Principles- Spinal/Epidural Flashcards

1
Q

Which type of surgery commonly involves the use of epidural anesthesia as an adjunct to general anesthesia (GETA)?

A) Ophthalmic surgery
B) Thoracic surgery
C) Cosmetic surgery
D) Dental surgery

A

Correct Answer: B) Thoracic surgery

Rationale: Epidural anesthesia is often used as an adjunct to general anesthesia in thoracic surgery to help manage pain post-operatively.

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2
Q

For which of the following procedures is neuraxial anesthesia indicated?

A) Cardiac surgery
B) Vascular surgery on the legs
C) Cranial surgery
D) ENT surgery

A

Correct Answer: B) Vascular surgery on the legs

Rationale: The slide indicates that vascular surgery on the legs is one of the clinical indications for the use of neuraxial anesthesia.

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3
Q

Which surgery listed as an indication for neuraxial anesthesia involves the lower extremities?

A) Orthopaedic surgery
B) Thoracic surgery
C) Ophthalmic surgery
D) Plastic surgery

A

Correct Answer: A) Orthopaedic surgery

Rationale: Orthopaedic surgery, which often involves the lower extremities, is listed as an indication for the use of neuraxial anesthesia.

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4
Q

Spinal anesthesia is used in surgical procedures involving which areas of the body?

A) Upper abdomen
B) Lower abdomen and perineum
C) Skull and brain
D) Chest and arms

A

Correct Answer: B) Lower abdomen and perineum

Rationale: The slide specifies that neuraxial anesthesia is indicated for surgical procedures involving the lower abdomen, perineum, and lower extremities.

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5
Q

Which of the following is NOT an indication for the use of neuraxial anesthesia according to the slide?

A) Surgical procedures involving the lower abdomen
B) Vascular surgery on the legs
C) Orthopaedic surgery
D) Cardiac surgery

A

Correct Answer: D) Cardiac surgery

Rationale: Cardiac surgery is not mentioned as an indication for the use of neuraxial anesthesia on the slide.

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6
Q

Which of the following is a benefit of neuraxial anesthesia in reducing postoperative complications?

A) Increased narcotic usage
B) Reduced postoperative ileus
C) Increased bleeding
D) Increased respiratory complications

A

Correct Answer: B) Reduced postoperative ileus

Rationale: Neuraxial anesthesia helps in reducing postoperative ileus, which is a common complication after surgery.

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7
Q

Neuraxial anesthesia is beneficial in reducing the need for which type of medication postoperatively?

A) Antibiotics
B) Antihistamines
C) Narcotics
D) Antipyretics

A

Correct Answer: C) Narcotics

Rationale: One of the significant benefits of neuraxial anesthesia is the reduction in the need for narcotics, which are often used for pain management after surgery.

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8
Q

Which type of postoperative complication related to blood clots is reduced by the use of neuraxial anesthesia?

A) Deep vein thrombosis (DVT)
B) Embolic stroke
C) Thromboembolic events
D) Myocardial infarction

A

Correct Answer: C) Thromboembolic events

Rationale: Neuraxial anesthesia helps in reducing thromboembolic events, which are complications related to blood clots.

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9
Q

What is the term for nausea and vomiting that occurs after surgery, and what are some risk factors for it?

A) Postoperative nephrotic vomiting; obesity, diabetes, and hypertension
B) Postoperative nausea and vomiting (PONV); smoking, age above 40, and being female
C) Postoperative necrotic vomiting; high BMI, sedentary lifestyle, and male gender
D) Postoperative neuralgia and vomiting; genetic predisposition, youth, and male gender

A

Correct Answer: B) Postoperative nausea and vomiting (PONV); smoking, age above 40, and being female

Rationale: PONV stands for postoperative nausea and vomiting, with risk factors including smoking, being over 40 years old, and being female.

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10
Q

Which benefit of neuraxial anesthesia relates to the reduction of respiratory issues after surgery?

A) Reduced pneumonia incidence
B) Reduced respiratory complications
C) Improved asthma control
D) Decreased COPD exacerbations

A

Correct Answer: B) Reduced respiratory complications

Rationale: Neuraxial anesthesia is beneficial in reducing respiratory complications that can occur postoperatively.

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11
Q

What is one of the benefits of neuraxial anesthesia related to mental state post-surgery?

A) Sedation
B) Great mental alertness
C) Confusion
D) Hallucinations

A

Correct Answer: B) Great mental alertness

Rationale: Neuraxial anesthesia helps in maintaining great mental alertness post-surgery, unlike general anesthesia which can cause grogginess and confusion.

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12
Q

How does neuraxial anesthesia affect urinary retention post-surgery?

A) It increases urinary retention
B) It decreases urinary retention
C) It has no effect on urinary retention
D) It causes urinary incontinence

A

Correct Answer: B) It decreases urinary retention

Rationale: (Note that with opioid adjuncts, you will have increased retention). One of the benefits of neuraxial anesthesia is less urinary retention, which helps patients recover more quickly.

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13
Q

Which benefit of neuraxial anesthesia contributes to quicker postoperative recovery activities?

A) Increased need for sedation
B) Quicker to eat, void, and ambulate
C) Delayed discharge times
D) Increased postoperative pain

A

Correct Answer: B) Quicker to eat, void, and ambulate

Rationale: Neuraxial anesthesia allows for quicker postoperative recovery activities, enabling patients to eat, void, and ambulate sooner.

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14
Q

What is one way neuraxial anesthesia can reduce the length of hospital stay after surgery?

A) Increased risk of complications
B) Avoid unexpected overnight admission from complications of general anesthesia
C) Requirement for extended monitoring
D) Increased incidence of postoperative infections

A

Correct Answer: B) Avoid unexpected overnight admission from complications of general anesthesia

Rationale: By reducing complications associated with general anesthesia, neuraxial anesthesia can help avoid unexpected overnight admissions, thus shortening hospital stay.

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15
Q

How does neuraxial anesthesia affect discharge times from the Post-Anesthesia Care Unit (PACU)?

A) It delays discharge times
B) It has no effect on discharge times
C) It results in quicker PACU discharge times
D) It increases the need for PACU monitoring

A

Correct Answer: C) It results in quicker PACU discharge times

Rationale: Neuraxial anesthesia leads to quicker PACU discharge times, allowing patients to be moved out of the recovery unit sooner.

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16
Q

What type of pain management does neuraxial anesthesia provide before surgical incision?

A) Postoperative analgesia
B) Reactive analgesia
C) Preemptive analgesia
D) Delayed analgesia

A

Correct Answer: C) Preemptive analgesia

Rationale: Neuraxial anesthesia offers preemptive analgesia, which helps manage pain before the surgical incision is made.

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17
Q

How does neuraxial anesthesia affect the body’s stress response to surgery?

A) It exacerbates the stress response
B) It has no effect on the stress response
C) It blunts the stress response
D) It eliminates the stress response

A

Correct Answer: C) It blunts the stress response

Rationale: One of the benefits of neuraxial anesthesia is that it blunts the body’s stress response to surgery, aiding in a smoother recovery process.

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18
Q

Which of the following spinal deformities is a relative contraindication for neuraxial anesthesia due to potential technical difficulties and complications?

A) Spinal stenosis
B) Scoliosis
C) Kyphoscoliosis
D) All of the above

A

Correct Answer: D) All of the above

Rationale: Spinal stenosis, scoliosis, and kyphoscoliosis are all deformities of the spinal column that can complicate the administration of neuraxial anesthesia, making them relative contraindications.

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19
Q

Why is a preexisting disease of the spinal cord, such as Multiple Sclerosis or post-polio syndrome, considered a relative contraindication for neuraxial anesthesia?

A) It has no impact on anesthesia administration
B) It can exacerbate the underlying progressive, degenerative disease
C) It always leads to complete anesthesia failure
D) It poses no risk but is avoided for convenience

A

Correct Answer: B) It can exacerbate the underlying progressive, degenerative disease

Rationale: Neuraxial anesthesia can potentially exacerbate preexisting progressive, degenerative diseases of the spinal cord, such as Multiple Sclerosis or post-polio syndrome, hence it is considered a relative contraindication.

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20
Q

Which condition listed is a common chronic issue that can complicate the administration of neuraxial anesthesia?

A) Chronic hypertension
B) Chronic headache/backache
C) Chronic renal failure
D) Chronic obstructive pulmonary disease (COPD)

A

Correct Answer: B) Chronic headache/backache

Rationale: Chronic headache and backache can complicate the administration of neuraxial anesthesia, as they may indicate an increased risk of puncture headache or exacerbate existing pain

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21
Q

What is a recommended course of action if neuraxial anesthesia cannot be successfully administered after multiple attempts?

A) Continue attempting until successful
B) Switch to general anesthesia after three unsuccessful attempts
C) Consult another anesthesiologist for more attempts
D) Use only local anesthesia

A

Correct Answer: B) Switch to general anesthesia after three unsuccessful attempts

Rationale: If neuraxial anesthesia cannot be performed successfully after three attempts, it is recommended to switch to general anesthesia to avoid complications and patient discomfort.

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22
Q

How should a clinician approach neuraxial anesthesia in patients with spinal deformities to improve the chances of success?

A) Use a standard approach without modifications
B) Employ different positioning and approach techniques
C) Avoid neuraxial anesthesia altogether
D) Increase the dosage of anesthetic

A

Correct Answer: B) Employ different positioning and approach techniques

Rationale: In patients with spinal deformities, using different positioning and approach techniques can improve the chances of successfully administering neuraxial anesthesia.

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23
Q

What is a primary absolute contraindication for neuraxial anesthesia due to the risk of epidural hematoma?

A) Prothrombin time (PT) of 13 seconds
B) Platelet count of 120,000
C) International normalized ratio (INR) > 1.5
D) Activated Partial Thromboplastin Time (aPTT) of 30 seconds

A

Correct Answer: C) International normalized ratio (INR) > 1.5

Rationale: An INR greater than 1.5 indicates a higher risk of bleeding, which is a contraindication for neuraxial anesthesia due to the risk of epidural hematoma.

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24
Q

What type of headache is a potential complication of neuraxial anesthesia, and how should a patient’s history be considered to mitigate this risk?

A) Tension headache; check for history of migraines
B) Puncture headache; check for previous headaches or back pain
C) Cluster headache; check for family history of headaches
D) Sinus headache; check for sinus infections

A

Correct Answer: B) Puncture headache; check for previous headaches or back pain

Rationale: Puncture headache is a potential complication of neuraxial anesthesia. It is important to check for a history of previous headaches or back pain to assess the risk and manage accordingly.

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25
Q

Which laboratory value, would be an absolute contraindication for performing neuraxial anesthesia?

A) Prothrombin time (PT) of 14 seconds
B) Platelet count of 150,000
C) Bleeding time of 5 minutes
D) Activated Partial Thromboplastin Time (aPTT) of 66 seconds

A

Correct Answer: D) Activated Partial Thromboplastin Time (aPTT) of 66 seconds

Rationale: An elevated aPTT indicates a coagulation disorder, making neuraxial anesthesia risky due to potential bleeding complications.

greater than 2X normal which is
aPTT: 25-32 seconds
Bleeding time = 3-7 minutes
Prothrombin time (PT) = 12 to 14 seconds

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26
Q

Why is patient refusal considered an absolute contraindication for neuraxial anesthesia?

A) It can lead to legal complications and lack of patient cooperation
B) It has no impact on the procedure
C) It is only a relative contraindication
D) It increases the efficacy of the procedure

A

Correct Answer: A) It can lead to legal complications and lack of patient cooperation

Rationale: Performing neuraxial anesthesia against a patient’s wishes can lead to legal issues and reduce patient cooperation during and after the procedure.

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27
Q

What is the significance of platelet count below 100,000 in the context of neuraxial anesthesia?

A) It indicates a strong immunity
B) It suggests a higher risk of bleeding complications
C) It is within normal range and not concerning
D) It signifies no issues related to anesthesia

A

Correct Answer: B) It suggests a higher risk of bleeding complications

Rationale: A platelet count below 100,000 increases the risk of bleeding, which is a significant concern when performing neuraxial anesthesia. Consider trends

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28
Q

How does evidence of a dermal site infection impact the decision to proceed with neuraxial anesthesia?

A) It has no impact on the procedure
B) It requires additional antibiotics before proceeding
C) It is an absolute contraindication due to the risk of spreading the infection to the spinal area
D) It indicates the need for a higher dose of anesthetic

A

Correct Answer: C) It is an absolute contraindication due to the risk of spreading the infection to the spinal area

Rationale: Dermal site infection poses a risk of spreading infection to the spinal area, making it an absolute contraindication for neuraxial anesthesia.

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29
Q

What is the role of platelet activation in the hemostatic process, and how does it relate to bleeding time?

A) Platelet activation is irrelevant to hemostasis
B) Longer bleeding time indicates a problem with platelet activation and adhesion
C) Shorter bleeding time signifies issues with platelet activation
D) Platelet activation decreases bleeding time without affecting hemostasis

A

Correct Answer: B) Longer bleeding time indicates a problem with platelet activation and adhesion

Rationale: Platelet activation is crucial for hemostasis. Longer bleeding time suggests problems with platelet adhesion and activation, which are essential for forming a stable clot.

vWB: call platelets to join together.. sticky

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30
Q

Which valvular condition is considered an absolute contraindication for neuraxial anesthesia when the valve area is ≤ 1.0 cm²?

A) Mild mitral stenosis
B) Moderate aortic stenosis
C) Severe aortic stenosis
D) Mild tricuspid regurgitation

A

Correct Answer: C) Severe aortic stenosis

Rationale: Severe aortic stenosis with a valve area of 0.7 - 1.0 cm², (below 0.7 is critical).. is an absolute contraindication for neuraxial anesthesia due to the risk of hemodynamic instability and myocardial ischemia.

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31
Q

Idiopathic hypertrophic subaortic stenosis (HSS) poses a particular risk during neuraxial anesthesia. What is the primary concern with this condition?

A) Increased risk of bleeding
B) Decreased systemic vascular resistance (SVR) leading to hypotension and worsening ischemia
C) Increased intracranial pressure
D) Enhanced coagulation leading to thrombosis

A

Correct Answer: B) Decreased systemic vascular resistance (SVR) leading to hypotension and worsening ischemia

Rationale: In patients with HSS, a decrease in SVR can lead to hypotension and worsen ischemia, creating a dangerous cycle of decreased cardiac output and increased myocardial ischemia.

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32
Q

What is the impact of severe congestive heart failure (CHF) with an ejection fraction (EF) < 30-40% on the suitability for neuraxial anesthesia?

A) It is considered a relative contraindication
B) It has no impact on anesthesia choice
C) It is an absolute contraindication due to preload dependence and risk of hemodynamic collapse
D) It requires only minor adjustments in anesthetic management

A

Correct Answer: C) It is an absolute contraindication due to preload dependence and risk of hemodynamic collapse

Rationale: Severe CHF with an EF < 30-40% is an absolute contraindication for neuraxial anesthesia due to the risk of hemodynamic instability and the patient’s dependence on adequate preload.

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32
Q

What does an increased intracranial pressure (ICP) imply for the administration of neuraxial anesthesia?

A) It is safe to proceed with neuraxial anesthesia
B) It requires only careful monitoring during the procedure
C) It is an absolute contraindication due to the risk of brain herniation
D) It necessitates the use of higher doses of anesthetics

A

Correct Answer: C) It is an absolute contraindication due to the risk of brain herniation

Rationale: Increased ICP is an absolute contraindication for neuraxial anesthesia because the procedure can exacerbate the pressure, leading to brain herniation and severe neurological damage.

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33
Q

Which clinical signs are used to determine the severity of aortic stenosis (AS) in the absence of an echocardiogram?

A) Hypertension, tachycardia, and edema
B) Angina, syncope, and heart failure
C) Bradycardia, hypotension, and dyspnea
D) Palpitations, dizziness, and cyanosis

A

Correct Answer: B) Angina, syncope, and heart failure

Rationale: Angina, syncope, and heart failure are key clinical signs indicating severe aortic stenosis. These symptoms suggest significant obstruction and poor prognosis, warranting caution with neuraxial anesthesia.
Failure is the most significant

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34
Q

Why is an operation duration exceeding the duration of local anesthetic considered a contraindication for neuraxial anesthesia?

A) It results in prolonged sedation
B) It may require conversion to general anesthesia mid-operation, risking complications
C) It ensures complete anesthetic coverage
D) It has no clinical significance

A

Correct Answer: B) It may require conversion to general anesthesia mid-operation, risking complications

Rationale: If the operation is expected to last longer than the duration of the local anesthetic, there is a risk of needing to convert to general anesthesia during the procedure, which can introduce additional risks and complications.

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35
Q

What is the primary difference in the onset time between spinal and epidural anesthesia?

A) Spinal has a slower onset than epidural
B) Epidural has a rapid onset
C) Spinal has a rapid onset while epidural is slower
D) Both have the same onset time

A

Correct Answer: C) Spinal has a rapid onset while epidural is slower

Rationale: Spinal anesthesia typically works within 5 minutes, whereas epidural anesthesia takes about 10-15 minutes to take effect.

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36
Q

Which characteristic of spinal anesthesia makes it likely to cause hypotension compared to epidural anesthesia?

A) Rapid onset of action
B) Minimal motor block
C) Controlled spread of local anesthetic
D) Segmental nature of the block

A

Correct Answer: A) Rapid onset of action

Rationale: The rapid onset of spinal anesthesia can cause a sudden drop in blood pressure, making hypotension more likely compared to the slower onset and gradual effect of epidural anesthesia.

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37
Q

In what way is the spread of anesthesia different between spinal and epidural techniques?

A) Spinal anesthesia spread can be controlled with the volume of local anesthetic
B) Epidural anesthesia often extends higher than expected
C) Spinal anesthesia may extend extracranially, whereas epidural spread is controlled
D) Both have an unpredictable spread

A

Correct Answer: C) Spinal anesthesia may extend extracranially, whereas epidural spread is controlled

Rationale: The spread of spinal anesthesia can be higher than expected and may extend extracranially, while epidural anesthesia spread can be controlled with the volume of local anesthetic.

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38
Q

What is a notable difference in the nature of the block between spinal and epidural anesthesia?

A) Spinal anesthesia provides a segmental block
B) Epidural anesthesia provides a dense block
C) Spinal anesthesia provides a dense block, whereas epidural provides a segmental block
D) Both provide a dense block

A

Correct Answer: C) Spinal anesthesia provides a dense block, whereas epidural provides a segmental block

Rationale: Spinal anesthesia typically results in a dense block affecting a larger area, while epidural anesthesia provides a segmental block, allowing for more localized control.

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39
Q

How does the motor block differ between spinal and epidural anesthesia?

A) Spinal anesthesia results in minimal motor block
B) Epidural anesthesia results in a dense motor block
C) Spinal anesthesia results in a dense motor block, while epidural has minimal motor block
D) Both result in dense motor blocks

A

Correct Answer: C) Spinal anesthesia results in a dense motor block, while epidural has minimal motor block

Rationale: Spinal anesthesia results in a dense motor block due to the higher concentration of local anesthetic, whereas epidural anesthesia results in minimal motor block, allowing for better motor function preservation.

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40
Q

Which statement best describes the relationship between maternal and fetal blood pressure during spinal anesthesia?

A) Fetal blood pressure is independent of maternal blood pressure
B) Fetal blood pressure directly mirrors maternal blood pressure
C) Fetal blood pressure is higher than maternal blood pressure
D) Fetal blood pressure is lower than maternal blood pressure

A

Correct Answer: B) Fetal blood pressure directly mirrors maternal blood pressure

Rationale: During spinal anesthesia, the fetal blood pressure can be influenced by maternal blood pressure changes, making it crucial to manage maternal hypotension effectively to avoid fetal distress.

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41
Q

What is a key difference in the onset of anesthesia between spinal and epidural techniques?

A) Spinal anesthesia has a slower onset than epidural
B) Epidural anesthesia takes effect in 5 minutes
C) Spinal anesthesia has a rapid onset of 5 minutes, while epidural is slower at 10-15 minutes
D) Both spinal and epidural have the same onset time

A

Correct Answer: C) Spinal anesthesia has a rapid onset of 5 minutes, while epidural is slower at 10-15 minutes

Rationale: Spinal anesthesia typically has a rapid onset within 5 minutes, whereas epidural anesthesia takes 10-15 minutes to take effect.

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42
Q

Why does epidural anesthesia require more skill for placement compared to spinal anesthesia?

A) Epidural anesthesia uses a smaller needle
B) Epidural anesthesia is placed at a fixed level
C) Epidural anesthesia involves threading a catheter and avoiding the spinal cord
D) Epidural anesthesia has no influence from gravity

A

Correct Answer: C) Epidural anesthesia involves threading a catheter and avoiding the spinal cord

Rationale: The placement of an epidural involves threading a catheter and requires precision to avoid the spinal cord, necessitating greater skill compared to the simpler spinal injection.

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43
Q

Which characteristic of spinal anesthesia allows for manipulation of dermatome spread after dosing?

A) Segmental block nature
B) Incremental dosing
C) Influence of baricity and patient positioning within the first 5 minutes
D) Volume-based control

A

Correct Answer: C) Influence of baricity and patient positioning within the first 5 minutes

Rationale: Spinal anesthesia allows for manipulation of the spread of anesthesia by adjusting the patient’s position and utilizing the baricity of the anesthetic solution within the first 5 minutes after administration.

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44
Q

How does the concentration and dosing of local anesthetic differ between spinal and epidural anesthesia?

A) Spinal uses volume-based dosing, epidural uses dose-based
B) Spinal anesthesia involves a concentrated and fixed dose, while epidural dosing varies with volume
C) Epidural uses a fixed dose, spinal uses volume-based dosing
D) Both use the same concentration and dosing method

A

Correct Answer: B) Spinal anesthesia involves a concentrated and fixed dose, while epidural dosing varies with volume

Rationale: Spinal anesthesia typically uses a concentrated and fixed dose, whereas epidural anesthesia dosing varies with the volume administered.

