn line.

Subgluteal approach;
Line drawn btw greater trochanter and ischial turbidity. Insert needle 4 cm caudal to midpoint of drawn line

75
Q

Poplital block landmark?

A

Posterior approach;
Line drawn btwn biceps femoris tendon (lateral) and semitindinosus and semimembransous muscle (medial). Insert needle 8 cm superior to poplital crease at midpoint btw tendons.

Lateral approach;
Insert needle 8 cm above poplital crease in groove btw Vastus lateralis and biceps femoris

76
Q

Ankle block land marks?

A

Saphenous;
Medial surface of tibial tubrosity, at dorsomedial aspect of upper calf. Or at the medial malleolus.

Deep peronal;
Lateral to extensor hallucis longus tendonat 1-2 digit webspace

Superficial peronal;
Lateral to extensor digitorum longus tendon

Posterior tibial;
Posterior to the posterior tibial artery

Sural;
Posterior to the lateral malleolus.

77
Q

Superficial cervical plexus block covers which roots?

A

C2-4

78
Q

Caudal space is

A

Lowest entertainment level of epidural space

79
Q

Chemical stimuli that mediate the activation of peripheral nociceptors include …

whereas spinal cord inhibition is mediated by …

A

prostaglandins, substance P, calcitonin gene-related peptide, glutamate, bradykinin, protons, ATP, and proinflammatory cytokine

opioids, γ-aminobutyric acid (GABA), and/or glycine.

80
Q

Maximum therapeutic dosages of acetaminophen?

A

Daily maximum dose of 3 grams in adults.

2.6 g/day in children and the elderly.

2 g/day for chronic alcoholics or liver disease patients

Anesthesia subspecialty (9 decks)

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