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45
Q

What factor primarily influences the spread of local anesthetic in spinal anesthesia?

A) Position of the patient alone
B) Volume of anesthetic
C) Baricity of the anesthetic and initial patient positioning
D) Skill of the practitioner

A

Correct Answer: C) Baricity of the anesthetic and initial patient positioning

Rationale: The spread of local anesthetic in spinal anesthesia is primarily influenced by the baricity of the anesthetic solution and the initial positioning of the patient.

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46
Q

Why is local anesthetic toxicity more likely with epidural anesthesia compared to spinal anesthesia?

A) Higher concentration of local anesthetic used in spinal anesthesia
B) Greater volume of local anesthetic used in epidural anesthesia
C) Rapid onset of spinal anesthesia increases toxicity risk
D) Epidural anesthesia uses less anesthetic overall

A

Correct Answer: B) Greater volume of local anesthetic used in epidural anesthesia

Rationale: The larger volume of local anesthetic used in epidural anesthesia increases the risk of systemic toxicity compared to the smaller, more concentrated doses used in spinal anesthesia.

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47
Q

How many vertebrae comprise the human vertebral column, and what are the sections they are divided into?

A) 30 vertebrae; Cervical, Thoracic, Lumbar, Sacral
B) 33 vertebrae; Cervical, Thoracic, Lumbar, Sacral, Coccygeal
C) 31 vertebrae; Cervical, Thoracic, Lumbar, Sacral, Coccygeal
D) 34 vertebrae; Cervical, Thoracic, Lumbar, Sacral, Coccygeal

A

Correct Answer: B) 33 vertebrae; Cervical, Thoracic, Lumbar, Sacral, Coccygeal

Rationale: The human vertebral column consists of 33 vertebrae divided into five sections: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral (fused), and 4 coccygeal (fused).

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48
Q

What characteristic is unique to the cervical vertebrae among the other vertebrae in the spinal column?

A) Presence of large vertebral bodies
B) Presence of intervertebral foramina
C) Presence of transverse foramina
D) Fusion of vertebrae

A

Correct Answer: C) Presence of transverse foramina

Rationale: Cervical vertebrae are distinguished by the presence of transverse foramina, which allow for the passage of the vertebral arteries.

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49
Q

Which type of spinal curvature is associated with an exaggerated inward curve of the lumbar spine?

A) Scoliosis
B) Kyphosis
C) Lordosis
D) Normal curvature

A

Correct Answer: C) Lordosis

Rationale: Lordosis is characterized by an exaggerated inward curve of the lumbar spine, often referred to as swayback.

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50
Q

Which spinal levels are typically targeted for spinal anesthesia placement?

A) C1-C2
B) T1-T2
C) L3-L4, L4-L5, L5-S1
D) S1-S2

A

Correct Answer: C) L3-L4, L4-L5, L5-S1

Rationale: Spinal anesthesia is typically administered at the lumbar levels L3-L4, L4-L5, and L5-S1 to avoid damage to the spinal cord, which ends at approximately the L1-L2 level in adults.

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51
Q

In terms of spinal anatomy, what does the term “baricity” refer to, and how does it affect the administration of spinal anesthesia?

A) Baricity refers to the size of the vertebrae; it affects the amount of anesthetic needed
B) Baricity refers to the density of the anesthetic solution relative to cerebrospinal fluid; it affects the spread of the anesthetic
C) Baricity refers to the concentration of the anesthetic solution; it affects the duration of anesthesia
D) Baricity refers to the position of the patient; it has no effect on the spread of the anesthetic

A

Correct Answer: B) Baricity refers to the density of the anesthetic solution relative to cerebrospinal fluid; it affects the spread of the anesthetic

Rationale: Baricity describes the density of the anesthetic solution compared to cerebrospinal fluid (CSF). Hyperbaric solutions are denser and tend to sink, whereas hypobaric solutions are lighter and rise. Isobaric solutions have the same density as CSF and tend to remain at the level of injection.

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52
Q

Which part of the vertebral column is fused and provides a stable base for the spinal column, as well as attachment points for the pelvis?

A) Cervical vertebrae
B) Thoracic vertebrae
C) Lumbar vertebrae
D) Sacral vertebrae

A

Correct Answer: D) Sacral vertebrae

Rationale: The sacral vertebrae are fused to form the sacrum, which provides a stable base for the spinal column and attachment points for the pelvis.

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53
Q

What are the two main parts of each vertebra, excluding C1?

A) Vertebral body and spinous process
B) Anterior segment (body) and posterior segment (vertebral arch)
C) Transverse process and vertebral foramen
D) Superior articular process and inferior articular process

A

Correct Answer: B) Anterior segment (body) and posterior segment (vertebral arch)

Rationale: Each vertebra, except for C1, is divided into an anterior segment known as the body and a posterior segment called the vertebral arch.

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54
Q

Which structures link the anterior and posterior segments of a vertebra?

A) Transverse process and spinous process
B) Pedicle and lamina
C) Superior and inferior articular processes
D) Vertebral body and vertebral foramen

A

Correct Answer: B) Pedicle and lamina

Rationale: The pedicle and lamina link the anterior and posterior segments of a vertebra, forming the vertebral arch.

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55
Q

What is the function of the vertebral foramen?

A) It serves as an attachment point for muscles
B) It houses the spinal cord, nerve roots, and the epidural space
C) It connects the ribs to the vertebrae
D) It provides structural support to the vertebral column

A

Correct Answer: B) It houses the spinal cord, nerve roots, and the epidural space

Rationale: The vertebral foramen is a crucial space within the vertebra that houses the spinal cord, nerve roots, and the epidural space, providing a protective cushioning area around the spinal cord.

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56
Q

Which vertebra is unique and does not have the typical two-part structure of the anterior and posterior segments?

A) C2
B) L1
C) S1
D) C1

A

Correct Answer: D) C1

Rationale: The C1 vertebra, also known as the atlas, is unique because it does not have a typical vertebral body or spinous process, differentiating it from other vertebrae.

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57
Q

What is the primary purpose of the epidural space within the vertebral column?

A) It facilitates the movement of intervertebral discs
B) It provides a pathway for the spinal nerves
C) It serves as a cushioning area for the spinal cord and houses the administration of epidural anesthesia
D) It connects the anterior and posterior segments of the vertebrae

A

Correct Answer: C) It serves as a cushioning area for the spinal cord and houses the administration of epidural anesthesia

Rationale: The epidural space is a protective cushioning area around the spinal cord and is the site for administering epidural anesthesia.

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58
Q

How do the structures of the vertebra, such as the lamina and pedicle, contribute to the stability and function of the spinal column?

A) They allow for flexibility and movement of the vertebral column
B) They connect the ribs to the vertebrae
C) They form the vertebral foramen, which provides stability and protects the spinal cord
D) They are sites for muscle attachment

A

Correct Answer: C) They form the vertebral foramen, which provides stability and protects the spinal cord

Rationale: The lamina and pedicle form the vertebral foramen, which is crucial for providing stability to the spinal column and protecting the spinal cord and nerve roots.

Epidural space is also inside the foramen

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59
Q

What is the primary anatomical function of the transverse processes of the vertebrae?

A) They protect the spinal cord
B) They serve as attachment points for muscles and ligaments
C) They provide cushioning between vertebrae
D) They connect the vertebrae to the ribs

A

Correct Answer: B) They serve as attachment points for muscles and ligaments

Rationale: The transverse processes stick out laterally from the vertebrae and provide attachment points for muscles and ligaments, aiding in the stability and movement of the spine.

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60
Q

Which vertebral structure serves as a crucial landmark for locating the midline of the back during procedures such as epidural or spinal anesthesia?

A) Transverse process
B) Vertebral foramen
C) Spinous process
D) Pedicle

A

Correct Answer: C) Spinous process

Rationale: The spinous process sticks out posteriorly and serves as an important landmark for finding the midline of the back, which is crucial for procedures like epidural or spinal anesthesia.

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61
Q

How does the location and function of the spinous process differ from that of the transverse process in a vertebra?

A) The spinous process extends laterally while the transverse process extends posteriorly
B) The spinous process extends posteriorly and serves as a midline landmark, while the transverse process extends laterally and provides muscle attachment
C) Both processes extend laterally and serve the same function
D) The spinous process is involved in cushioning, while the transverse process protects the spinal cord

A

Correct Answer: B) The spinous process extends posteriorly and serves as a midline landmark, while the transverse process extends laterally and provides muscle attachment

Rationale: The spinous process extends posteriorly and serves as a landmark for midline, while the transverse process extends laterally and provides attachment points for muscles and ligaments.

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62
Q

Why is it important to use the midline approach when administering epidural or spinal anesthesia?

A) It reduces the risk of damaging the spinal cord
B) It ensures the anesthetic spreads evenly
C) It prevents infection at the injection site
D) It facilitates easier access to the intervertebral discs

A

Correct Answer: A) It reduces the risk of damaging the spinal cord

Rationale: Using the midline approach helps in accurately placing the needle between the spinous processes, reducing the risk of damaging the spinal cord and other critical structures.

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63
Q

Which vertebral structure connects the vertebral body to the posterior elements, including the lamina and spinous process?

A) Transverse process
B) Pedicle
C) Vertebral foramen
D) Superior articular proces

A

Correct Answer: B) Pedicle

Rationale: The pedicle is the structure that connects the vertebral body to the posterior elements such as the lamina and spinous process, forming the sides of the vertebral arch.

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64
Q

What is a key anatomical difference between the spinous processes of the lumbar vertebrae compared to the thoracic and cervical vertebrae?

A) Lumbar spinous processes tilt downward
B) Thoracic and cervical spinous processes extend directly backwards
C) Lumbar spinous processes extend directly backwards
D) Lumbar spinous processes are shorter and thinner

A

Correct Answer: C) Lumbar spinous processes extend directly backwards

Rationale: Unlike the cervical and thoracic vertebrae, whose spinous processes tilt downward (caudal direction), the lumbar spinous processes extend directly backwards (posteriorly), facilitating easier access to the epidural and intrathecal spaces.

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65
Q

Why does the approach to needle insertion differ between the lumbar and thoracic regions during spinal or epidural anesthesia?

A) The thoracic region has more space between vertebrae
B) The lumbar spinous processes are angled downward
C) The thoracic spinous processes tilt downward, requiring a cephalad needle approach
D) The lumbar region requires a caudal needle approach

A

Correct Answer: C) The thoracic spinous processes tilt downward, requiring a cephalad needle approach

Rationale: In the thoracic region, the spinous processes tilt downward (caudally), necessitating a cephalad (upward) approach for needle insertion, whereas the lumbar region’s spinous processes extend directly backwards, allowing for a more straightforward approach.

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66
Q

Which region of the vertebral column requires a 40-degree needle angulation for proper epidural or spinal anesthesia placement?

A) Cervical region
B) Thoracic region
C) Lumbar region
D) Sacral region

A

Correct Answer: B) Thoracic region

Rationale: In the thoracic region, the spinous processes tilt downward at approximately a 40-degree angle, necessitating the same angulation for proper needle placement during epidural or spinal anesthesia.

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67
Q

How does the orientation of the lumbar spinous processes facilitate spinal anesthesia?

A) By providing a wider surface area for needle insertion
B) By requiring a cephalad approach
C) By sticking out directly backwards, simplifying the approach
D) By tilting downward, making access easier

A

Correct Answer: C) By sticking out directly backwards, simplifying the approach

Rationale: The lumbar spinous processes extend directly backwards (posteriorly), making it easier to reach the spaces around the spinal cord, such as the epidural and intrathecal spaces, simplifying the approach for spinal anesthesia.

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68
Q

What is the clinical significance of the spinous process orientation when performing a midline approach for neuraxial blocks?

A) It determines the type of anesthetic used
B) It affects the duration of anesthesia
C) It guides the angle and direction of needle insertion
D) It has no clinical significance

A

Correct Answer: C) It guides the angle and direction of needle insertion

Rationale: The orientation of the spinous processes is critical for guiding the angle and direction of needle insertion during a midline approach for neuraxial blocks, ensuring proper placement and effectiveness of the anesthesia.

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69
Q

What is the primary function of the intervertebral discs located between each vertebra?

A) Provide structural support to the spinal cord
B) Act as shock absorbers
C) Facilitate the passage of spinal nerves
D) Connect the vertebrae to the ribs

A

Correct Answer: B) Act as shock absorbers

Rationale: Intervertebral discs are soft pads located between each vertebra that act as shock absorbers, helping to cushion and protect the spinal column during movement.

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70
Q

Which structures form the anterior and posterior sides of the intervertebral foramina?

A) Anterior: vertebral body and pedicle; Posterior: spinous process and lamina
B) Anterior: intervertebral disc and vertebral body; Posterior: facet joints
C) Anterior: transverse process and intervertebral disc; Posterior: vertebral foramen
D) Anterior: nucleus pulposus and annulus fibrosus; Posterior: pedicle and lamina

A

Correct Answer: B) Anterior: intervertebral disc and vertebral body; Posterior: facet joints

Rationale: The anterior side of the intervertebral foramen is formed by the vertebral body and the intervertebral disc, while the posterior side is formed by the facet joints.

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71
Q

What is the potential impact of intervertebral disc degeneration on the foramina?

A) It has no impact on the foramina
B) It makes the foramina larger
C) It causes the foramina to become smaller, potentially compressing spinal nerves
D) It strengthens the foramina, preventing nerve compression

A

Correct Answer: C) It causes the foramina to become smaller, potentially compressing spinal nerves

Rationale: As intervertebral discs degenerate, the foramina can become smaller, which may lead to compression of the spinal nerves, causing pain, numbness, or weakness.

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72
Q

Which posterior vertebral structure primarily contributes to the formation of the intervertebral foramen through which spinal nerves exit?

A) Spinous process
B) Vertebral body
C) Pedicle
D) Facet joint

A

Correct Answer: D) Facet joint

Rationale: The facet joints form the posterior side of the intervertebral foramen, which is the opening through which spinal nerves exit the vertebral column.

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73
Q

How can the anatomical orientation of the intervertebral discs affect patients with disc problems during spinal anesthesia?

A) It makes it easier for them to bend forward
B) It causes them to experience no pain while bending
C) It can make bending forward difficult and painful, requiring alternative positioning for the procedure
D) It has no effect on their ability to bend forward

A

Correct Answer: C) It can make bending forward difficult and painful, requiring alternative positioning for the procedure

Rationale: Patients with disc problems often find it difficult and painful to bend forward, so alternative positioning, such as lying on their side, may be required for spinal anesthesia.

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74
Q

What technique can be employed to administer spinal anesthesia in patients with severe back issues who cannot bend forward easily?

A) Standing approach
B) Lateral approach with the patient lying on their side
C) Prone approach
D) Supine approach with the patient flat on their back

A

Correct Answer: B) Lateral approach with the patient lying on their side

Rationale: For patients with severe back issues, a lateral approach with the patient lying on their side can be an effective alternative to the traditional sitting position for spinal anesthesia.

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75
Q

Which two parts form each facet joint in the vertebral column?

A) Vertebral body and transverse process
B) Inferior articular process of one vertebra and superior articular process of the vertebra below
C) Spinous process and pedicle
D) Lamina and transverse process

A

Correct Answer: B) Inferior articular process of one vertebra and superior articular process of the vertebra below

Rationale: Each facet joint is formed by the inferior articular process of one vertebra connecting with the superior articular process of the vertebra directly below it.

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76
Q

What is the primary function of the facet joints in the vertebral column?

A) To absorb shock between vertebrae
B) To provide a passage for spinal nerves
C) To guide and limit the spine’s movement, keeping motions controlled
D) To connect the vertebrae to the ribs

A

Correct Answer: C) To guide and limit the spine’s movement, keeping motions controlled

Rationale: Facet joints help guide and limit the spine’s movement, ensuring that the motions of the back are controlled and stable.

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77
Q

How can an injury to a facet joint impact the spinal nerves?

A) It has no effect on the spinal nerves
B) It can press on nearby spinal nerves, causing pain and muscle spasms
C) It strengthens the spinal nerves
D) It only affects the muscles, not the nerves

A

Correct Answer: B) It can press on nearby spinal nerves, causing pain and muscle spasms

Rationale: If a facet joint gets injured, it can press on nearby spinal nerves, leading to pain, muscle spasms, and potentially affecting the area of skin (dermatome) served by that nerve.

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78
Q

Which movement is facilitated by the function of the facet joints?

A) Rotation of the vertebrae
B) Flexion (bending forward) and extension (bending backward)
C) Lateral bending
D) None of the above

A

Correct Answer: B) Flexion (bending forward) and extension (bending backward)

Rationale: Facet joints facilitate and control flexion (bending forward) and extension (bending backward) movements of the vertebral column.

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79
Q

What symptoms might indicate an issue with the facet joints that could affect spinal anesthesia procedures?

A) Increased flexibility
B) Muscle weakness without pain
C) Pain and muscle spasms in the area of the skin served by the affected nerve (dermatome)
D) Enhanced movement and stability of the spine

A

Correct Answer: C) Pain and muscle spasms in the area of the skin served by the affected nerve (dermatome)

Rationale: Symptoms such as pain and muscle spasms in the area of the skin served by the affected nerve (dermatome) may indicate an issue with the facet joints, which could affect the procedure.

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80
Q

What anatomical landmark corresponds with the level of the L4 vertebra and is commonly used for locating the site for spinal anesthesia?

A) Vertebra prominens (C7)
B) Root of the spine of the scapula (T3)
C) Superior aspect of the iliac crest
D) Posterior superior iliac spine

A

Correct Answer: C) Superior aspect of the iliac crest

Rationale: The superior aspect of the iliac crest aligns with the level of the L4 vertebra and is used as a key landmark for locating the site for spinal anesthesia.

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81
Q

What is the clinical significance of the intercristal line (Tuffier’s Line) in spinal anesthesia?

A) It aligns with the C7 vertebra
B) It helps identify the L4-L5 intervertebral space for safe needle insertion
C) It corresponds to the T3 vertebra in infants
D) It is used to measure spinal cord length

A

Correct Answer: B) It helps identify the L4-L5 intervertebral space for safe needle insertion

Rationale: The intercristal line (Tuffier’s Line) runs across the top edges of the iliac crests and matches the L4 vertebra, helping to identify the L4-L5 intervertebral space for safe needle insertion.

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82
Q

Why is it important to locate the posterior superior iliac spine when performing midline procedures such as epidural or spinal anesthesia?

A) It helps identify the T7 vertebra
B) It aligns with the L1-L2 intervertebral space
C) It serves as a landmark to maintain midline alignment during needle insertion
D) It indicates the end of the spinal cord

A

Correct Answer: C) It serves as a landmark to maintain midline alignment during needle insertion

Rationale: Locating the posterior superior iliac spine helps practitioners maintain midline alignment during needle insertion for procedures like epidural or spinal anesthesia. S2

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83
Q

In infants up to one year of age, the intercristal line corresponds with which intervertebral space?

A) L3-L4
B) L4-L5
C) L5-S1
D) S1-S2

A

Correct Answer: C) L5-S1

Rationale: In infants up to one year of age, the intercristal line corresponds with the L5-S1 intervertebral space, which is important for accurately locating the site for spinal procedures in this age group.

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84
Q

Which spinal level is considered safe for administering spinal anesthesia in adults to avoid the spinal cord and is above Tuffier’s line?

A) L5-S1
B) L4-L5
C) L3-L4
D) S1-S2

A

Correct Answer: C) L3-L4

Rationale: The spinal cord typically ends around the L1 level in adults, so administering spinal anesthesia at the L3-L4 intervertebral space is considered safe to avoid the spinal cord.

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85
Q

Which vertebral level is typically targeted for spinal anesthesia in pediatric patients to avoid the spinal cord?

A) L1-L2
B) L2-L3
C) L3-L4
D) L4-L5

A

Correct Answer: D) L4-L5

Rationale: In pediatric patients, the spinal cord extends to approximately the L3 vertebral level. To avoid the spinal cord and reduce the risk of injury, spinal anesthesia is typically administered at the L4-L5 intervertebral space​ - or hiatus (NYSORA)​​ (OpenAnesthesia)​.

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86
Q

What is the sacral hiatus, and where is it located?

A) A fused bone at the top of the sacrum
B) An opening at the base of the sacrum, aligning with the S5 vertebra
C) A ligament connecting the sacrum to the coccyx
D) A bony projection on the lateral aspect of the sacrum

A

Correct Answer: B) An opening at the base of the sacrum, aligning with the S5 vertebra

Rationale: The sacral hiatus is an opening located at the base of the sacrum, aligning with the S5 vertebra. It is covered by the sacrococcygeal ligament and acts as an access point for caudal anesthesia.

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87
Q

Which ligament covers the sacral hiatus and is crucial for performing caudal anesthesia?

A) Anterior longitudinal ligament
B) Posterior longitudinal ligament
C) Sacrococcygeal ligament
D) Ligamentum flavum

A

Correct Answer: C) Sacrococcygeal ligament

Rationale: The sacrococcygeal ligament covers the sacral hiatus and is crucial for the administration of caudal anesthesia, providing access to the epidural space.

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88
Q

What anatomical structures serve as landmarks for locating the sacral hiatus when performing caudal anesthesia, especially in pediatric patients?

A) Iliac crests
B) Sacral cornua
C) Ischial tuberosities
D) Pubic symphysis

A

Correct Answer: B) Sacral cornua

Rationale: The sacral cornua are bony projections on either side of the sacral hiatus and serve as important landmarks for locating the hiatus when performing caudal anesthesia, particularly in pediatric patients.

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89
Q

Why is the sacral hiatus considered a safe access point for caudal anesthesia in pediatric patients?

A) It is located far from the spinal cord
B) It provides direct access to the spinal cord
C) It is located at the level of the lumbar vertebrae
D) It is covered by a thick layer of muscle

A

Correct Answer: A) It is located far from the spinal cord

Rationale: The sacral hiatus is considered a safe access point for caudal anesthesia in pediatric patients because it is located at the base of the sacrum, far from the spinal cord, reducing the risk of injury.

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90
Q

What is the clinical significance of the incomplete lamina of the S5 vertebra in relation to caudal anesthesia?

A) It increases the risk of nerve damage
B) It creates the sacral hiatus, allowing for caudal anesthesia access
C) It prevents the use of the sacral hiatus for anesthesia
D) It causes the sacrum to fuse with the coccyx

A

Correct Answer: B) It creates the sacral hiatus, allowing for caudal anesthesia access

Rationale: The incomplete lamina of the S5 vertebra results in the formation of the sacral hiatus, which serves as an access point for caudal anesthesia.

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91
Q

Where does the spinal cord originate and terminate in adults and infants?

A) Originates at the foramen magnum, terminates at L4 in adults and L2 in infants
B) Originates at the medulla oblongata, terminates at L1-L2 in adults and L3 in infants
C) Originates at the cerebellum, terminates at L2-L3 in adults and L4 in infants
D) Originates at the brainstem, terminates at L3 in adults and L1-L2 in infants

A

Correct Answer: B) Originates at the medulla oblongata, terminates at L1-L2 in adults and L3 in infants

Rationale: The spinal cord originates at the medulla oblongata and terminates at the L1-L2 vertebrae in adults and at the L3 vertebra in infants. This is critical to know for safely performing spinal anesthesia and avoiding the spinal cord.

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92
Q

What is the conus medullaris and where is it located?

A) The beginning of the spinal cord at the brainstem
B) The tapered end of the spinal cord, located at L1-L2 in adults and L3 in infants
C) The bundle of spinal nerves extending from L2 to S5
D) The space between the dura mater and the vertebrae

A

Correct Answer: B) The tapered end of the spinal cord, located at L1-L2 in adults and L3 in infants

Rationale: The conus medullaris is the tapered end of the spinal cord. In adults, it is located at the L1-L2 vertebrae, and in infants, it is at the L3 vertebra.

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93
Q

What is the function of the cauda equina, and where is it located?

A) It provides support to the vertebral column, located between L1 and L3
B) It is a bundle of spinal nerves extending from the conus medullaris to the dural sac, located from L2 to S5
C) It is the origin of the spinal cord, located at the medulla oblongata
D) It encloses the cerebrospinal fluid, located from T12 to L1

A

Correct Answer: B) It is a bundle of spinal nerves extending from the conus medullaris to the dural sac, located from L2 to S5

Rationale: The cauda equina is a bundle of spinal nerves that extend from the conus medullaris to the dural sac, consisting of nerve roots from L2 to S5 and the coccygeal nerve.

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94
Q

Why is it important to consider the termination level of the dural sac in spinal anesthesia?

A) To ensure the needle does not penetrate the vertebral body
B) To avoid damage to the spinal cord, especially in infants where the dural sac ends lower
C) To correctly identify a viable spot for spinal anesthetics.
D) To determine the dosage of local anesthetic

A

C) To correctly identify a viable spot for spinal anesthetics.

Rationale: if you are below the dural sac you will not be in the CSF, therefore no spinal anesthetic.

The dural sac contains the cerebrospinal fluid and extends to S2 in adults and S3 in infants

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95
Q

Which nerve roots are involved in the cauda equina, and what potential symptoms might arise from their compression?

A) C1 to C7; motor weakness in the arms
B) T1 to T12; thoracic pain and weakness
C) L2 to S5; lower back pain, numbness, and muscle weakness in the lower limbs
D) S1 to S5; bladder and bowel dysfunction

A

Correct Answer: C) L2 to S5; lower back pain, numbness, and muscle weakness in the lower limbs

Rationale: The cauda equina consists of nerve roots from L2 (conus medullaris @ L1) to S5. (and coccygeal nerve). Compression of these nerves can result in lower back pain, numbness, and muscle weakness in the lower limbs, as well as potential bowel and bladder dysfunction.

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96
Q

Where does the dural sac end in adults and infants, and why is this significant for spinal anesthesia?

A) S1 in adults, S2 in infants; significant for identifying lumbar puncture sites
B) S2 in adults, S3 in infants; significant for avoiding cerebrospinal fluid leakage
C) S2 in adults, S3 in infants; significant because areas below this do not contain cerebrospinal fluid
D) S1 in adults, S2 in infants; significant for epidural anesthesia placement

A

Correct Answer: C) S2 in adults, S3 in infants; significant because areas below this do not contain cerebrospinal fluid

Rationale: The dural sac ends at S2 in adults and at S3 in infants. This is significant for spinal anesthesia because areas below these levels do not contain cerebrospinal fluid (CSF), meaning they are not suitable for spinal anesthesia.

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97
Q

What is the primary function of the filum terminale, and what are its parts?

A) Conducts nerve impulses; internal filum and external filum
B) Anchors the spinal cord to the coccyx; internal filum and external filum
C) Protects the spinal cord from injuries; internal filum and external filum
D) Connects the spinal cord to the brain; internal filum and external filum

A

Correct Answer: B) Anchors the spinal cord to the coccyx; internal filum and external filum

Rationale: The filum terminale’s primary function is to anchor the spinal cord to the coccyx. It consists of two parts: the internal filum terminale (from the conus medullaris to the dural sac) and the external filum terminale (from the dural sac to the coccyx).

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98
Q

Which structure continues from the end of the spinal cord and extends down to the coccyx, and what is it a continuation of?

A) Cauda equina; continuation of the dura mater
B) Filum terminale; continuation of the pia mater
C) Conus medullaris; continuation of the arachnoid mater
D) Dural sac; continuation of the spinal cord

A

Correct Answer: B) Filum terminale; continuation of the pia mater

Rationale: The filum terminale continues from the end of the spinal cord (conus medullaris) and extends to the coccyx. It is a continuation of the pia mater and serves to anchor the spinal cord in place.

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99
Q

Why is it important to avoid performing spinal anesthesia below the S2 level in adults?

A) To prevent damage to the cauda equina
B) Because the filum terminale ends at S2
C) Because there is no cerebrospinal fluid below S2
D) To avoid puncturing the sacrococcygeal ligament

A

Correct Answer: C) Because there is no cerebrospinal fluid below S2

Rationale: Below the S2 level in adults, there is no cerebrospinal fluid (CSF), which is essential for the proper administration and effect of spinal anesthesia.

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100
Q

What does the cauda equina consist of, and why is it clinically significant?

A) A bundle of spinal nerves from L2 to S5; it is significant for lower limb and pelvic organ function
B) The terminal end of the spinal cord; it is significant for spinal cord termination
C) Nerve roots from the coccyx to the sacrum; it is significant for sacral nerve function
D) A structure continuing from the pia mater; it anchors the spinal cord

A

Correct Answer: A) A bundle of spinal nerves from L2 to S5; it is significant for lower limb and pelvic organ function

Rationale: The cauda equina consists of a bundle of spinal nerves extending from the L2 to S5 vertebrae. It is clinically significant as it affects the function of the lower limbs and pelvic organs, and its compression can lead to cauda equina syndrome, a serious condition requiring immediate medical attention.

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101
Q

What is the origin of the anterior and posterior spinal arteries?

A) Subclavian artery
B) Carotid artery
C) Vertebral artery
D) Cranial Vault

A

Correct Answer: C) Vertebral artery

Rationale: Both the anterior and posterior spinal arteries originate from the vertebral artery. This is important for understanding the blood supply to the spinal cord.

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102
Q

Which part of the spinal cord does the anterior spinal artery primarily supply, and what is its function?

A) Posterior 1/3, sensory function
B) Anterior 2/3, motor function
C) Anterior 2/3, both motor and sensory functions
D) Lateral 1/3, autonomic functions

A

Correct Answer: B) Anterior 2/3, motor function

Rationale: The anterior spinal artery supplies the anterior two-thirds of the spinal cord, which is predominantly involved in motor functions (efferent pathways).

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103
Q

How does the collateral circulation of the posterior spinal arteries protect the spinal cord from ischemia?

A) By providing multiple pathways for blood to reach the sensory parts of the spinal cord
B) By increasing the flow of cerebrospinal fluid
C) By decreasing the blood pressure in the spinal arteries
D) By directly supplying the motor neurons

A

Correct Answer: A) By providing multiple pathways for blood to reach the sensory parts of the spinal cord

Rationale: The posterior spinal arteries have many connections (collateral anastomotic links) with the subclavian and intercostal arteries, which help protect the sensory part of the spinal cord from ischemia by providing alternative pathways for blood flow.

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104
Q

Why is the anterior spinal artery more vulnerable to ischemia compared to the posterior spinal arteries?

A) It has fewer protective anastomotic links
B) It supplies a smaller area of the spinal cord
C) It is located closer to the vertebral body
D) It is paired, unlike the posterior spinal arteries

A

Correct Answer: A) It has fewer protective anastomotic links

Rationale: The anterior spinal artery is a single artery and does not have as many protective anastomotic links as the paired posterior spinal arteries, making the motor part of the spinal cord it supplies more vulnerable to ischemia.

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105
Q

What is the clinical significance of the anterior spinal artery syndrome?

A) It primarily affects the sensory pathways of the spinal cord
B) It results in motor deficits due to ischemia of the anterior two-thirds of the spinal cord
C) It causes increased cerebrospinal fluid production
D) It exclusively affects the upper cervical spinal cord

A

Correct Answer: B) It results in motor deficits due to ischemia of the anterior two-thirds of the spinal cord

Rationale: Anterior spinal artery syndrome occurs due to ischemia of the anterior two-thirds of the spinal cord, leading to motor deficits and affecting the motor pathways.

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106
Q

What are the primary consequences of anterior spinal artery syndrome?

A) Loss of proprioception and vibration sensation
B) Motor paralysis and loss of pain and temperature sensation below the affected area
C) Complete sensory and motor paralysis
D) Loss of fine touch and pressure sensation

A

Correct Answer: B) Motor paralysis and loss of pain and temperature sensation below the affected area

Rationale: Anterior spinal artery syndrome primarily results in motor paralysis and the loss of pain and temperature sensation below the affected area, as it affects the anterior two-thirds of the spinal cord which is responsible for motor functions and some sensory functions.

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107
Q

Which artery provides crucial blood supply to the lower two-thirds of the spinal cord, and where does it typically arise?

A) Iliac artery; between the T4 and T6 regions
B) Artery of Adamkiewicz; between the T9 and L2 regions
C) Posterior spinal artery; between the T1 and T3 regions
D) Radicular artery; between the L2 and S1 regions

A

Correct Answer: B) Artery of Adamkiewicz; between the T9 and L2 regions

Rationale: The artery of Adamkiewicz is a crucial artery that supplies blood to the lower two-thirds of the spinal cord. It typically arises from the aorta between the T9 and L2 regions.

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108
Q

Which factors can lead to ischemia of the anterior spinal artery?

A) Hypertension, vasculopathy, hyperlipidemia
B) Low blood pressure, mechanical blockage, vasculopathy, bleeding
C) Diabetes, hyperthyroidism, smoking
D) High cholesterol, obesity, sedentary lifestyle

A

Correct Answer: B) Low blood pressure, mechanical blockage, vasculopathy, bleeding

Rationale: Ischemia of the anterior spinal artery can be caused by low blood pressure (profound hypotension), mechanical blockage, blood vessel disease (vasculopathy), and bleeding (hemorrhage).

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109
Q

Which ligament is particularly thick in the lower back and forms the sidewalls of the epidural space, indicating entry into the epidural space when pierced?

A) Anterior longitudinal ligament
B) Posterior longitudinal ligament
C) Ligamentum flavum
D) Supraspinous ligament

A

Correct Answer: C) Ligamentum flavum

Rationale: The ligamentum flavum is particularly thick in the lower back and forms the sidewalls of the epidural space. Piercing this ligament indicates entry into the epidural space during procedures.

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110
Q

What is the function of the interspinous ligament?

A) Connecting the tips of the spinous processes
B) Providing stability by joining adjacent vertebrae
C) Running along the front of the vertebral bodies
D) Indicating entry into the epidural space

A

Correct Answer: B) Providing stability by joining adjacent vertebrae

Rationale: The interspinous ligament is located between the spinous processes of the vertebrae and provides stability by joining adjacent vertebrae.

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111
Q

Which ligament runs along the back of the vertebral bodies inside the spinal column and is important to avoid during spinal procedures?

A) Anterior longitudinal ligament
B) Posterior longitudinal ligament
C) Ligamentum flavum
D) Supraspinous ligament

A

Correct Answer: B) Posterior longitudinal ligament

Rationale: The posterior longitudinal ligament runs along the back of the vertebral bodies inside the spinal column and should be avoided during spinal procedures to prevent damage to the spinal cord.

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112
Q

What is the main function of the supraspinous ligament?

A) Connecting the anterior aspects of the vertebrae
B) Running along the length of the vertebral bodies
C) Connecting the tips of the spinous processes from the upper back to the lower back
D) Providing sensory innervation to the spinal cord

A

Correct Answer: C) Connecting the tips of the spinous processes from the upper back to the lower back

Rationale: The supraspinous ligament runs along the back, connecting the tips of the spinous processes from the upper back down to the lower back, providing stability.

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113
Q

Why is it important to avoid going past the Dura Mater during epidural procedures?

A) It can cause damage to the vertebral bodies
B) It can result in hitting the spinal cord if above L1
C) It can lead to a punctured dura mater
D) It can cause a drop in cerebrospinal fluid pressure

A

Correct Answer: B) It can result in hitting the spinal cord if above L1

Rationale: Avoiding going past the Dura Mater during epidural procedures is crucial because, if above L1, it can result in hitting the spinal cord, leading to serious complications.

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114
Q

What are the layers traversed during a midline spinal approach?

A) Skin, subcutaneous fat, ligamentum flavum, dura mater, subdural space, arachnoid mater, subarachnoid space
B) Skin, subcutaneous fat, supraspinous ligament, interspinous ligament, ligamentum flavum, dura mater, subdural space, arachnoid mater, subarachnoid space
C) Skin, subcutaneous fat, anterior longitudinal ligament, dura mater, subdural space, arachnoid mater, subarachnoid space
D) Skin, subcutaneous fat, supraspinous ligament, ligamentum flavum, dura mater, subdural space, arachnoid mater, subarachnoid space

A

Correct Answer: B) Skin, subcutaneous fat, supraspinous ligament, interspinous ligament, ligamentum flavum, dura mater, subdural space, arachnoid mater, subarachnoid space

Rationale: In a midline approach, the needle passes through the skin, subcutaneous fat, supraspinous ligament, interspinous ligament, ligamentum flavum, dura mater, subdural space, arachnoid mater, and finally into the subarachnoid space where cerebrospinal fluid (CSF) is obtained.

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115
Q

In which situations is the paramedian approach preferred over the midline approach for spinal anesthesia?

A) When the patient has lower back pain
B) When the interspinous ligament is calcified or the patient cannot flex their spine
C) For faster onset of anesthesia
D) When the patient is allergic to local anesthetics

A

Correct Answer: B) When the interspinous ligament is calcified or the patient cannot flex their spine

Rationale: The paramedian approach is preferred when the interspinous ligament is calcified or when the patient cannot flex their spine. This approach bypasses the interspinous ligament and allows for easier needle placement.

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116
Q

What angle and positioning are used for the paramedian approach in spinal anesthesia?

A) 10 degrees off the midline, 2 cm lateral and 2 cm inferior
B) 15 degrees off the midline, 1 cm lateral and 1 cm inferior
C) 20 degrees off the midline, 1 cm lateral and 1 cm superior
D) 5 degrees off the midline, 2 cm lateral and 1 cm inferior

A

Correct Answer: B) 15 degrees off the midline, 1 cm lateral and 1 cm inferior

Rationale: In the paramedian approach, the needle is inserted 15 degrees off the midline, positioned 1 cm lateral and 1 cm inferior to the interspace between the vertebrae.

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117
Q

Why is it critical to know the different layers traversed during a spinal anesthesia procedure?

A) To ensure the patient remains comfortable
B) To minimize the dose of anesthetic used
C) To avoid puncturing the spinal cord and ensure correct placement of the needle
D) To determine the duration of the anesthesia

A

Correct Answer: C) To avoid puncturing the spinal cord and ensure correct placement of the needle

Rationale: Knowing the different layers traversed during a spinal anesthesia procedure is critical to avoid puncturing the spinal cord and to ensure the needle is correctly placed in the subarachnoid space.

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118
Q

Which ligament must be pierced to enter the epidural space during a epidural procedure?

A) Anterior longitudinal ligament
B) Posterior longitudinal ligament
C) Ligamentum flavum
D) Supraspinous ligament

A

Correct Answer: C) Ligamentum flavum

Rationale: Piercing the ligamentum flavum indicates entry into the epidural space during a spinal procedure.

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119
Q

What are the layers of the meninges, from outermost to innermost?

A) Arachnoid mater, dura mater, pia mater
B) Dura mater, pia mater, arachnoid mater
C) Dura mater, arachnoid mater, pia mater
D) Pia mater, dura mater, arachnoid mater

A

Correct Answer: C) Dura mater, arachnoid mater, pia mater

Rationale: The meninges consist of three layers that cover the brain and spinal cord. From outermost to innermost, they are: dura mater, arachnoid mater, and pia mater.

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120
Q

Which space is found between the dura mater and the ligamentum flavum?

A) Subarachnoid space
B) Epidural space
C) Subdural space
D) Intraspinal space

A

Correct Answer: B) Epidural space

Rationale: The epidural space is located between the dura mater and the ligamentum flavum. It is the space where epidural anesthesia is administered.

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121
Q

What is the significance of the subarachnoid space in spinal anesthesia?

A) It contains the cerebrospinal fluid (CSF) necessary for intrathecal anesthesia
B) It provides a cushion for the spinal cord against mechanical injury
C) It houses the blood vessels that supply the spinal cord
D) It is the potential space for epidural injections

A

Correct Answer: A) It contains the cerebrospinal fluid (CSF) necessary for intrathecal anesthesia

Rationale: The subarachnoid space contains cerebrospinal fluid (CSF), which is essential for intrathecal (spinal) anesthesia. This space is accessed to deliver the anesthetic directly into the CSF.

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122
Q

During a spinal anesthesia procedure using the midline approach, which structure is pierced immediately before entering the subarachnoid space?

A) Arachnoid mater
B) Ligamentum flavum
C) Dura mater
D) Pia mater

A

Correct Answer: C) Dura mater

Rationale: (POP) In a spinal anesthesia procedure, the needle passes through the dura mater immediately before entering the subarachnoid space, where cerebrospinal fluid (CSF) is present.

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123
Q

Which of the following is a potential space and is not typically present under normal physiological conditions?

A) Epidural space
B) Subarachnoid space
C) Subdural space
D) Intrathecal space

A

Correct Answer: C) Subdural space

Rationale: The subdural space is a potential space that is not typically present under normal physiological conditions. It can become apparent when there is bleeding or other pathology that separates the dura mater from the arachnoid mater.

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124
Q

Which space contains cerebrospinal fluid (CSF) and is crucial for spinal anesthesia?

A) Epidural space
B) Subdural space
C) Subarachnoid space
D) Intraspinal space

A

Correct Answer: C) Subarachnoid space

Rationale: The subarachnoid space, located between the arachnoid mater and the pia mater, contains cerebrospinal fluid (CSF). This space is critical for spinal anesthesia as it allows the anesthetic to mix directly with the CSF.

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125
Q

What is the significance of the epidural space in regional anesthesia?

A) It is the space where cerebrospinal fluid is collected
B) It contains fat and small blood vessels and is the site for epidural anesthesia
C) It is a potential space between the dura mater and the arachnoid mater
D) It is located within the pia mater

A

Correct Answer: B) It contains fat and small blood vessels and is the site for epidural anesthesia

Rationale: The epidural space, located outside the dura mater, contains fat and small blood vessels (epidural veins). It is the site where epidural anesthesia is administered.

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126
Q

What happens if an epidural needle inadvertently enters the subdural space?

A) The block will have no effect
B) The block can spread caudally, potentially causing unexpected results
C) The patient will feel immediate pain
D) The needle will encounter cerebrospinal fluid

A

Correct Answer: B) The block can spread caudally, potentially causing unexpected results

Rationale: If an epidural needle inadvertently enters the subdural space, the block can spread caudally, potentially causing unexpected and unintended effects.

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127
Q

What is the cranial boundary of the epidural space?

A) Foramen magnum
B) Sacrococcygeal ligament
C) Posterior longitudinal ligament
D) Ligamentum flavum

A

Correct Answer: A) Foramen magnum

Rationale: The cranial boundary of the epidural space is at the foramen magnum, located at the base of the skull.

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128
Q

Which ligament forms the anterior border of the epidural space?

A) Ligamentum flavum
B) Posterior longitudinal ligament
C) Anterior longitudinal ligament
D) Sacrococcygeal ligament

A

Correct Answer: B) Posterior longitudinal ligament

Rationale: The anterior border of the epidural space is lined by the posterior longitudinal ligament along the vertebrae.

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129
Q

Which of the following is NOT a boundary of the epidural space?

A) Foramen magnum
B) Sacrococcygeal ligament
C) Pia mater
D) Vertebral pedicles

A

Correct Answer: C) Pia mater

Rationale: The boundaries of the epidural space include the foramen magnum (cranial), sacrococcygeal ligament (caudal), posterior longitudinal ligament (anterior), and vertebral pedicles (lateral). The pia mater is not a boundary of the epidural space; it is the innermost layer of the meninges covering the spinal cord.

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130
Q

What marks the posterior border of the epidural space?

A) Posterior longitudinal ligament
B) Ligamentum flavum and vertebral lamina
C) Sacrococcygeal ligament
D) Vertebral bodies

A

Correct Answer: B) Ligamentum flavum and vertebral lamina

Rationale: The posterior border of the epidural space is framed by the ligamentum flavum and the bony plates of the vertebrae (vertebral lamina).

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131
Q

Which statement is true regarding the epidural space?

A) It is located inside the dura mater and contains cerebrospinal fluid (CSF)
B) It is located outside the dura mater and contains fat and small blood vessels
C) It extends only from the cervical to the lumbar regions
D) It is formed by the pia mater and the arachnoid mater

A

Correct Answer: B) It is located outside the dura mater and contains fat and small blood vessels

Rationale: The epidural space is located outside the dura mater and contains fat and small blood vessels (epidural veins). It extends from the foramen magnum to the sacrococcygeal ligament at the bottom.

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132
Q

What is the primary function of the fatty tissue in the epidural space?

A) Provide structural support
B) Absorb and decrease the availability of certain drugs
C) Cushion the spinal cord
D) Facilitate the passage of blood vessels

A

Correct Answer: B) Absorb and decrease the availability of certain drugs

Rationale: Fatty tissue in the epidural space can absorb and decrease the availability of drugs like bupivacaine more than lidocaine or fentanyl.

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133
Q

Which statement about the epidural veins (Batson’s Plexus) is accurate?

A) They have valves that prevent backflow of blood.
B) Their density decreases laterally.
C) They are valveless and can become engorged under certain conditions.
D) They do not drain blood from the spinal cord linings.

A

Correct Answer: C) They are valveless and can become engorged under certain conditions.

Rationale: The epidural veins are valveless and form a plexus that drains blood from the spinal cord and its linings. They can become engorged under conditions like obesity or pregnancy, increasing the risk during needle procedures.

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134
Q

Why is it crucial to avoid injecting into the epidural veins during an epidural procedure?

A) It can cause immediate systemic toxicity.
B) It leads to rapid absorption of the local anesthetic.
C) It may cause thrombosis.
D) All of the above.

A

Correct Answer: D) All of the above.

Rationale: Injecting into the epidural veins can cause immediate systemic toxicity, lead to rapid absorption of the local anesthetic, and may cause thrombosis.

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135
Q

What anatomical feature increases the risk of hitting an epidural vein during needle procedures?

A) The presence of numerous valves
B) Increased density of veins laterally
C) Thickening of the ligamentum flavum
D) Narrowing of the epidural space cranially

A

Correct Answer: B) Increased density of veins laterally

Rationale: The density of epidural veins increases laterally, making it more likely to hit a vein if the needle is inserted too far to the side.

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136
Q

In which condition is the epidural space particularly engorged, increasing the risk during needle procedures?

A) Hypotension
B) Dehydration
C) Pregnancy
D) Hypercalcemia

A

Correct Answer: C) Pregnancy

Rationale: The epidural space, particularly the epidural veins, can become engorged under conditions like pregnancy, increasing the risk during needle procedures.

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137
Q

The presence of the plica mediana dorsalis is controversial and not definitively confirmed. If it does exist, where is it thought to be located, and what potential impact might it have on epidural anesthesia?

A. Between the supraspinous ligament and the interspinous ligament; it might act as a barrier to medication spread within the epidural space.
B. Between the ligamentum flavum and the dura mater; it might act as a barrier to medication spread within the epidural space.
C. Between the interspinous ligament and the ligamentum flavum; it might facilitate the spread of medications within the epidural space.
D. Between the dura mater and the arachnoid mater; it might act as a barrier to CSF flow.

A

Answer: B. Between the ligamentum flavum and the dura mater; it might act as a barrier to medication spread within the epidural space.

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138
Q

Which of the following clinical scenarios is most likely attributed to the presence of the plica mediana dorsalis during an epidural procedure?

A. The patient experiences bilateral sensory and motor block despite accurate catheter placement.
B. The patient has an effective motor block but incomplete sensory block.
C. The patient exhibits a unilateral block where only one side of the body is affected.
D. The patient reports severe headache and back pain immediately after the procedure.

A

Answer: C. The patient exhibits a unilateral block where only one side of the body is affected.

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139
Q

What steps might a clinician take if they suspect the presence of the plica mediana dorsalis is causing a unilateral block during an epidural anesthesia procedure?

A. Increase the dosage of local anesthetic injected through the catheter.
B. Reposition the patient and pull the catheter back by approximately 1 cm.
C. Push the catheter further into the epidural space.
D. Switch to a different type of anesthetic agent.

A

Answer: B. Reposition the patient and pull the catheter back by approximately 1 cm.

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140
Q

Which structure in the epidural space is considered a potential barrier to medication spread and is sometimes linked to complications in catheter placement?

A. Ligamentum flavum
B. Dura mater
C. Plica mediana dorsalis
D. Epidural veins (Batson’s plexus)

A

Answer: C. Plica mediana dorsalis

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141
Q

In the context of epidural anesthesia, which of the following is the most appropriate description of the plica mediana dorsalis?

A. A structure that enhances the uniform spread of anesthetic agents within the epidural space.
B. A connective tissue band that may exist between the ligamentum flavum and the dura mater, potentially causing unilateral blocks.
C. A ligament that runs along the anterior border of the epidural space, preventing anterior spread of medications.
D. A vascular plexus that drains blood from the spinal cord and is located laterally in the epidural space.

A

Answer: B. A connective tissue band that may exist between the ligamentum flavum and the dura mater, potentially causing unilateral blocks.

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142
Q

What is the primary target space when performing a spinal anesthetic procedure?

A) Epidural space
B) Subarachnoid space
C) Subdural space
D) Interspinous ligament

A

Answer: B - Subarachnoid space
Rationale: The subarachnoid space, also known as the intrathecal space, is the primary target for spinal anesthesia as it contains cerebrospinal fluid (CSF), nerve roots, and the spinal cord itself.

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143
Q

What sensation is typically felt during spinal anesthesia when the needle passes through the dura mater?

A) Sharp pain
B) No sensation
C) A characteristic “pop”
D) Tingling in the legs

A

Answer: C - A characteristic “pop”
Rationale: The “pop” sensation is commonly felt when the needle pierces the dura mater, indicating entry into the subarachnoid space.

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144
Q

What are the key contents of the subarachnoid space?

A) Fat and small blood vessels
B) Cerebrospinal fluid (CSF), nerve roots, and the spinal cord
C) Lymphatic vessels and adipose tissue
D) Only cerebrospinal fluid (CSF)

A

Answer: B - Cerebrospinal fluid (CSF), nerve roots, and the spinal cord

Rationale: The subarachnoid space contains cerebrospinal fluid (CSF), nerve roots, and the spinal cord, which are crucial for the proper functioning of the central nervous system.

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145
Q

What could potentially happen if the needle is advanced too far anteriorly during a spinal anesthetic procedure?

A) It could cause an epidural hematoma
B) It could pass through several layers including the pia mater, spinal cord, and posterior longitudinal ligament before reaching bone
C) It could result in a unilateral block
D) It could get lodged in the interspinous ligament

A

Answer: B - It could pass through several layers including the pia mater, spinal cord, and posterior longitudinal ligament before reaching bone

Rationale: Advancing the needle too far anteriorly can cause it to pass through multiple layers, potentially leading to serious complications by damaging the spinal cord and associated structures.

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146
Q

What can happen if local anesthetic is inadvertently injected into the subdural space during an epidural procedure?

a) Failed spinal block
b) High spinal effect
c) Increased blood pressure
d) No effect

A

Answer: b) High spinal effect

Rationale: If local anesthetic is inadvertently injected into the subdural space during an epidural, it can cause a “high spinal” effect, meaning the medication affects a larger area than intended.

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147
Q

What is the result of an accidental injection into the subdural space during spinal anesthesia?

a) Enhanced anesthesia
b) Failed spinal block
c) Prolonged anesthesia
d) No effect

A

Answer: b) Failed spinal block

Rationale: An accidental injection into the subdural space during spinal anesthesia can result in a failed spinal block due to improper delivery of the anesthetic.

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148
Q

What is the primary role of the dura mater?
A) It directly covers the spinal cord.
B) It acts as a middle protective layer between other meningeal layers.
C) It is a tough fibrous shield that protects the spinal cord.
D) It contains cerebrospinal fluid (CSF) and nerve roots.

A

Answer:
C) It is a tough fibrous shield that protects the spinal cord.

Rationale:
The dura mater is the outermost layer of the meninges and serves as a tough fibrous shield that protects the spinal cord. It starts at the foramen magnum and extends down to the dural sac.

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149
Q

Which meningeal layer lies directly beneath the dura mater?
A) Pia mater
B) Arachnoid mater
C) Subarachnoid space
D) Epidural space

A

Answer:
B) Arachnoid mater

Rationale:
The arachnoid mater is the second meningeal layer, situated directly beneath the dura mater. It acts as a protective middle layer between the dura mater and the pia mater.

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150
Q

What is the significance of the pia mater in spinal anesthesia procedures?
A) It should be punctured during the procedure.
B) It is a potential space.
C) It directly covers the spinal cord and should never be punctured.
D) It acts as the primary target for spinal anesthesia.

A

Answer:
C) It directly covers the spinal cord and should never be punctured.

Rationale:
The pia mater is the innermost meningeal layer that is highly vascular and directly attached to the surface of the spinal cord. It should never be punctured during spinal anesthesia procedures to avoid damaging the spinal cord.

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151
Q

How many pairs of spinal nerves are there in the human body?
a) 32
b) 29
c) 31
d) 33

A

Correct Answer: c) 31
Rationale: The human body has 31 pairs of spinal nerves.

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152
Q

Which of the following is true about the C8 nerve?
a) It exits above the C8 vertebra
b) It exits below the C7 vertebra
c) It exits above the C7 vertebra
d) It exits below the C8 vertebra

A

Correct Answer: b) It exits below the C7 vertebra
Rationale: The C8 nerve is unique because it exits below the C7 vertebra. The rest exit below from that point.

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153
Q

What type of information does the anterior (ventral) nerve root carry?

a) Sensory information from the body to the spinal cord
b) Motor and autonomic information from the spinal cord to the body
c) Sensory and motor information to the body
d) Autonomic and sensory information from the body to the spinal cord

A

Correct Answer: b) Motor and autonomic information from the spinal cord to the body

Rationale: The anterior (ventral) nerve root is responsible for carrying motor and autonomic information from the spinal cord to the body.

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154
Q

Which of the following nerves is not correctly paired with its corresponding vertebrae?

a) C1 nerve exits above the C1 vertebra
b) C2 nerve exits above the C2 vertebra
c) C7 nerve exits below the C7 vertebra
d) C8 nerve exits below the C7 vertebra

A

Correct Answer: c) C7 nerve exits below the C7 vertebra

Rationale: The C1 to C7 nerves exit above their corresponding vertebrae, with the C8 nerve exiting below the C7 vertebra.

12 thoracic nerves
5 lumbar
5 sacral
1 coccygeal

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155
Q

What is a dermatome?
a) A nerve that controls muscle movement
b) An area of skin that receives sensory nerves from a single spinal nerve root
c) A bone in the spinal column
d) A blood vessel in the spinal cord

A

Correct Answer: b) An area of skin that receives sensory nerves from a single spinal nerve root

Rationale: A dermatome is defined as an area of skin that receives sensory nerves from a single spinal nerve root.

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156
Q

Which spinal nerve serves the umbilicus (belly button) area?
a) L3
b) T10
c) S1
d) C5

A

Correct Answer: b) T10

Rationale: The umbilicus (belly button) area is actually served by the T10 nerve.

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157
Q

Which of the following statements about dermatomes and spinal nerves is correct?

a) Dermatomes are aligned with the vertebrae of the spine
b) Each dermatome is served by multiple spinal nerve roots
c) A dermatome may appear to align with one part of the spine but is connected to a different spinal nerve root
d) The spinal nerves serving dermatomes are responsible for motor control only

A

Correct Answer: c) A dermatome may appear to align with one part of the spine but is connected to a different spinal nerve root

Rationale: Although a dermatome may physically appear to align with a certain part of the spine, it is actually connected to a different spinal nerve root.

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158
Q

For a surgical procedure planned around the level of the nipples, which spinal nerve should the block target?
a) T4
b) T10
c) L1
d) S1

A

Correct Answer: a) T4

Rationale: The area at the level of the nipples is served by the T4 nerve, so the block should target the T4 spinal nerve.

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159
Q

Which cranial nerve is responsible for the sensory innervation of the face?
a) Cranial Nerve II
b) Cranial Nerve V
c) Cranial Nerve VII
d) Cranial Nerve IX

A

Correct Answer: b) Cranial Nerve V

Rationale: The sensory information from the face is transmitted through the trigeminal nerve, which is Cranial Nerve V.

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160
Q

What is the primary function of the V1 branch of the trigeminal nerve?

a) Sensory input from the lower jaw and teeth
b) Sensory input from the forehead, scalp, and upper eyelids
c) Sensory input from the cheeks and upper lip
d) Motor function for facial expressions

A

Correct Answer: b) Sensory input from the forehead, scalp, and upper eyelids

Rationale: The V1 branch, also known as the ophthalmic nerve, handles sensation from the forehead, scalp, and upper eyelids.

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161
Q

The V2 branch of the trigeminal nerve is responsible for sensory input from which areas?

a) Forehead, scalp, and upper eyelids
b) Lower jaw, lower teeth, and part of the tongue
c) Lower eyelids, cheeks, nostrils, upper lip, and upper teeth
d) Paranasal sinuses and upper face

A

Correct Answer: c) Lower eyelids, cheeks, nostrils, upper lip, and upper teeth

Rationale: The V2 branch, also known as the maxillary nerve, is responsible for sensory input from the lower eyelids, cheeks, nostrils, upper lip, and upper teeth.

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162
Q

Which of the following branches of the trigeminal nerve also has a motor function?

a) V1 - Ophthalmic Nerve
b) V2 - Maxillary Nerve
c) V3 - Mandibular Nerve
d) None of the above

A

Correct Answer: c) V3 - Mandibular Nerve
R
ationale: The V3 branch, also known as the mandibular nerve, conveys sensations from the lower jaw, lower teeth, lower lip, and part of the tongue, and it also has a motor function for the muscles of mastication. mylohyoid m.

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163
Q

Which dermatome level is targeted for peri-anal or anal surgery, commonly referred to as a “saddle block”?
a) S2-S5
b) T10
c) L2
d) T8

A

Correct Answer: a) S2-S5

Rationale: The dermatome level S2-S5 is targeted for peri-anal or anal surgery, known as a “saddle block.”

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164
Q

For a foot or ankle surgery, which dermatome level should be blocked?
a) S2
b) L1
c) T6
d) L2

A

Correct Answer: d) L2

Rationale: The dermatome level L2 is appropriate for blocking during foot or ankle surgery.

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165
Q

A patient undergoing a cesarean section should have which dermatome level blocked?
a) T10
b) L1
c) T4
d) T8

A

Correct Answer: c) T4

Rationale: The dermatome level T4 is targeted for a cesarean section or upper abdominal procedures.

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166
Q

Which dermatome level corresponds to a vaginal delivery or uterine procedure?
a) L2
b) S3
c) T10
d) T6

A

Correct Answer: c) T10

Rationale: The dermatome level T10 is used for vaginal delivery, uterine procedures, hip procedures, tourniquet, and TURP (transurethral resection of the prostate).

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167
Q

Testicular Procedure dermatome?

A

T8

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168
Q

What is the primary target of the local anesthetic (LA) in spinal anesthesia?
a) Postganglionic fibers
b) Myelinated preganglionic fibers of the spinal nerve roots
c) Sympathetic ganglia
d) Dorsal root ganglion (DRG)

A

Correct Answer: b) Myelinated preganglionic fibers of the spinal nerve roots

Rationale: In spinal anesthesia, the local anesthetic acts on the myelinated preganglionic fibers of the spinal nerve roots and inhibits neural transmission in the superficial layers of the spinal cord.

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169
Q

In the context of epidural anesthesia, what is the process by which the local anesthetic (LA) reaches the nerve roots?

a) Direct injection into the nerve roots
b) Diffusion through the dural cuff
c) Infiltration of the spinal cord directly
d) Absorption through the bloodstream

A

Correct Answer: b) Diffusion through the dural cuff

Rationale: In epidural anesthesia, the local anesthetic diffuses through the dural cuff to reach the nerve roots.

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170
Q

What is a potential complication related to the leakage of the local anesthetic (LA) in epidural anesthesia?

a) Infiltration of the cerebrospinal fluid
b) Blockade of postganglionic fibers
c) Leakage into the paravertebral area through the intervertebral foramen
d) Absorption by the paraspinal muscles

A

Correct Answer: c) Leakage into the paravertebral area through the intervertebral foramen

Rationale: The local anesthetic can leak through the intervertebral foramen into the paravertebral area, potentially affecting surrounding structures.

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171
Q

Which of the following factors does NOT affect the spread of local anesthetic in the spinal or epidural space?

a) Patient position
b) Dose
c) Barbotage
d) Site of injection

A

Correct Answer: c) Barbotage

Rationale: Barbotage (repeated aspiration and reinjection of CSF) does not affect the spread of local anesthetic, although it may influence the procedure duration.

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172
Q

Why is dose considered crucial when using a hypo- or isobaric solution for local anesthesia?

a) It determines the patient’s position during the procedure
b) It affects how far and wide the anesthetic spreads
c) It correlates with the patient’s age
d) It is related to the volume of CSF

A

Correct Answer: b) It affects how far and wide the anesthetic spreads

Rationale: Dose is the most reliable factor affecting the spread of anesthetic when using hypo- or isobaric solutions.

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173
Q

Which of the following is a non-controllable factor that affects the spread of local anesthetic in the spinal space?

a) Patient position
b) Baricity
c) Increased intra-abdominal pressure
d) Site of injection

A

Correct Answer: c) Increased intra-abdominal pressure

Rationale: Increased intra-abdominal pressure due to conditions like obesity, pregnancy, or ascites is a non-controllable factor that affects the spread of local anesthetic.

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174
Q

In patients with decreased cerebrospinal fluid (CSF) volume, what adjustment should be made to the dose of local anesthetic?
a) Increase the dose
b) Decrease the dose
c) Maintain the same dose
d) Switch to a different anesthetic

A

Correct Answer: b) Decrease the dose

Rationale: In patients with decreased CSF volume, such as those who are elderly, pregnant, or have obesity or ascites, the dose of local anesthetic should be lowered to prevent excessive spread of the block.

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175
Q

Which controllable factor is considered the most important drug-related factor affecting the spread of local anesthetic in epidural anesthesia?
a) Local anesthetic dose
b) Local anesthetic volume
c) Patient position
d) Local anesthetic concentration

A

Correct Answer: b) Local anesthetic volume

Rationale: Local anesthetic volume is the most important drug-related factor affecting the spread in epidural anesthesia.

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175
Q

What is the most important procedure-related factor affecting the spread of local anesthetic in epidural anesthesia?
a) Speed of injection
b) Patient height
c) Level of injection
d) Addition of vasoconstrictors

A

Correct Answer: c) Level of injection

Rationale: The level of injection is the most important procedure-related factor for determining the spread of the anesthetic.

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176
Q

Which factor does NOT significantly affect the spread of local anesthetic in epidural anesthesia?

a) Additives in the anesthetic
b) Local anesthetic volume
c) Local anesthetic dose
d) Pregnancy

A

Correct Answer: a) Additives in the anesthetic

Rationale: Additives in the anesthetic may change the onset time or duration but do not significantly affect the spread.

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177
Q

For pain medication administered through the epidural, what is the typical drip rate in cc per hour?
a) 2-4 cc
b) 5-7 cc
c) 8-12 cc
d) 15-20 cc

A

Correct Answer: c) 8-12 cc

Rationale: The typical drip rate for pain medication through an epidural is 8-12 cc per hour.

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178
Q

In the lumbar region, how does the local anesthetic spread in epidural anesthesia?

a) Mostly spreads caudad
b) Mostly spreads cephalad
c) Spreads equally caudad and cephalad
d) Does not spread significantly

A

Correct Answer: b) Mostly spreads cephalad

Rationale: In the lumbar region, the local anesthetic mostly spreads cephalad.

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179
Q

When administering an epidural block for a procedure, what is the recommended dose per segment?
a) 0.5-1 mL
b) 1-2 mL
c) 2-4 mL
d) 4-6 mL

A

Correct Answer: b) 1-2 mL

Rationale: The recommended dose per segment for an epidural block is 1-2 mL.

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180
Q

Which nerve fiber type is characterized by heavy myelination and is responsible for motor function and proprioception?
a) Aα (alpha)
b) Aβ (beta)
c) Aγ (gamma)
d) C

A

Correct Answer: a) Aα (alpha)

Rationale: Aα (alpha) fibers are heavily myelinated and are responsible for skeletal muscle motor function and proprioception.

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181
Q

Which nerve fiber subtype has the fastest conduction velocity and is blocked fourth in sequence during anesthesia?
a) Aδ (delta)
b) B
c) Aα (alpha)
d) C

A

Correct Answer: c) Aα (alpha)

Rationale: Aα (alpha) fibers have the fastest conduction velocity (++++) and are blocked fourth in sequence.

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182
Q

What is the primary function of Aγ (gamma) nerve fibers?
a) Fast pain and temperature sensation
b) Skeletal muscle tone
c) Touch and pressure sensation
d) Preganglionic ANS fibers

A

Correct Answer: b) Skeletal muscle tone

Rationale: Aγ (gamma) fibers are medium myelinated and are responsible for skeletal muscle tone.

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183
Q

Which nerve fibers are typically blocked first during the onset of anesthesia?
a) Aα (alpha)
b) Aδ (delta)
c) B
d) C

A

Correct Answer: c) B

Rationale: B fibers, which are lightly myelinated and serve preganglionic autonomic functions, are typically blocked first.

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184
Q

Which type of nerve fibers are associated with postganglionic autonomic nervous system (ANS) functions and have the second onset of block during anesthesia?

a) Aα (alpha)
b) Aβ (beta)
c) B
d) C

A

Correct Answer: d) C

Rationale: C fibers, which are unmyelinated and associated with postganglionic ANS functions, have the second onset of block during anesthesia.

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185
Q

What does differential blockade refer to in the context of local anesthesia?

a) The even distribution of anesthesia across all nerve fibers
b) The varying sensitivity of different types of nerve fibers to local anesthetics
c) The sequential activation of motor and sensory neurons
d) The complete blockage of all nerve fibers at the same concentration

A

Correct Answer: b) The varying sensitivity of different types of nerve fibers to local anesthetics

Rationale: Differential blockade refers to how different types of nerve fibers have varying sensitivities to local anesthetics, affecting the level of block achieved.

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185
Q

At lower concentrations of local anesthetic (LA) than needed for motor blockage, which type of blockade occurs?
a) Motor blockade
b) Sensory blockade
c) Complete neural blockade
d) Autonomic blockade
e) both b & d

A

e) both b & d

rationale: sensory blockade occurs at a lower concentration than that of a motor blockade and autonomic at even lower concentrations.

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186
Q

Which of the following is a sign that the local anesthetic has affected the autonomic function during a spinal anesthesia procedure?

a) Muscle spasm
b) Hypotension and bradycardia
c) Increased heart rate
d) Sensory loss in the lower extremities

A

Correct Answer: b) Hypotension and bradycardia

Rationale: The first indication that local anesthetic has affected autonomic function is hypotension and bradycardia, which means the autonomic preganglionic fibers are blocked.

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187
Q

Which fibers are responsible for fast pain and temperature sensation and are typically affected third during a block?

a) Aα (alpha) fibers
b) Aβ (beta) fibers
c) Aγ (gamma) fibers
d) Aδ (delta) fibers

A

Correct Answer: d) Aδ (delta) fibers

Rationale: Aδ (delta) fibers are responsible for fast pain and temperature sensation and are typically affected third during a block.

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188
Q

Which type of nerve fibers require the highest concentration of local anesthetic to achieve a block?
a) B fibers
b) C fibers
c) Aα (alpha) fibers
d) Aδ (delta) fibers

A

Correct Answer: c) Aα (alpha) fibers

Rationale: Aα (alpha) fibers, which are responsible for motor function and proprioception, require the highest concentration of local anesthetic to achieve a block.

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189
Q

In the context of differential blockade, how much higher is the sensory block level compared to the motor block level?
a) 1 level
b) 2 levels
c) 4 levels
d) 6 levels

A

Correct Answer: b) 2 levels

Rationale: The sensory block level is 2 levels higher than the motor block level.

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190
Q

What is the difference in levels between the sympathetic block and the sensory block in a differential blockade?

a) 1-2 levels
b) 2-4 levels
c) 2-6 levels
d) 4-6 levels

A

Correct Answer: c) 2-6 levels

Rationale: The sympathetic block level is 2-6 levels higher than the sensory block level.

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191
Q

Which type of blockade occurs at the lowest concentrations of local anesthetic, affecting neither sensory nor motor neurons?

a) Motor blockade
b) Sensory blockade
c) Autonomic blockade
d) Complete neural blockade

A

Correct Answer: c) Autonomic blockade

Rationale: Autonomic blockade occurs at the lowest concentrations of local anesthetic, affecting neither sensory nor motor neurons. (highest blockade)

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192
Q

If a patient has a sensory block at T10, at which level would you expect the motor block to occur?
a) T8
b) T10
c) T12
d) L1

A

Correct Answer: c) T12

Rationale: If the sensory block is at T10, the motor block would occur 2 levels lower, at T12.

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193
Q

Why is it important to anticipate treatment for symptoms when the sensory block is at T10?

a) T10 affects respiratory function
b) Possible affects on cardiac accelerators
c) The motor block is too high
d) It does not have any significant impact

A

Correct Answer: b) Possible affects on cardiac accelerators

Rationale: The T1-T4 levels include the cardiac accelerators, and blocking these levels can decrease heart rate and blood pressure. If the sensory block is at T10, it’s important to anticipate and treat symptoms related to this bc autonomic functions can be impacted as high as 6 levels from sensory; thus reaching T4.

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194
Q

During the nerve block onset, which fibers are responsible for the loss of pain and temperature sensation?

a) Aα (alpha) and Aβ (beta)
b) Aγ (gamma) and Aβ (beta)
c) C and Aδ (delta)
d) B and Aγ (gamma)

A

Correct Answer: c) C and Aδ (delta)

Rationale: C and Aδ (delta) fibers are responsible for the loss of pain and temperature sensation during the onset of a nerve block.

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195
Q

Which fibers are associated with the loss of motor tone during a nerve block?
a) Aα (alpha)
b) Aγ (gamma)
c) Aβ (beta)
d) B fibers

A

Correct Answer: b) Aγ (gamma)

Rationale: Aγ (gamma) fibers are associated with the loss of motor tone during a nerve block.

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195
Q

In what order does nerve block recovery occur for the following fibers: B, Aα (alpha), C?
a) C → Aα (alpha) → B
b) Aα (alpha) → C → B
c) B → Aα (alpha) → C
d) B → C → Aα (alpha)

A

Correct Answer: b) Aα (alpha) → C → B

Rationale: During recovery from a nerve block, motor function (Aα fibers) comes back first, followed by sensory (C fibers), and B fibers are blocked the longest and recover last.

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196
Q

Which nerve fibers are associated with the loss of touch and pressure during a nerve block?
a) Aα (alpha)
b) Aβ (beta)
c) Aγ (gamma)
d) C fibers

A

Correct Answer: b) Aβ (beta)

Rationale: Aβ (beta) fibers are associated with the loss of touch and pressure during a nerve block.

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197
Q

What is the last fiber type to recover after a nerve block?
a) Aα (alpha)
b) Aβ (beta)
c) C fibers
d) B fibers

A

Correct Answer: d) B fibers

Rationale: B fibers are blocked the longest and are the last to recover after a nerve block.

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198
Q

Which sense is the first to be blocked when monitoring a sensory block?
a) Pain
b) Touch
c) Temperature
d) Pressure

A

Correct Answer: c) Temperature

Rationale: Temperature is the first sense to be blocked; for example, the patient may not feel cold from an alcohol pad.

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199
Q

What is the second sense to be blocked during sensory block monitoring?
a) Pressure
b) Temperature
c) Pain
d) Touch

A

Correct Answer: c) Pain

Rationale: Pain is the second sense to be blocked, which can be assessed using stimuli like a pinprick.

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200
Q

What is the last sense to be blocked during sensory block monitoring?
a) Temperature
b) Pain
c) Touch
d) Proprioception

A

Correct Answer: c) Touch

Rationale: Touch or pressure is the last sense to be blocked, involving light touch or pressure sensation.

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201
Q

According to the Modified Bromage Scale, what does a score of 2 indicate?
a) No motor block
b) Slight motor block
c) Moderate motor block
d) Complete motor block

A

Correct Answer: c) Moderate motor block

Rationale: A score of 2 on the Modified Bromage Scale indicates a moderate motor block where the patient cannot raise an extended leg or move the knee but can move the feet.

0: No motor block.
1: Slight motor block. The patient cannot raise an extended leg but can still move the knees and feet.
2: Moderate motor block. The patient cannot raise an extended leg or move the knee but can move the feet.
3: Complete motor block. The patient cannot move the legs, knees, or feet

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202
Q

What is the primary concern for transferring a patient from the Post Anesthesia Care Unit (PACU) regarding motor function?
a) Ensuring complete motor block
b) Ensuring the patient is awake
c) Ensuring motor function return
d) Ensuring the patient has no pain

A

Correct Answer: c) Ensuring motor function return

Rationale: The primary concern for transferring a patient from the PACU is ensuring the return of motor function.

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203
Q

Which level of motor block is typically desired for surgical procedures according to the Modified Bromage Scale?
a) 0-1
b) 1-2
c) 2-3
d) 0-3

A

Correct Answer: c) 2-3

Rationale: For surgical procedures, a level 3 (complete motor block) or possibly level 2 (moderate motor block) is typically desired to ensure adequate anesthesia.

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204
Q

What is the primary cause of decreased preload in patients under neuraxial anesthesia?

a) Increased heart rate
b) Vasoconstriction
c) Sympathectomy causing venous dilation and blood pooling
d) Increased cardiac output

A

Correct Answer: c) Sympathectomy causing venous dilation and blood pooling

Rationale: Sympathectomy causes veins to dilate, leading to blood pooling in the periphery and reducing the blood returning to the heart, thereby decreasing preload.

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205
Q

In elderly or cardiac patients, how much can systemic vascular resistance (SVR) decrease due to neuraxial anesthesia?
a) 5%
b) 10%
c) 15%
d) 25%

A

Correct Answer: d) 25%

Rationale: In elderly or cardiac patients, SVR can decrease by up to 25%.

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206
Q

What is the initial response of cardiac output (CO) to neuraxial anesthesia, and how does it change over time?
a) Initially increases, then decreases
b) Initially decreases, then increases
c) Remains constant
d) Decreases gradually

A

Correct Answer: a) Initially increases, then decreases

Rationale: Cardiac output may initially increase due to changes in blood vessel dilation speeds, but it eventually decreases over time. Due to reduced SNS tone.

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207
Q

Why is ondansetron given to manage the Bezold-Jarisch reflex?
a) It increases heart rate
b) It decreases stroke volume
c) It blocks 5-HT3 receptors involved in the reflex
d) It enhances sympathetic tone

A

Correct Answer: c) It blocks 5-HT3 receptors involved in the reflex

Rationale: Ondansetron is given because the Bezold-Jarisch reflex is mediated by 5-HT3 receptors in the vagus nerve and ventricular myocardium, and blocking these receptors helps manage the reflexive bradycardia and prevent potential asystole.

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208
Q

What cardiovascular effect is associated with the activation of the Bezold-Jarisch reflex during neuraxial anesthesia?
a) Hypertension
b) Tachycardia
c) Bradycardia and potential asystole
d) Increased cardiac output

A

Correct Answer: c) Bradycardia and potential asystole

Rationale: The Bezold-Jarisch reflex can cause significant bradycardia and potentially lead to asystole due to ventricular underfilling.

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209
Q

What is the effect of the reverse Bainbridge reflex?
a) Increases heart rate by 15-20 beats per minute
b) Decreases heart rate by 15- 20 beats per minute
c) Increases systemic vascular resistance
d) Decreases cardiac output

A

Correct Answer: b) Decreases heart rate by 15-20 beats per minute

Rationale: The reverse Bainbridge reflex triggers a decrease in heart rate by approximately 20 beats per minute due to reduced stretching of the heart’s right atrium. (theory)

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210
Q

What can result from unopposed parasympathetic tone to the cardioaccelerator fibers during neuraxial anesthesia?
a) Hypertension and tachycardia
b) Bradycardia, hypotension, and sudden cardiac arrest
c) Increased cardiac output
d) Increased systemic vascular resistance

A

Correct Answer: b) Bradycardia, hypotension, and sudden cardiac arrest

Rationale: Unopposed parasympathetic tone to the cardioaccelerator fibers can result in profound bradycardia, hypotension, and sudden cardiac arrest.

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211
Q

In which demographic is sudden cardiac arrest more commonly seen due to high parasympathetic tone?
a) Elderly patients
b) Children
c) Young adults
d) Middle-aged adults

A

Correct Answer: c) Young adults

Rationale: Sudden cardiac arrest can be seen in young adults with high parasympathetic tone.

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212
Q

What is the incidence rate of sudden cardiac arrest during spinal anesthesia?
a) 1:1,000
b) 1:10,000
c) 7:10,000
d) 7:1,000

A

Correct Answer: c) 7:10,000

Rationale: The incidence rate of sudden cardiac arrest during spinal anesthesia is 7:10,000.

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213
Q

How long after the onset of spinal anesthesia can sudden cardiac arrest typically occur?
a) 10-20 minutes
b) 20-60 minutes
c) 1-2 hours
d) 2-4 hours

A

Correct Answer: b) 20-60 minutes

Rationale: Sudden cardiac arrest can typically occur 20-60 minutes after the onset of spinal anesthesia.

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214
Q

What treatment is recommended for hypotension with high heart rate during neuraxial anesthesia?
a) Ephedrine
b) Ondansetron
c) Phenylephrine
d) Atropine

A

Correct Answer: c) Phenylephrine (1mL)..

Rationale: For hypotension with a high heart rate, phenylephrine is recommended to decrease the heart rate and increase blood pressure .. Wait until HR goes down to take BP.. opposite with ephedrine.

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215
Q

What systolic blood pressure threshold indicates the need to treat hypotension during neuraxial anesthesia?
a) 120 mmHg
b) 100 mmHg
c) 90 mmHg
d) 80 mmHg

A

Correct Answer: d) 80 mmHg

Rationale: Treatment for hypotension is generally considered necessary when the systolic blood pressure drops to around 80 mmHg. Monitoring trends and being proactive in managing hypotension is crucial.

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216
Q

What role do vasopressors like phenylephrine play in preventing spinal-anesthesia induced hypotension?
a) They decrease heart rate
b) They constrict blood vessels to maintain blood pressure
c) They increase blood volume
d) They block pain receptors

A

Correct Answer: b) They constrict blood vessels to maintain blood pressure

Rationale: Vasopressors like phenylephrine help maintain blood pressure by constricting blood vessels.

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217
Q

How do 5-HT3 antagonists like ondansetron help in managing hypotension related to spinal anesthesia?

a) They increase heart rate
b) They mitigate reflexes that cause hypotension, such as the Bezold-Jarisch reflex
c) They constrict blood vessels
d) They increase stroke volume

A

Correct Answer: b) They mitigate reflexes that cause hypotension, such as the Bezold-Jarisch reflex

Rationale: Drugs like ondansetron can mitigate reflexes that cause hypotension, such as the Bezold-Jarisch reflex mediated by the vagus nerve.

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218
Q

What is the recommended approach to fluid management during spinal anesthesia to prevent hypotension?

a) Pre-block hydration with 1-2 liters of fluids
b) Co-loading with intravenous fluids right after the spinal block
c) Avoiding all intravenous fluids
d) Administering fluids only if hypotension occurs

A

Correct Answer: b) Co-loading with intravenous fluids right after the spinal block

Rationale: Co-loading with intravenous fluids (around 15 mL/kg) right after the spinal block is effective in preventing drops in blood pressure.

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219
Q

Why should excessive fluids be avoided in patients with heart problems during spinal anesthesia?

a) They can increase heart rate excessively
b) They can overload the circulatory system
c) They can cause vasoconstriction
d) They can lead to dehydration

A

Correct Answer: b) They can overload the circulatory system

Rationale: Excessive fluid can overload the circulatory system, especially in patients with heart problems.

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220
Q

What is a key preventive method for optimizing blood flow and reducing risks during spinal anesthesia?

a) Administering vasoconstrictors
b) Adjusting the patient’s position
c) Pre-block hydration
d) Increasing fluid intake

A

Correct Answer: b) Adjusting the patient’s position

Rationale: Adjusting the patient’s position, such as slight pelvic tilting, can optimize blood flow and reduce risks

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221
Q

Why is Trendelenburg positioning not recommended with hyperbaric spinal anesthesia?
a) It can increase the risk of aspiration
b) It can cause excessive sedation
c) It affects the cardiac accelerators negatively
d) It leads to vasodilation

A

Correct Answer: c) It affects the cardiac accelerators negatively

Rationale: Trendelenburg positioning is not recommended with hyperbaric spinal anesthesia because it can negatively affect the cardiac accelerators.

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222
Q

Which vasopressor is preferred for treating symptomatic bradycardia during spinal anesthesia?
a) Phenylephrine
b) Ephedrine
c) Dopamine
d) Norepinephrine

A

Correct Answer: b) Ephedrine

Rationale: Ephedrine is preferred if there is symptomatic bradycardia because it increases heart rate and blood pressure.

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222
Q

What is the role of atropine in the treatment of spinal-anesthesia induced hypotension?
a) Vasoconstriction
b) Fluid management
c) Treatment of bradycardia
d) Increasing stroke volume

A

Correct Answer: c) Treatment of bradycardia

Rationale: Atropine may be used if the patient is experiencing bradycardia.

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223
Q

Which type of fluids should be administered first to maintain adequate blood volume during spinal anesthesia?
a) Crystalloids
b) Colloids
c) Blood products
d) Hypertonic solutions

A

Correct Answer: a) Crystalloids

Rationale: Crystalloids should be administered first to maintain adequate blood volume.

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224
Q

Why should colloids be used cautiously in fluid management during spinal anesthesia?

a) They are less effective than crystalloids
b) They can cause renal issues
c) They increase the risk of hypertension
d) They do not increase blood volume

A

Correct Answer: b) They can cause renal issues

Rationale: Colloids can cause renal issues and should be used cautiously.

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225
Q

What is a potential risk of using a >20-degree tilt in the Trendelenburg position?
a) Increased cardiac output
b) Reduced cerebral perfusion
c) Increased heart rate
d) Enhanced block effectiveness

A

Correct Answer: b) Reduced cerebral perfusion

Rationale: Using a >20-degree tilt can reduce cerebral perfusion because the tilt can reduce venous brain drainage.

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226
Q

Why should position adjustments be made cautiously before the block is set during spinal anesthesia?
a) To avoid increasing block height due to gravity
b) To enhance fluid absorption
c) To prevent nausea and vomiting
d) To improve patient comfort

A

Correct Answer: a) To avoid increasing block height due to gravity

Rationale: If the block is not set yet, position adjustments can influence the block height due to gravity, potentially increasing it.

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227
Q

What impact does a high thoracic level (T4) dermatome spread of local anesthetic have on tidal volume and arterial blood gases (ABG)?

a) Tidal volume increases, ABG decreases
b) Tidal volume decreases, ABG remains unchanged
c) Tidal volume and ABG remain unchanged
d) Tidal volume remains unchanged, ABG decreases

A

Correct Answer: c) Tidal volume and ABG remain unchanged

Rationale: Even with high thoracic level (T4) spread of local anesthetic, tidal volume and ABG remain unchanged.

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228
Q

Which pulmonary function is decreased due to the loss of abdominal muscle contribution in forced expiration?

a) Tidal volume
b) Inspiratory reserve volume
c) Expiratory reserve volume (ERV)
d) Total lung capacity

A

Correct Answer: c) Expiratory reserve volume (ERV)

Rationale: The loss of abdominal muscle contribution in forced expiration results in a decrease in ERV.

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229
Q

Why should caution be used in patients with COPD or Pickwickian syndrome during neuraxial anesthesia?

a) They are at risk of hypertension
b) They may experience increased tidal volume
c) They are at higher risk of dyspnea and panic
d) They have a higher risk of renal issues

A

Correct Answer: c) They are at higher risk of dyspnea and panic

Rationale: Patients with COPD or Pickwickian syndrome may experience feelings of dyspnea and panic due to loss of sensory feedback from the chest area.

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230
Q

What is a common cause of apnea during neuraxial anesthesia?

a) High concentrations of local anesthetics
b) Reduced blood flow to the brainstem
c) Increased tidal volume
d) Increased blood pressure

A

Correct Answer: b) Reduced blood flow to the brainstem

Rationale: Apnea is typically due to reduced blood flow to the brainstem, affecting the brain’s breathing centers.

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231
Q

What advice should be given to patients experiencing dyspnea due to a high thoracic blockade during neuraxial anesthesia?

a) They should be given sedatives
b) They will be fine and can raise the head of the bed a bit
c) They should hold their breath
d) They should lie completely flat

A

Correct Answer: b) They will be fine and can raise the head of the bed a bit

Rationale: Reassuring patients that they will be fine and raising the head of the bed a bit can help alleviate dyspnea caused by a high thoracic blockade. (maybe a little nasal cannula)

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232
Q

Under what conditions could high concentrations of local anesthetics in the spinal fluid rarely cause nerve paralysis that stops breathing?

a) If the patient is hypertensive
b) If the block spreads very high and affects the phrenic nerve
c) If the patient is dehydrated
d) If the patient is sedated

A

Correct Answer: b) If the block spreads very high and affects the phrenic nerve

Rationale: High concentrations of local anesthetics in the spinal fluid can rarely cause nerve paralysis that stops breathing if the block spreads very high and affects the phrenic nerve.

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233
Q

What nerve primarily mediates parasympathetic innervation to the GI tract?
a) Phrenic nerve
b) Vagus nerve
c) Sciatic nerve
d) Splanchnic nerve

A

Correct Answer: b) Vagus nerve

Rationale: Parasympathetic innervation to the GI tract is primarily mediated via the vagus nerve, which originates in the medulla.

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234
Q

Which sensations are transmitted by parasympathetic afferent fibers to the GI tract?
a) Pain and temperature
b) Satiety, distension, and nausea
c) Touch and pressure
d) Motor control and proprioception

A

Correct Answer: b) Satiety, distension, and nausea

Rationale: Parasympathetic afferent fibers transmit sensations of satiety, distension, and nausea.

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235
Q

What effect do parasympathetic efferent fibers have on the GI tract?
a) Inhibit peristalsis and gastric secretion
b) Transmit visceral pain
c) Promote tonic contractions, sphincter relaxation, peristalsis, and secretion
d) Cause sphincter contraction and vasoconstriction

A

Correct Answer: c) Promote tonic contractions, sphincter relaxation, peristalsis, and secretion

Rationale: Parasympathetic efferent fibers promote tonic contractions, sphincter relaxation, peristalsis, and secretion.

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236
Q

From which spinal levels does the sympathetic innervation of the GI tract originate?
a) T1-T4
b) T2-T6
c) T5-L2
d) L1-L4

A

Correct Answer: c) T5-L2

Rationale: Sympathetic innervation of the GI tract stems from T5-L2.

237
Q

What is the primary role of sympathetic afferent fibers in the GI tract?
a) Transmit visceral pain
b) Promote peristalsis and secretion
c) Inhibit sphincter contraction
d) Enhance vasodilation

A

Correct Answer: a) Transmit visceral pain

Rationale: Sympathetic afferent fibers in the GI tract transmit visceral pain.

238
Q

From which spinal levels does the sympathetic innervation of the stomach originate?
a) T4 and T5
b) T8
c) T10
d) T11-L1

A

Correct Answer: b) T8

Rationale: The sympathetic innervation of the stomach originates from the T8 spinal level.

239
Q

Which organs are innervated by sympathetic fibers originating from the T10-L1 spinal levels?

a) Heart and liver
b) Kidney and testes
c) Small intestine and colon
d) Diaphragm and esophagus

A

Correct Answer: b) Kidney and testes

Rationale: The kidney and testes are innervated by sympathetic fibers originating from the T10-L1 spinal levels.

240
Q

What is the effect of neuraxial anesthesia on sympathetic tone in GI?

a) Increases sympathetic tone
b) Reduces sympathetic tone
c) No effect on sympathetic tone
d) Alters sympathetic tone unpredictably

A

Correct Answer: b) Reduces sympathetic tone

Rationale: Local anesthetics used in neuraxial blocks decrease the activity of sympathetic nerves, thereby reducing sympathetic tone.

241
Q

What happens to parasympathetic activity as a result of neuraxial anesthesia - GI?

a) Decreases
b) Increases
c) Remains unchanged
d) Becomes inhibited

A

Correct Answer: b) Increases

Rationale: With less sympathetic inhibition, the parasympathetic system becomes more dominant, leading to increased parasympathetic activity.

242
Q

Which of the following changes occurs due to unopposed vagal tone after neuraxial anesthesia?

a) Constriction of sphincters
b) Decrease in peristalsis
c) Relaxation of sphincters
d) Decreased GI blood flow

A

Correct Answer: c) Relaxation of sphincters

Rationale: Unopposed vagal tone results in the relaxation of sphincters.

243
Q

What is the incidence rate of nausea and vomiting due to neuraxial anesthesia?
a) 10%
b) 15%
c) 20%
d) 25%

A

Correct Answer: c) 20%

Rationale: There is a 20% incidence of nausea and vomiting among patients due to the effects of Small, contracted gut with active peristalsis

244
Q

Why is increased peristalsis a result of neuraxial anesthesia?

a) Due to the unopposed sympathetic tone
b) Because of decreased parasympathetic activity
c) As a result of increased parasympathetic activity
d) Due to reduced GI blood flow

A

Correct Answer: c) As a result of increased parasympathetic activity

Rationale: Increased parasympathetic activity leads to increased peristalsis in the GI tract.

245
Q

How can the occurrence of nausea and vomiting be explained in the context of neuraxial anesthesia?
a) Unopposed parasympathetic activity
b) Hyperactive sympathetic responses
c) Increased GI blood flow
d) Reduction of abdominal muscle contraction

A

Correct Answer: a) Unopposed parasympathetic activity

Rationale: The occurrence of nausea and vomiting is due to unopposed parasympathetic activity or hypotension affecting the chemoreceptor trigger zone.

246
Q

What condition must be maintained to ensure there is no change in renal blood flow during neuraxial anesthesia?

a) Heart rate
b) Cardiac output
c) Mean arterial pressure (MAP)
d) Respiratory rate

A

Correct Answer: c) Mean arterial pressure (MAP)

Rationale: No change in renal blood flow occurs when MAP is maintained.

247
Q

How does sympathetic blockade above T10 affect bladder control?
a) Increases detrusor contraction
b) Relaxes urinary sphincter tone
c) Decreases bladder capacitance
d) Enhances bladder control

A

Correct Answer: b) Relaxes urinary sphincter tone

Rationale: Sympathetic blockade above T10 affects bladder control by relaxing urinary sphincter tone (incontinence).

248
Q

What is the effect of adding neuraxial opioids on bladder function?
a) Increases detrusor contraction
b) Increases bladder capacitance
c) Decreases bladder capacitance
d) Enhances urinary sphincter tone

A

Correct Answer: b) Increases bladder capacitance

Rationale: The addition of neuraxial opioids increases bladder capacitance (retention). By decrease in detrusor contraction.

249
Q

What is a common clinical implication of the changes in bladder function caused by neuraxial anesthesia?
a) Enhanced urinary output
b) Urinary retention or incontinence
c) Reduced need for urinary catheters
d) Improved bladder control

A

Correct Answer: b) Urinary retention or incontinence

Rationale: These changes lead to urinary retention or incontinence and the need for a Foley catheter with neuraxial anesthesia.

250
Q

Why is urinary catheterization often required during neuraxial anesthesia procedures?
a) To prevent bladder infections
b) To monitor urine output closely
c) Due to decreased detrusor contraction and increased bladder capacitance
d) To ensure hydration

A

Correct Answer: c) Due to decreased detrusor contraction and increased bladder capacitance

Rationale: Urinary catheterization is often required because neuraxial anesthesia can lead to decreased detrusor contraction and increased bladder capacitance, resulting in urinary retention. Or the incontinence from the relaxed sphincter.

251
Q

What is the effect of neuraxial anesthesia on detrusor muscle contraction?
a) Increases contraction
b) Decreases contraction
c) No effect on contraction
d) Alternates contraction

A

Correct Answer: b) Decreases contraction

Rationale: Neuraxial anesthesia decreases detrusor muscle contraction.

252
Q

What are some of the physiological effects caused by the activation of somatic and visceral afferent fibers from pain, tissue trauma, and inflammation?

a) Decreased cortisol and norepinephrine
b) Elevated cortisol, epinephrine, norepinephrine, and vasopressin
c) Increased blood glucose and insulin sensitivity
d) Reduced heart rate and blood pressure

A

Correct Answer: b) Elevated cortisol, epinephrine, norepinephrine, and vasopressin

Rationale: Activation of somatic and visceral afferent fibers from pain, tissue trauma, and inflammation causes elevated cortisol, epinephrine, norepinephrine, vasopressin, and activation of the renin-angiotensin-aldosterone system.

253
Q

How does neuraxial blockade affect the neuroendocrine response during major invasive surgery?

a) It amplifies the neuroendocrine response
b) It partially suppresses the neuroendocrine response
c) It has no effect on the neuroendocrine response
d) Totally block the neuroendocrine response

A

Correct Answer: b) It partially suppresses the neuroendocrine response

Rationale: Neuraxial blockade can partially suppress the neuroendocrine response during major invasive surgery.

254
Q

In which type of surgery can neuraxial blockade totally block the neuroendocrine response?

a) Upper extremity surgery
b) Lower extremity surgery
c) Abdominal surgery
d) Thoracic surgery

A

Correct Answer: b) Lower extremity surgery

Rationale: Neuraxial blockade can totally block the neuroendocrine response in lower extremity surgeries.

255
Q

When do maximal benefits of neuraxial blockade occur in relation to surgical stimulus?

a) After the surgical stimulus
b) During the surgical stimulus
c) Before the surgical stimulus
d) Unrelated to the timing of the surgical stimulus

A

Correct Answer: c) Before the surgical stimulus

Rationale: Maximal benefits occur if the neuraxial blockade occurs before the surgical stimulus.

256
Q

Which system is activated by elevated levels of cortisol, epinephrine, norepinephrine, and vasopressin during surgical trauma?

a) Parasympathetic nervous system
b) Renin-angiotensin-aldosterone system
c) Digestive system
d) Musculoskeletal system

A

Correct Answer: b) Renin-angiotensin-aldosterone system

Rationale: Elevated levels of these hormones activate the renin-angiotensin-aldosterone system.

257
Q

Why is regional anesthesia considered better than general anesthesia in terms of the stress response?

a) It causes more pain relief
b) It reduces the stress response more effectively
c) It has fewer side effects
d) It is easier to administer

A

Correct Answer: b) It reduces the stress response more effectively

Rationale: Regional anesthesia is better than general anesthesia because it more effectively reduces the stress response.

258
Q

What portion of the local anesthetic molecule is responsible for its lipophilic properties?

a) Intermediate chain
b) Tertiary amine
c) Aromatic ring
d) Ester linkage

A

Correct Answer: c) Aromatic ring

Rationale: The aromatic ring is the lipophilic portion of the local anesthetic molecule.

259
Q

Which of the following local anesthetics is metabolized by the liver?
a) Procaine
b) Benzocaine
c) Cocaine
d) Tetracaine

A

Correct Answer: c) Cocaine

Rationale: Cocaine is an ester local anesthetic that is also metabolized by the liver.

260
Q

What is a common allergen produced by ester local anesthetics that can cause allergic reactions?

a) Methylparaben
b) Para-aminobenzoic acid (PABA)
c) Polyvinylpyrrolidone
d) Chlorhexidine

A

Correct Answer: b) Para-aminobenzoic acid (PABA)

Rationale: Ester local anesthetics produce para-aminobenzoic acid (PABA), which can cause allergic reactions.

261
Q

Which local anesthetic class is more commonly associated with allergic reactions?
a) Amides
b) Esters
c) Both amides and esters
d) Neither amides nor esters

A

Correct Answer: b) Esters

Rationale: Allergic reactions are more commonly associated with ester local anesthetics.

262
Q

What is a rare cause of allergic reactions to amide local anesthetics?

a) High lipid solubility
b) Metabolism by the liver
c) Presence of methylparaben, similar to PABA
d) Cross-sensitivity with ester local anesthetics

A

Correct Answer: c) Presence of methylparaben, similar to PABA

Rationale: Amide allergic reactions are rare but can be caused by the presence of the preservative methylparaben, which is similar to PABA.

263
Q

What is the primary mechanism by which local anesthetics block nerve conduction?
a) By increasing sodium influx
b) By blocking sodium channels
c) By increasing potassium efflux
d) By binding to calcium channels

A

Correct Answer: b) By blocking sodium channels

Rationale: Local anesthetics block nerve conduction primarily by inhibiting sodium channels, preventing the influx of sodium ions necessary for action potential propagation.

264
Q

Where do local anesthetics exert their action to block nerve conduction?
a) Outside the cell membrane
b) Inside the cell membrane
c) In the extracellular matrix
d) In the synaptic cleft

A

Correct Answer: b) Inside the cell membrane

Rationale: Local anesthetics exert their action by blocking sodium channels from within the cell membrane, thus preventing action potentials.

265
Q

Local anesthetics are classified as which type of chemical compounds?
a) Strong acids
b) Weak acids
c) Strong bases
d) Weak bases

A

Correct Answer: d) Weak bases

Rationale: Local anesthetic agents are weak bases.

266
Q

How does the pKa of a local anesthetic influence its onset of action?
a) Lower pKa results in faster onset
b) Higher pKa results in faster onset
c) pKa has no influence on onset
d) pKa only affects duration, not onset

A

Correct Answer: a) Lower pKa results in faster onset

Rationale: Lower since basic to make it more similar to physiological pH. Compounds with a pKa close to physiologic pH have a faster onset of blockade because more molecules remain in the non-ionized state, which can more easily penetrate cell membranes.

267
Q

Why do local anesthetics with a pKa close to physiological pH have a faster onset of action?
a) Because they are more ionized at physiological pH
b) Because they are less ionized at physiological pH
c) Because they are more soluble in water
d) Because they bind more strongly to sodium channels

A

Correct Answer: b) Because they are less ionized at physiological pH

Rationale: Local anesthetics with a pKa close to physiological pH have a faster onset of action because more molecules remain in the non-ionized state, allowing them to penetrate cell membranes more effectively.

268
Q

What is the effect of local anesthetics on action potentials?

a) They increase the frequency of action potentials
b) They decrease the amplitude of action potentials
c) They prevent the initiation and propagation of action potentials
d) They increase the duration of action potentials

A

Correct Answer: c) They prevent the initiation and propagation of action potentials

Rationale: By blocking sodium channels, local anesthetics prevent the initiation and propagation of action potentials.

269
Q

Which factor is NOT listed as influencing the vascular uptake and plasma concentration of local anesthetics?
a) Site of injection
b) Tissue blood flow
c) Physicochemical properties
d) Patient’s age

A

Correct Answer: d) Patient’s age

Rationale: The factors listed include site of injection, tissue blood flow, physicochemical properties, metabolism, and the addition of vasoconstrictors. Patient’s age is not listed.

270
Q

Which site of local anesthetic injection results in the highest blood concentrations?
a) Epidural
b) Intercostal
c) Intravenous
d) Subcutaneous

A

Correct Answer: c) Intravenous

Rationale: Intravenous injection of local anesthetics results in the highest blood concentrations.

271
Q

How does the addition of vasoconstrictors influence the vascular uptake of local anesthetics?
a) Increases vascular uptake
b) Decreases vascular uptake
c) Has no effect on vascular uptake
d) Increases metabolism

A

Correct Answer: b) Decreases vascular uptake

Rationale: The addition of vasoconstrictors decreases vascular uptake by constricting blood vessels, which reduces the absorption rate of local anesthetics into the bloodstream.

272
Q

Which of the following injection sites would result in lower blood concentrations of local anesthetic compared to paracervical injection?
a) Intercostal
b) Intravenous
c) Tracheal
d) Sciatic

A

Correct Answer: d) Sciatic

Rationale: Sciatic injections result in lower blood concentrations of local anesthetic compared to paracervical injections.

273
Q

What is the primary reason for using lidocaine in a Bier block?
a) It has a rapid onset and moderate duration of action
b) It has better safety profile
c) It is not metabolized by the liver
d) It does not cause vasoconstriction

A

b) It has better safety profile

Safer than bupivicaine, must be injected in vein.

274
Q

Which injection technique results in the lowest blood concentrations of local anesthetic?
a) Epidural
b) Subcutaneous
c) Intercostal
d) Tracheal

A

Correct Answer: b) Subcutaneous

Rationale: Subcutaneous injection results in the lowest blood concentrations of local anesthetic due to slower absorption.

275
Q

What does the term “baricity” refer to in the context of local anesthetic solutions?
a) Viscosity of the solution
b) Concentration of the drug
c) Density of the solution compared to CSF
d) pH of the solution

A

Correct Answer: c) Density of the solution compared to CSF

Rationale: Baricity refers to the density of a local anesthetic solution compared to cerebrospinal fluid (CSF).

276
Q

Which baricity type describes a solution with a density equal to that of CSF?
a) Hyperbaric
b) Hypobaric
c) Isobaric
d) Homobaric

A

Correct Answer: c) Isobaric

Rationale: An isobaric solution has a baricity of 1, meaning its density matches that of CSF.

277
Q

How does a hyperbaric solution behave within the CSF?
a) Stays in place where it is injected
b) Sinks within the CSF, moving downward
c) Rises within the CSF, moving upward
d) Spreads evenly in all directions

A

Correct Answer: b) Sinks within the CSF, moving downward

Rationale: A hyperbaric solution has a density greater than CSF and sinks within the CSF, moving downward from the point of injection.

278
Q

Which of the following local anesthetics can be prepared as a hyperbaric solution?
a) Bupivacaine 0.5% in saline
b) Lidocaine 0.5% in water
c) Procaine 10% in water
d) Tetracaine 0.2% in water

A

Correct Answer: c) Procaine 10% in water

Rationale: Procaine 10% in water is prepared as a hyperbaric solution due to its higher density compared to CSF.

279
Q

Why is isobaric local anesthetic suitable for hip surgery?
a) It has the longest duration of action
b) It stays in place where it is injected
c) It provides the fastest onset of action
d) It causes the least amount of side effects

A

Correct Answer: b) It stays in place where it is injected

Rationale: Isobaric local anesthetics are suitable for hip surgery because they tend to stay in place where they are injected, providing a more predictable anesthetic effect.

280
Q

What is the behavior of a hypobaric solution within the CSF?

a) Sinks within the CSF, moving downward
b) Rises within the CSF, moving upward
c) Stays in place where it is injected
d) Disperses uniformly

A

Correct Answer: b) Rises within the CSF, moving upward

Mix LA with dextrose for hyperbaric solution. Saline for Iso, water for hypo.

Rationale: A hypobaric solution has a density less than CSF and rises within the CSF, moving upward from the point of injection.

281
Q

Which vertebral levels are identified as the highest points (apex) in the spinal column for hyperbaric solutions?
a) C2 and T1
b) C3 and L3
c) T3 and S1
d) T6 and S2

A

Correct Answer: b) C3 and L3

Rationale: The highest points in the spinal column for hyperbaric solutions are C3 and L3.

282
Q

Which vertebral levels are identified as the lowest points (trough) in the spinal column for hyperbaric solutions?
a) C3 and L3
b) T1 and T2
c) T6 and S2
d) L1 and L2

A

Correct Answer: c) T6 and S2

Rationale: The lowest points in the spinal column for hyperbaric solutions are T6 and S2.

283
Q

What happens to a hyperbaric solution injected at the L4-L5 level in the spinal column?
a) It rises to T3 and T4
b) It stays at L4-L5
c) It moves downward to T6 and S2
d) It rises to C3

A

Correct Answer: c) It moves downward to T6 and S2

Rationale: A hyperbaric solution injected at the L4-L5 level will move downward to the lower points of T6 and S2. (caudally and cephalad)

284
Q

Which local anesthetic has the longest duration when administered without epinephrine?

a) Lidocaine
b) Bupivacaine
c) 2-Chloroprocaine
d) Tetracaine

A

Correct Answer: b) Bupivacaine

Rationale: Bupivacaine has a duration of 130-220 minutes without epinephrine, which is longer than the other local anesthetics listed.

285
Q

What is the primary method of elimination for local anesthetics in the CSF?

a) Metabolism by the liver
b) Metabolism by pseudocholinesterase
c) Vascular reabsorption
d) Renal excretion

A

Correct Answer: c) Vascular reabsorption

Rationale: Local anesthetics are eliminated by reuptake through vascular reabsorption, primarily via vessels in the pia mater.

286
Q

Which factor is responsible for the slow reuptake of lipophilic local anesthetics?

a) High affinity for epidural fat
b) Low affinity for epidural fat
c) High rate of renal excretion
d) Low rate of renal excretion

A

Correct Answer: a) High affinity for epidural fat

Rationale: Lipophilic drugs have slow reuptake because they have a high affinity for epidural fat, which slows their absorption and prolongs their duration of action.

287
Q

Which local anesthetic has the fastest onset time ?

a) Bupivacaine
b) Levobupivacaine
c) 2-Chloroprocaine
d) Tetracaine

A

Correct Answer: c) 2-Chloroprocaine

Rationale: 2-Chloroprocaine has an onset time of 2-4 minutes, which is faster than the other local anesthetics listed.

288
Q

What is the typical dose range for bupivacaine to achieve a T4 level spinal block?

a) 5-10 mg
b) 10-15 mg
c) 12-20 mg
d) 25-30 mg

A

Correct Answer: c) 12-20 mg

Rationale: According to the table, the dose range for bupivacaine to achieve a T4 level spinal block is 12-20 mg.

289
Q

What is the typical duration of action for levobupivacaine without epinephrine?

a) 80-150 minutes
b) 90-180 minutes
c) 100-200 minutes
d) 140-230 minutes

A

Correct Answer: d) 140-230 minutes

Rationale: According to the table, levobupivacaine has a duration of action of 140-230 minutes without epinephrine.

290
Q

Which local anesthetic has the shortest duration of action without epinephrine?

a) Bupivacaine
b) 2-Chloroprocaine
c) Ropivacaine
d) Tetracaine

A

Correct Answer: b) 2-Chloroprocaine

Rationale: 2-Chloroprocaine has a duration of action of 40-90 minutes without epinephrine, which is shorter than the other local anesthetics listed.

291
Q

What is the onset time for ropivacaine?

a) 1-3 minutes
b) 2-5 minutes
c) 3-8 minutes
d) 4-10 minutes

A

Correct Answer: c) 3-8 minutes

Rationale: The onset time for ropivacaine is 3-8 minutes according to the table.

292
Q

Which local anesthetic requires the highest dose to achieve a T4 level block?

a) Bupivacaine 0.5%
b) Levobupivacaine 0.5%
c) 2-Chloroprocaine 3%
d) Tetracaine 0.5%

A

Correct Answer: c) 2-Chloroprocaine 3%

Rationale: 2-Chloroprocaine 3% requires a dose of 40-60 mg to achieve a T4 level block, which is higher than the other local anesthetics listed.

293
Q

What is the effect of adding epinephrine to bupivacaine on its duration of action?

a) Decreases by 20-50%
b) No effect
c) Increases by 10-20%
d) Increases by 20-50%

A

Correct Answer: d) Increases by 20-50%

Rationale: Adding epinephrine to bupivacaine increases its duration of action by 20-50%.

294
Q

Which local anesthetic has an onset time of 4-8 minutes and a duration of action of 130-220 minutes without epinephrine?

a) Ropivacaine
b) Levobupivacaine
c) Bupivacaine
d) 2-Chloroprocaine

A

Correct Answer: c) Bupivacaine

Rationale: Bupivacaine has an onset time of 4-8 minutes and a duration of action of 130-220 minutes without epinephrine.

295
Q

For a procedure requiring a spinal block at the T10 level, which local anesthetic would require the smallest dose?

a) Bupivacaine 0.5%
b) Levobupivacaine 0.5%
c) Ropivacaine 0.5%
d) Tetracaine 0.5%

A

Correct Answer: d) Tetracaine 0.5%

Rationale: Tetracaine 0.5% requires a dose of 6-10 mg to achieve a T10 level block, which is smaller than the other local anesthetics listed.

296
Q

What is the typical duration of action for ropivacaine without epinephrine?

a) 40-90 minutes
b) 80-210 minutes
c) 90-120 minutes
d) 130-220 minutes

A

Correct Answer: b) 80-210 minutes

Rationale: Ropivacaine has a duration of action of 80-210 minutes without epinephrine according to the table.

297
Q

What is the recommended volume for incremental dosing in epidural pharmacology to avoid accidental high spinal?

a) 1 mL
b) 3 mL
c) 5 mL
d) 10 mL

A

Correct Answer: c) 5 mL

298
Q

Which of the following is NOT an advantage of using incremental dosing with 5 mL in epidural anesthesia?

a) Avoiding accidental high spinal
b) Preventing local anesthetic toxicity
c) Reducing the risk of rapid autonomic blockade
d) Increasing the duration of anesthesia

A

Correct Answer: d) Increasing the duration of anesthesia

299
Q

What is the typical onset time for an epidural block after administration?

a) 2-5 minutes
b) 5-10 minutes
c) 10-25 minutes
d) 30-45 minutes

A

Correct Answer: c) 10-25 minutes

300
Q

What can be added to an epidural solution to act as an intravenous marker?

a) Sodium bicarbonate
b) Epinephrine
c) Lidocaine
d) Bupivacaine

A

Correct Answer: b) Epinephrine

301
Q

Which of the following complications can occur due to rapid autonomic blockade from epidural anesthesia?

a) Hypertension
b) Tachycardia
c) Cardiac arrest
d) Seizures

A

Correct Answer: c) Cardiac arrest

302
Q

What is the spread direction of local anesthetic from the catheter insertion site in epidural anesthesia?

a) Only cephalad
b) Only caudad
c) Both cephalad and caudad
d) Remains localized

A

Correct Answer: c) Both cephalad and caudad

303
Q

Why is incremental dosing important in epidural anesthesia?

a) To ensure rapid onset
b) To minimize the risk of local anesthetic systemic toxicity
c) To increase the potency of the anesthetic
d) To decrease the duration of anesthesia

A

Correct Answer: b) To minimize the risk of local anesthetic systemic toxicity

304
Q

What concentration of 2-Chloroprocaine is typically used for surgical anesthesia in epidural applications?
a) 1%
b) 2%
c) 3%
d) 0.5%

A

Correct Answer: c) 3%

Rationale: The 3% concentration of 2-Chloroprocaine is commonly used for surgical anesthesia because it provides a dense block necessary for surgical procedures. The 2% solution is also available but is typically used for less intense blocks.

305
Q

Why is 2-Chloroprocaine particularly popular in obstetrics (OB)?

a) Long duration of action
b) Minimal side effects
c) Rapid onset and short duration
d) Low potency

A

Correct Answer: c) Rapid onset and short duration

Rationale: 2-Chloroprocaine is favored in obstetric anesthesia due to its rapid onset, which is essential for quickly managing labor pain, and its short duration, allowing for flexibility in dosing and minimizing prolonged motor blockade.

306
Q

What is the primary metabolic pathway for 2-Chloroprocaine?
a) Hepatic metabolism
b) Renal excretion
c) Plasma cholinesterase metabolism
d) Biliary excretion

A

Correct Answer: c) Plasma cholinesterase metabolism

Rationale: 2-Chloroprocaine is metabolized rapidly by plasma cholinesterase (Esters), which accounts for its short duration of action and necessitates redosing every 45 minutes if continuous anesthesia is required.

307
Q

What is a common dosing interval for redosing 2-Chloroprocaine in continuous epidural anesthesia?
a) Every 20 minutes
b) Every 45 minutes
c) Every 60 minutes
d) Every 90 minutes

A

Correct Answer: b) Every 45 minutes

Rationale: Due to its rapid metabolism by plasma cholinesterase, 2-Chloroprocaine typically requires redosing every 45 minutes to maintain effective anesthesia during continuous epidural administration.

308
Q

Why does 2-Chloroprocaine have a rapid onset despite having a pKa of 8.7?
a) High lipid solubility
b) High concentration
c) Low protein binding
d) High vascular uptake

A

Correct Answer: b) High concentration

Rationale: The rapid onset of 2-Chloroprocaine is primarily due to its high concentration (2% and 3%), which allows a sufficient number of molecules to remain non-ionized and rapidly diffuse into the nerve cells, overcoming the typical delay caused by its higher pKa.

309
Q

Is 2-Chloroprocaine classified as an ester or an amide local anesthetic?
a) Ester
b) Amide
c) Both
d) Neither

A

Correct Answer: a) Ester

Rationale: 2-Chloroprocaine is classified as an ester local anesthetic, which is metabolized by plasma cholinesterase. This classification influences its metabolism, duration of action, and potential for allergic reactions compared to amide anesthetics

310
Q

What is the purpose of adding NaHCO3 to a local anesthetic solution?
a) To increase its potency
b) To decrease the pH
c) To increase the pH
d) To reduce toxicity

A

Correct Answer: c) To increase the pH and speed up the onset of the block

Rationale: Adding NaHCO3 (1 mEq/10 mL of local anesthetic) increases the pH of the local anesthetic, increases the concentration of nonionized free base, the rate of diffusion, and the speed of onset of the block.

311
Q

How much NaHCO3 is typically added to 10 mL of local anesthetic for alkalinization?
a) 0.5 mEq
b) 1 mEq
c) 2 mEq
d) 5 mEq

A

Correct Answer: b) 1 mEq

Rationale: The typical amount of NaHCO3 added to 10 mL of local anesthetic for alkalinization is 1 mEq.

312
Q

What is the effect of increasing the pH of a local anesthetic solution?
a) Increases the ionized form of the drug
b) Decreases the rate of diffusion
c) Increases the nonionized free base concentration and diffusion rate
d) Slows the onset of the block

A

Correct Answer: c) Increases the nonionized free base concentration and diffusion rate

Rationale: Increasing the pH increases the concentration of the nonionized free base form of the local anesthetic, which increases the rate of diffusion and speeds up the onset of the block

313
Q

What is the recommended top-up dose for maintaining an epidural block?

a) 25% of the initial dose
b) 50% of the initial dose
c) 70% of the initial dose
d) 100% of the initial dose

A

Correct Answer: b) 50% of the initial dose

Rationale: The slide indicates that the top-up dose should be 50% - 75% of the initial dose to maintain the block without letting it wear off too much.

314
Q

How should the timing for the top-up dose be managed in epidural anesthesia?

a) Administer before the block decreases more than 2 dermatomes
b) Administer only after the block has completely worn off
c) Administer at fixed intervals regardless of block level
d) Administer whenever the patient feels discomfort

A

Correct Answer: a) Administer before the block decreases more than 2 dermatomes

Rationale: The slide notes that the top-up dose should be given before the block decreases more than 2 dermatomes to ensure effective and continuous anesthesia.

315
Q

Which local anesthetic has the fastest onset when used for an epidural?

a) Lidocaine 2%
b) Bupivacaine 0.5%
c) Ropivacaine 0.75%
d) 2-Chloroprocaine 3%

A

Correct Answer: d) 2-Chloroprocaine 3%

Rationale: According to the slide, 2-chloroprocaine has a rapid onset, typically within 5-15 minutes, making it the fastest among the listed options.

316
Q

What factor determines the block density in epidural anesthesia?

a) Volume of the local anesthetic
b) Concentration of the local anesthetic
c) Speed of administration
d) Patient’s body weight

A

Correct Answer: b) Concentration of the local anesthetic

Rationale: The slide explains that the concentration of the local anesthetic affects how dense or strong the block is, with higher concentrations leading to denser blocks.

317
Q

Which 2 local anesthetic is commonly used at a 0.5% concentration for epidural anesthesia?

a) Lidocaine
b) Bupivacaine
c) 2-Chloroprocaine
d) Levobupivacaine

A

Correct Answer: b) Bupivacaine & d) Levobupivacaine

318
Q

What is the onset time for Lidocaine 2% when used for epidural anesthesia?

a) 5-15 minutes
b) 10-20 minutes
c) 15-25 minutes
d) 20-30 minutes

A

Correct Answer: b) 10-20 minutes

Rationale: According to the slide, Lidocaine 2% has an onset time of 10-20 minutes, making it a relatively quick-acting option for epidural anesthesia.

319
Q

Which of the following neuraxial pharmacologic adjuncts does NOT extend the duration of the block?
a) Alpha-2 agonists
b) Vasopressors
c) Opioids
d) Dexmedetomidine

A

Correct Answer: c) Opioids

Rationale: Opioids, such as sufentanil, fentanyl, and morphine, do not extend the duration of the block but do provide analgesia and improve the density of the block.

320
Q

Which of the following is NOT a vasopressor used as a neuraxial pharmacologic adjunct?
a) Epinephrine
b) Phenylephrine
c) Clonidine

A

Correct Answer: c) Clonidine

Rationale: Clonidine is an alpha-2 agonist, not a vasopressor. Vasopressors such as epinephrine and phenylephrine are used to extend the duration of the block without affecting density or analgesia.

321
Q

Which of the following is true about alpha-2 agonists when used as neuraxial pharmacologic adjuncts?

a) They provide postoperative analgesia but do not improve density.
b) They improve density, duration, and analgesia of the block.
c) They are primarily used as IV markers.
d) They do not extend the duration of the block.

A

Correct Answer: b) They improve density, duration, and analgesia of the block.

Rationale: Alpha-2 agonists, such as dexmedetomidine and clonidine, improve the density, duration, and analgesia of the block.

322
Q

Which of the following is NOT listed as an investigative agent for neuraxial pharmacologic adjuncts?
a) Neostigmine
b) Magnesium
c) Ketamine
d) Epinephrine

A

Correct Answer: d) Epinephrine

Rationale: Epinephrine is listed as a vasopressor, not as an investigative agent. Investigative agents include neostigmine, magnesium, ketamine, and versed.

323
Q

What is the primary purpose of adding vasopressors to neuraxial anesthesia?
a) To improve the density of the block
b) To provide postoperative analgesia
c) To extend the duration of the block
d) To act as a sensory adjunct

A

Correct Answer: c) To extend the duration of the block

Rationale: Vasopressors such as epinephrine and phenylephrine are added to extend the duration of the block. They do not improve the density or provide postoperative analgesia.

324
Q

What is a key difference in the pharmacokinetic and pharmacodynamic (PK/PD) relationships of neuraxial opioids compared to IV, IM, or PO opioids?

a) They have a slower onset of action.
b) They have a shorter duration of action.
c) They target the substantia gelatinosa of the dorsal horn.
d) They are less effective in pain relief.

A

Correct Answer: c) They target the substantia gelatinosa of the dorsal horn.

Rationale:
Neuraxial opioids specifically target the substantia gelatinosa of the dorsal horn (Lamina 2), which is different from the PK/PD relationships of IV, IM, or PO opioids.

325
Q

Which of the following is true about the categorization of neuraxial opioids?

a) They are categorized based on their ability to cross the blood-brain barrier.
b) They are categorized into more hydrophilic or lipophilic groups.
c) They are categorized based on their molecular weight.
d) They are categorized based on their color.

A

Correct Answer: b) They are categorized into more hydrophilic or lipophilic groups.

Rationale:
Neuraxial opioids are categorized based on their hydrophilic or lipophilic properties, which affects their duration of action and side effect profile.

326
Q

What effect does mixing neuraxial opioids with local anesthetics have?

a) Decreases the density of the block.
b) Results in a stronger and more dense block.
c) Shortens the duration of the block.
d) Causes more systemic side effects.

A

Correct Answer: b) Results in a stronger and more dense block.

Rationale:
Mixing neuraxial opioids with local anesthetics results in a stronger and more dense block, enhancing the analgesic effect.

327
Q

What is a critical consideration when using opioids for neuraxial anesthesia?

a) They should be mixed with preservatives to prolong shelf life.
b) They should be preservative-free to avoid neurotoxicity.
c) They should always be used in combination with vasopressors.
d) They should not be used in obstetric anesthesia.

A

Correct Answer: b) They should be preservative-free to avoid neurotoxicity.

Rationale:
It is essential to use preservative-free opioids for neuraxial anesthesia to prevent neurotoxicity and other adverse effects.

328
Q

What effect do neuraxial opioids have on neurotransmission?

a) Decreased cAMP and decreased K+ conductance

b) Increased cAMP and increased K+ conductance

c) Decreased cAMP and increased K+ conductance

d) Increased cAMP and decreased K+ conductance

A

Correct Answer: c) Decreased cAMP and increased K+ conductance

Rationale:
Neuraxial opioids reduce neurotransmission by decreasing cAMP levels and increasing potassium conductance, which hyperpolarizes the neuron and decreases its excitability. This mechanism contributes to the analgesic effects of opioids when used in neuraxial anesthesia.

329
Q

Which of the following describes a characteristic of hydrophilic neuraxial opioids?

a) Limited spread in CSF

b) Rapid onset (5-10 minutes)

c) Short duration of effect (2-4 hours)

d) Takes longer to start working (30-60 minutes)

A

Correct Answer: d) Takes longer to start working (30-60 minutes)

Rationale: Hydrophilic opioids, such as morphine and hydromorphone, take longer to start working (30-60 minutes) because they spread widely in the CSF and stay longer, providing extended pain relief.

330
Q

Which statement is true about the systemic absorption of lipophilic neuraxial opioids?

a) They are absorbed less, hence they stay longer in CSF.

b) They are absorbed more by the body, leading to shorter duration of action.

c) They have a slow onset due to limited systemic absorption.

d) They cause respiratory depression that occurs late.

A

Correct Answer: b) They are absorbed more by the body, leading to shorter duration of action.

Rationale: Lipophilic opioids, such as fentanyl and sufentanil, are absorbed more by the body (systemic absorption), leading to a shorter duration of action (2-4 hours) and typically cause respiratory depression early after administration.

331
Q

Neurotransmission in the substantia gelatinosa of the dorsal horn is reduced by neuraxial opioids through which mechanism?

a) Increased cAMP levels and decreased K+ conductance

b) Decreased cAMP levels, decreased Ca++ conductance, and increased K+ conductance

c) Increased Ca++ conductance and decreased K+ conductance

d) Increased cAMP levels and increased Ca++ conductance

A

Correct Answer: b) Decreased cAMP levels, decreased Ca++ conductance, and increased K+ conductance

Rationale: Neuraxial opioids reduce neurotransmission by decreasing cAMP levels, decreasing Ca++ conductance, and increasing K+ conductance, which inhibits pain signal transmission.

332
Q

Which of the following opioids is categorized as lipophilic and has a rapid onset when administered neuraxially?

a) Morphine

b) Hydromorphone

c) Fentanyl

d) Meperidine

A

Correct Answer: c) Fentanyl

Rationale: Fentanyl is a lipophilic opioid that starts working quickly (5-10 minutes) when administered neuraxially, due to its limited spread in CSF and shorter duration of effect.

333
Q

What is a significant clinical concern regarding the duration of hydrophilic neuraxial opioids?

a) Rapid onset leading to immediate pain relief

b) Short duration requiring frequent dosing

c) Late-onset respiratory depression

d) Limited systemic absorption

A

Correct Answer: c) Late-onset respiratory depression

Rationale: Hydrophilic neuraxial opioids, such as morphine, have a significant clinical concern of causing late-onset respiratory depression due to their extended duration in the CSF and wide spread.

334
Q

Which category of opioids has a longer duration in the CSF, and what is a key feature of their spread?
a) Lipophilic; Limited spread
b) Hydrophilic; Spreads widely
c) Lipophilic; Spreads widely
d) Hydrophilic; Limited spread

A

Correct Answer: b) Hydrophilic; Spreads widely

Rationale:
Hydrophilic opioids such as morphine, hydromorphone, and meperidine have a longer duration in the CSF and spread widely, affecting a larger area for pain relief with more rostral spread.

334
Q

What is the typical onset time for lipophilic opioids when administered neuraxially?
a) 5-10 minutes
b) 30-60 minutes
c) 15-20 minutes
d) 60-120 minutes

A

Correct Answer: a) 5-10 minutes

Rationale:
Lipophilic opioids like fentanyl and sufentanil start working quickly (within 5-10 minutes) due to their ability to rapidly diffuse in the CSF.

335
Q

Which opioid is typically administered intrathecally in doses of 0.25 - 0.30 mg?
a) Sufentanil
b) Fentanyl
c) Hydromorphone
d) Morphine

A

Correct Answer: d) Morphine

Rationale:
Morphine is administered intrathecally at doses of 0.25 - 0.30 mg for effective pain relief.

336
Q

What is the typical epidural infusion dose range for fentanyl?
a) 10 - 20 mcg/hr
b) 25 - 100 mcg/hr
c) 0.1 - 1 mg/hr
d) 50 - 100 mcg/hr

A

Correct Answer: b) 25 - 100 mcg/hr

Rationale:
Fentanyl, when used as an epidural infusion, is typically dosed at 25 - 100 mcg/hr.

337
Q

What is the main site of action for neuraxial opioids?
a) Substantia nigra
b) Substantia gelatinosa of the dorsal horn (Lamina 2)
c) Cerebral cortex
d) Basal ganglia

A

Correct Answer: b) Substantia gelatinosa of the dorsal horn (Lamina 2)

Rationale:
Neuraxial opioids target the substantia gelatinosa of the dorsal horn (Lamina 2) to reduce pain transmission.

338
Q

Which opioid has an intrathecal dose range of 10-20 mcg?

a) Sufentanil
b) Fentanyl
c) Morphine
d) Meperidine

A

Correct Answer: b) Fentanyl

Rationale: According to the slide, fentanyl’s intrathecal dose range is 10-20 mcg.

339
Q

What is the typical epidural dose range for morphine?

a) 0.25-0.30 mg
b) 25-50 mcg
c) 2-5 mg
d) 10 mg

A

Correct Answer: c) 2-5 mg

Rationale: The slide indicates that the epidural dose range for morphine is 2-5 mg.

340
Q

How does drug movement differ between intrathecal and epidural administration?

a) Intrathecal administration diffuses through the fatty tissue of the epidural space.
b) Epidural administration diffuses quickly into the spinal cord.
c) Intrathecal administration quickly diffuses into the spinal cord.
d) Epidural administration immediately affects the spinal cord.

A

Correct Answer: c) Intrathecal administration quickly diffuses into the spinal cord.

Rationale: Intrathecal administration involves direct injection into the intrathecal space, allowing the drug to quickly diffuse into the spinal cord, whereas epidural administration involves diffusion through the fatty tissue of the epidural space before affecting the spinal cord. (crosses dural cuff)

341
Q

Which opioid listed has no specified intrathecal dose?

a) Sufentanil
b) Fentanyl
c) Hydromorphone
d) Meperidine

A

Correct Answer: c) Hydromorphone

Rationale: The slide does not provide an intrathecal dose for hydromorphone, only epidural and epidural infusion doses are listed.

342
Q

What is the purpose of a higher dose in epidural administration compared to intrathecal administration?

a) To increase the speed of onset.
b) To compensate for the drug spreading more in the CSF.
c) Because only a portion of the drug reaches the target area in the spinal cord.
d) To decrease systemic absorption.

A

Correct Answer: c) Because only a portion of the drug reaches the target area in the spinal cord.

Rationale: A higher dose is often required for epidural administration because only a portion of the drug reaches the target area in the spinal cord due to diffusion through the epidural space and some systemic absorption.

343
Q

What is the epidural dose range for Sufentanil?

a) 10-20 mcg
b) 25-50 mcg
c) 0.5-1 mg
d) 2-5 mg

A

Correct Answer: b) 25-50 mcg

Rationale: The slide indicates that the epidural dose range for Sufentanil is 25-50 mcg.

344
Q

What is the epidural infusion dose range for Hydromorphone?

a) 0.1-0.2 mg/hr
b) 25-50 mcg/hr
c) 50-100 mcg/hr
d) 0.1-1 mg/hr

A

Correct Answer: a) 0.1-0.2 mg/hr

Rationale: The slide indicates that the epidural infusion dose range for Hydromorphone is 0.1-0.2 mg/hr.

345
Q

Which opioid has an epidural dose range of 25-50 mcg?

a) Sufentanil
b) Fentanyl
c) Hydromorphone
d) Meperidine

A

a) Sufentanil

346
Q

What is the epidural infusion dose range for Morphine?

a) 10-20 mcg/hr
b) 25-50 mcg/hr
c) 0.1-0.2 mg/hr
d) 0.1-1 mg/hr

A

Correct Answer: d) 0.1-1 mg/hr

Rationale: The slide specifies that the epidural infusion dose range for Morphine is 0.1-1 mg/hr.

347
Q

Which opioid has an epidural dose range of 0.5-1 mg?

a) Sufentanil
b) Fentanyl
c) Hydromorphone
d) Meperidine

A

Correct Answer: c) Hydromorphone

Rationale: The slide indicates that the epidural dose range for Hydromorphone is 0.5-1 mg.

348
Q

What is the intrathecal dose for Meperidine?

a) 5-10 mcg
b) 10 mg
c) 0.25-0.30 mg
d) 25-50 mcg

A

Correct Answer: b) 10 mg

Rationale: The slide specifies that the intrathecal dose for Meperidine is 10 mg.

349
Q

Which of the following is true about the movement of drugs in intrathecal administration?

a) The opioid diffuses through the fatty tissue of the epidural space.
b) The opioid slowly crosses into the CSF to reach the spinal cord.
c) The opioid quickly diffuses into the spinal cord.
d) The opioid only affects the bloodstream.

A

Correct Answer: c) The opioid quickly diffuses into the spinal cord.

Rationale: Intrathecal administration involves direct injection into the intrathecal space, allowing the drug to quickly diffuse into the spinal cord.

350
Q

What is the incidence range of pruritus as a side effect when using neuraxial pharmacologic adjuncts?

a) 10-20%
b) 30-100%
c) 40-80%
d) 20-50%

A

Answer: b) 30-100%

Rationale: Pruritus is a troublesome side effect with a high incidence range of 30-100%, as highlighted on the slide.

351
Q

Which medication is considered the best treatment for pruritus caused by neuraxial pharmacologic adjuncts?

a) Benadryl
b) Naloxone
c) Ondansetron
d) Nubain

A

Answer: b) Naloxone

Rationale: Naloxone 0.1 mg IV is considered the best treatment for pruritus in this context.

352
Q

What is the recommended dose of Benadryl for treating pruritus related to neuraxial opioids?

a) 10-20 mg IV
b) 15-30 mg IV
c) 25-50 mg IV
d) 50-100 mg IV

A

Answer: c) 25-50 mg IV

Rationale: Benadryl is recommended at a dose of 25-50 mg IV for treating pruritus.

353
Q

For prophylaxis against pruritus, what is the recommended dose of Ondansetron?

a) 2 mg IV
b) 4 mg IV
c) 6 mg IV
d) 8 mg IV

A

Answer: b) 4 mg IV

Rationale: Ondansetron 4 mg IV is used for prophylaxis against pruritus.

354
Q

What is the mechanism of action of Buprenex in the treatment of pruritus?

a) Pure agonist
b) Pure antagonist
c) Mixed agonist/antagonist
d) Pure inverse agonist

A

Answer: c) Mixed agonist/antagonist

Rationale: Buprenex is a mixed agonist/antagonist, which is effective in treating pruritus.

355
Q

What should be done to minimize the incidence of pruritus when using morphine for neuraxial analgesia?

a) Increase the dose of morphine to over 500 mcg
b) Minimize the dose of morphine to less than 300 mcg
c) Use morphine in combination with Benadryl
d) Avoid using morphine altogether

A

Answer: b) Minimize the dose of morphine to less than 300 mcg

Rationale: Minimizing the dose of morphine to less than 300 mcg can help reduce the incidence of pruritus.

356
Q

Which type of opioid is more likely to cause delayed respiratory depression?

a) Lipophilic opioids
b) Hydrophilic opioids
c) Non-opioid analgesics
d) Local anesthetics

A

Correct Answer: b) Hydrophilic opioids

Rationale: Hydrophilic opioids like morphine have a higher incidence of delayed respiratory depression due to their hydrophilic properties causing more cephalad spread (prhrenic/accessory nerves) in the CSF.

357
Q

Which monitoring methods are required for intrathecal morphine to detect apnea?

a) Blood pressure monitoring
b) Capnography and pulse oximetry
c) ECG and temperature monitoring
d) Visual assessment and patient report

A

Correct Answer: b) Capnography and pulse oximetry

Rationale: Intrathecal morphine requires apnea monitoring using capnography and pulse oximetry to ensure patient safety due to the risk of respiratory depression. ALarms

358
Q

What is the most effective treatment for respiratory depression caused by neuraxial opioids?

a) Benadryl 25-50 mg IV
b) Naloxone 0.1-0.2 mg IV
c) Ondansetron 4 mg IV
d) Nubain 2.5-5.0 mg IV

A

Correct Answer: b) Naloxone 0.1-0.2 mg IV

Rationale: Naloxone is an opioid antagonist that effectively reverses respiratory depression caused by neuraxial opioids.

359
Q

What legal implications are associated with respiratory depression in outpatient surgery?

a) Prolonged hospital stay
b) Increased monitoring requirements
c) Potential legal consequences if not properly managed
d) Requirement for blood transfusions

A

Correct Answer: c) Potential legal consequences if not properly managed

Rationale: There are legal implications for outpatient surgeries if respiratory depression caused by neuraxial opioids is not properly managed, leading to potential harm to the patient.

360
Q

What is the recommended morphine dose to minimize the incidence of nausea when administered neuraxially?

a) < 100 mcg
b) < 200 mcg
c) < 300 mcg
d) < 400 mcg

A

Correct Answer: c) < 300 mcg

361
Q

Which treatment is used for neuraxial opioid-induced nausea and has a dose of 4 mg IV?

a) Naloxone
b) Ondansetron
c) Phenergan
d) Benadryl

A

Correct Answer: b) Ondansetron

362
Q

What is the incidence rate of urinary retention as a side effect of neuraxial opioids?

a) 10-20%
b) 20-30%
c) 30-40%
d) 40-50%

A

Correct Answer: c) 30-40%

363
Q

Which combination of neuraxial opioids has a very high incidence of nausea?

a) Morphine alone
b) Fentanyl/Sufentanil alone
c) Fentanyl/Sufentanil + Morphine
d) Hydromorphone + Fentanyl

A

Correct Answer: c) Fentanyl/Sufentanil + Morphine

364
Q

What is the recommended treatment for nausea caused by neuraxial opioids, given in a dose of 12.5-25 mg IM?

a) Naloxone
b) Ondansetron
c) Phenergan
d) Benadryl

A

Correct Answer: c) Phenergan

364
Q

Which two drugs are categorized as alpha-2 agonists in neuraxial pharmacologic adjuncts?

a) Clonidine and Dexmedetomidine
b) Fentanyl and Morphine
c) Ondansetron and Naloxone
d) Benadryl and Phenergan

A

Correct Answer: a) Clonidine and Dexmedetomidine

365
Q

What is the primary benefit of using alpha-2 agonists in neuraxial anesthesia?

a) Shortens the duration of the block
b) Intensifies and prolongs the block
c) Reduces the density of the block
d) Eliminates the need for other anesthetics

A

Correct Answer: b) Intensifies and prolongs the block

aprox 1 hour

366
Q

By approximately how much time do alpha-2 agonists prolong sensory and motor blockade?

a) 30 minutes
b) 1 hour
c) 2 hours
d) 4 hours

A

Correct Answer: b) 1 hour

367
Q

What are common side effects associated with alpha-2 agonists?

a) Hypertension and tachycardia
b) Hypotension, bradycardia, and sedation
c) Nausea and vomiting
d) Respiratory depression

A

Correct Answer: b) Hypotension, bradycardia, and sedation

368
Q

What is the typical dose range for clonidine when used as a neuraxial adjunct?

a) 5-10 mcg
b) 15-45 mcg
c) 50-100 mcg
d) 100-200 mcg

A

b) 15-45 mcg

369
Q

What is the typical dose for dexmedetomidine when used as a neuraxial adjunct?

a) 1 mcg
b) 3 mcg
c) 5 mcg
d) 10 mcg

A

Correct Answer: b) 3 mcg

Tubog says he typically uses 5-10 mcg

370
Q

What is the dose of epinephrine used as a vasoconstrictor in neuraxial pharmacology (Epi wash)?

a) 0.1 - 0.2 mg
b) 0.2 - 0.3 mg
c) 0.3 - 0.4 mg
d) 0.4 - 0.5 mg

A

Correct Answer: b) 0.2 - 0.3 mg

Rationale: Epinephrine is commonly used in doses of 0.2 to 0.3 mg to prolong the action of local anesthetics by reducing blood flow.

371
Q

What is the dose of phenylephrine used as a vasoconstrictor in neuraxial pharmacology?

a) 1 - 3 mg
b) 2 - 4 mg
c) 2 - 5 mg
d) 3 - 5 mg

A

Correct Answer: c) 2 - 5 mg

Rationale: Phenylephrine is typically used in doses of 2 to 5 mg to prolong the action of local anesthetics by reducing blood flow.

372
Q

What is the effect of adding epinephrine to tetracaine in neuraxial pharmacology?

a) No effect
b) Slight increase in duration
c) Profound increase in duration
d) Decrease in duration

A

Correct Answer: c) Profound increase in duration

Rationale: Adding epinephrine to tetracaine results in a profound increase in the duration of the anesthetic effect.

373
Q

What is the typical percentage increase in duration when epinephrine is added to bupivacaine or lidocaine?

a) 10 - 20%
b) 20 - 50%
c) 30 - 60%
d) 40 - 70%

A

Correct Answer: b) 20 - 50%

Rationale: When epinephrine is added to bupivacaine or lidocaine, there is a variable increase in duration, typically in the range of 20 - 50%.

373
Q

How does the use of vasoconstrictors like epinephrine affect the action of local anesthetics in neuraxial pharmacology?

a) Shortens the action
b) Prolongs the action by increasing blood flow
c) Prolongs the action by reducing blood flow
d) No significant effect

A

Correct Answer: c) Prolongs the action by reducing blood flow

Rationale: Vasoconstrictors like epinephrine prolong the action of local anesthetics by reducing blood flow, which decreases the rate at which the drug is absorbed into the bloodstream.

374
Q

Which patients should avoid neuraxial anesthesia due to the risk of epidural hematoma?

a) Patients on anticoagulants
b) Patients with diabetes
c) Patients with hypertension
d) Patients with asthma

A

Correct Answer: a) Patients on anticoagulants

375
Q

What are the symptoms of an epidural hematoma? (Select all that apply)

a) Lower extremity weakness and numbness
b) Headache
c) Low back pain
d) Bowel and bladder dysfunction

A

Correct Answers: a) Lower extremity weakness and numbness, c) Low back pain, d) Bowel and bladder dysfunction

376
Q

What is the recommended treatment for an epidural hematoma?

a) Pain management
b) Surgical decompression within 8 hours
c) Physical therapy
d) Anticoagulant therapy

A

Correct Answer: b) Surgical decompression within 8 hours

377
Q

What challenges do patients with cardiac stents face concerning neuraxial anesthesia?

a) Increased risk of infection
b) Difficulties due to the need to stop antiplatelets and anticoagulants
c) Higher risk of hypertension
d) Increased likelihood of allergic reactions

A

Correct Answer: b) Difficulties due to the need to stop antiplatelets and anticoagulants

Rationale: Stopping antiplatelets and anticoagulants increases stent thrombosis risk.
Continuing these medications raises bleeding risk, including epidural hematoma.

378
Q

How soon should surgical decompression be performed to optimize recovery chances in cases of epidural hematoma?

a) Within 24 hours
b) Within 12 hours
c) Within 8 hours
d) Within 4 hours

A

Correct Answer: c) Within 8 hours

379
Q

What is the primary mechanism of action of COX inhibitors like NSAIDs and Aspirin?

a) Enhances the action of cyclooxygenase
b) Inhibits cyclooxygenase which prevents the formation of thromboxane-A2
c) Increases platelet aggregation
d) Reduces prostaglandin synthesis without affecting thromboxane levels

A

Answer: b) Inhibits cyclooxygenase which prevents the formation of thromboxane-A2

Rationale: COX inhibitors prevent the formation of thromboxane-A2, which is essential for platelet aggregation. This mechanism reduces platelet clumping and is used for its antiplatelet effects.

380
Q

Which of the following is NOT a consideration when using Aspirin for neuraxial anesthesia?

a) Determine if Aspirin is used for primary or secondary prophylaxis
b) Always hold Aspirin for 4-6 days regardless of procedure risk
c) Secondary prophylaxis discontinuation increases risk of acute cardiovascular events
d) There is no distinction in guidelines between low dose (81mg) and regular dose (325mg) Aspirin

A

Answer: b) Always hold Aspirin for 4-6 days regardless of procedure risk

Rationale: Guidelines specify that for high-risk and intermediate-risk procedures, Aspirin should be held for 4-6 days, but for low-risk procedures, it generally does not need to be held. Central neuraxial blocks require no additional precautions regarding Aspirin.

381
Q

What is a significant risk associated with stopping Aspirin in patients using it for secondary prophylaxis?

a) Increased risk of gastrointestinal bleeding
b) Elevated risk of acute cardiovascular syndromes
c) Higher incidence of thromboembolism
d) Increased likelihood of developing hypertension

A

Answer: b) Elevated risk of acute cardiovascular syndromes

Rationale: Stopping Aspirin in patients using it for secondary prophylaxis poses a high risk, as 10% of acute cardiovascular syndromes are preceded by Aspirin withdrawal.

382
Q

For which type of prophylaxis is it crucial to determine the use of Aspirin when considering neuraxial anesthesia?

a) Tertiary prophylaxis
b) Primary prophylaxis
c) Secondary prophylaxis
d) Both primary and secondary prophylaxis

A

Answer: d) Both primary and secondary prophylaxis

Rationale: It is essential to know if Aspirin is used for preventing the first event (primary prophylaxis) or preventing recurrent events (secondary prophylaxis), as it influences the decision-making process regarding discontinuation before neuraxial anesthesia.

383
Q

What is the main clinical guideline for holding Aspirin before high-risk and intermediate-risk procedures?

a) Hold Aspirin for at least 7 days
b) Hold Aspirin for 2-3 days
c) Hold Aspirin for 4-6 days
d) Do not hold Aspirin

A

Answer: c) HoDL Aspirin for 4-6 days

Rationale: For high-risk and intermediate-risk procedures, clinical guidelines recommend holding Aspirin for 4-6 days to mitigate the bleeding risk.

384
Q

Which pathway does Aspirin inhibit that helps in its function as an antiplatelet agent?

a) 5-Lipoxygenase pathway
b) Arachidonic acid pathway
c) Thromboxane-A2 synthesis pathway
d) Leukotriene synthesis pathway

A

Answer: c) Thromboxane-A2 synthesis pathway

Rationale: Aspirin inhibits the cyclooxygenase enzyme (COX 1), thus preventing the formation of thromboxane-A2, a potent platelet aggregator and vasoconstrictor.

NSAIDS are mainly COX 2 but also 1

385
Q

For high-risk procedures, how long should NSAIDs be held?

a) 2 half-lives
b) 3 half-lives
c) 4 half-lives
d) 5 half-lives

A

Correct Answer: d) 5 half-lives

Rationale: High-risk procedures require holding NSAIDs for 5 half-lives to reduce the risk of bleeding complications during surgery.

386
Q

Which procedures fall under low cardiac risk (<1%) for NSAID consideration?

a) Carotid endarterectomy and head and neck surgeries
b) Endoscopic procedures and cataract surgery
c) Emergency surgeries and open aortic surgeries
d) Orthopedic surgeries and prostate surgery

A

Correct Answer: b) Endoscopic procedures and cataract surgery

Rationale: Endoscopic procedures and cataract surgery are considered low cardiac risk procedures and usually do not require holding NSAIDs.

387
Q

Which procedures fall under intermediate cardiac risk (1-5%) for NSAID consideration?

a) Carotid endarterectomy and head and neck surgeries
b) Endoscopic procedures and cataract surgery
c) Emergency surgeries and open aortic surgeries
d) Superficial surgeries and breast surgeries

A

Correct Answer: a) Carotid endarterectomy and head and neck surgeries

Rationale: Carotid endarterectomy and head and neck surgeries are considered intermediate cardiac risk procedures.

388
Q

What is the recommendation for NSAID use in low-risk procedures?

a) Hold NSAIDs for 1-2 days
b) Hold NSAIDs for 3-4 days
c) Do not need to routinely hold NSAIDs
d) Hold NSAIDs for 5 half-lives

A

Correct Answer: c) Do not need to routinely hold NSAIDs

Rationale: For low-risk procedures, it is generally not necessary to routinely hold NSAIDs.

389
Q

What is the consideration for NSAID use in central neuraxial blocks?

a) Hold NSAIDs for 1-2 days
b) Hold NSAIDs for 3-4 days
c) No additional precautions needed
d) Hold NSAIDs for 5 half-lives

A

Correct Answer: c) No additional precautions needed

Rationale: For central neuraxial blocks, no additional precautions are required regarding NSAID use.

390
Q

For intermediate risk procedures, what specific considerations should be taken for NSAID use?

a) Hold for 1-2 half-lives
b) Consider holding for cervical ESI and stellate ganglion block
c) Do not need to hold NSAIDs
d) Hold for 5 half-lives

A

Correct Answer: b) Consider holding for cervical ESI and stellate ganglion block

Rationale: For intermediate risk procedures, it’s recommended to consider holding NSAIDs for cervical epidural steroid injections (ESI) and stellate ganglion block.

391
Q

Which enzyme does Aspirin (ASA) primarily inhibit and what is its primary effect on platelets?

a) COX-2, reduces inflammation
b) COX-1, inhibits thromboxane A2 formation
c) COX-1, inhibits prostacyclin production
d) COX-2, inhibits leukotriene production

A

Correct Answer: b) COX-1, inhibits thromboxane A2 formation

Rationale: Aspirin primarily inhibits COX-1, leading to a reduction in thromboxane A2, a molecule that promotes platelet aggregation, thus providing its antiplatelet effects.

392
Q

What is the main difference in the mechanism of action between non-selective NSAIDs and Aspirin in terms of COX enzyme inhibition?

a) NSAIDs selectively inhibit COX-2, while Aspirin selectively inhibits COX-1
b) Both NSAIDs and Aspirin selectively inhibit COX-2
c) NSAIDs non-selectively inhibit both COX-1 and COX-2, while Aspirin selectively inhibits COX-1
d) NSAIDs selectively inhibit COX-1, while Aspirin non-selectively inhibits both COX-1 and COX-2

A

Correct Answer: c) NSAIDs non-selectively inhibit both COX-1 and COX-2, while Aspirin selectively inhibits COX-1

Rationale: Non-selective NSAIDs inhibit both COX-1 and COX-2 enzymes, affecting both inflammation and platelet aggregation, whereas Aspirin selectively inhibits COX-1 at low doses, providing its antiplatelet effect.

393
Q

Which of the following glycoprotein IIb/IIIa antagonists should be held for 4-8 hours before regional anesthesia?

a) Tirofiban
b) Abciximab
c) Eptifibatide
d) Both a and c

A

Answer: d) Both a and c

Rationale: Tirofiban and Eptifibatide both require holding for 4-8 hours before regional anesthesia.

394
Q

How long should Abciximab be held before regional anesthesia?

a) 4-8 hours
b) 8-12 hours
c) 12-24 hours
d) 24-48 hours

A

Answer: d) 24-48 hours

Rationale: Abciximab should be held for 24-48 hours before regional anesthesia due to its prolonged effect on platelet function.

395
Q

Tirofiban can be held for 24-48 hours before regional anesthesia. True or False?

A

Answer: False
Rationale: Tirofiban should be held for 4-8 hours before regional anesthesia.

396
Q

True or False?
Eptifibatide and Abciximab require the same duration to hold before regional anesthesia.

A

Answer: False
Rationale: Eptifibatide requires 4-8 hours, while Abciximab requires 24-48 hours before regional anesthesia.

397
Q

Why should Abciximab be held for a longer duration compared to Tirofiban and Eptifibatide before regional anesthesia?

A

Answer: Abciximab has a longer duration of action affecting platelet function, thus requiring a hold time of 24-48 hours to ensure platelet function recovery before regional anesthesia.

398
Q

What is the recommended hold time for Clopidogrel (Plavix) before regional anesthesia?

a) 1-3 days
b) 3-5 days
c) 5-7 days
d) 7-10 days

A

Answer: c) 5-7 days

Rationale: Clopidogrel, an antiplatelet agent, should be held for 5-7 days before regional anesthesia to allow for the recovery of platelet function and minimize the risk of bleeding complications.

399
Q

Prasugrel (Effient) should be held for how many days before regional anesthesia?

a) 3-5 days
b) 5-7 days
c) 7-10 days
d) 10-14 days

A

Answer: c) 7-10 days

Rationale: Prasugrel has a more prolonged effect on platelet aggregation, necessitating a hold time of 7-10 days prior to regional anesthesia to ensure patient safety.

400
Q

Which thienopyridine derivative requires the longest hold time before regional anesthesia?

a) Clopidogrel (Plavix)
b) Prasugrel (Effient)
c) Ticlopidine (Ticlid)
d) Abciximab (ReoPro)

A

Answer: c) Ticlopidine (Ticlid)

Rationale: Ticlopidine requires the longest hold time of 10 days before regional anesthesia due to its prolonged effect on platelet aggregation.

401
Q

What is the main mechanism of action of thienopyridine derivatives like Clopidogrel?

a) Inhibits thromboxane A2
b) Inhibits cyclooxygenase (COX)
c) Blocks ADP transferase
d) Inhibits fibrinogen

A

Answer: c) Blocks ADP transferase

Rationale: Thienopyridine derivatives inhibit platelet aggregation by blocking ADP transferase, thus preventing the formation of platelet clumps.

402
Q

Which factor does Unfractionated Heparin inhibit?

a) Factor 2
b) Factor 5
c) Factor 7
d) Factor 8

A

Correct Answer: a) Factor 2

Rationale: Unfractionated Heparin potentiates antithrombin, an enzyme inhibitor, and inhibits thrombin, which is also known as Factor 2, along with other factors like 9, 10, 11, and 12. (intrinsic pathway)

403
Q

For low-dose Unfractionated Heparin (UFH) therapy (<5,000 U), how long should it be held before regional anesthesia?

a) 1-2 hours
b) 4-6 hours
c) 12 hours
d) 24 hours

A

Correct Answer: b) 4-6 hours

Rationale: For low-dose UFH (<5,000 U), the recommended hold time before regional anesthesia is 4-6 hours to minimize bleeding risk.

404
Q

What is the recommended hold time for higher-dose Unfractionated Heparin (≤20,000 U daily) before regional anesthesia?

a) 4-6 hours
b) 12 hours
c) 18 hours
d) 24 hours

A

Correct Answer: b) 12 hours

Rationale: Higher doses of UFH (≤20,000 U daily) should be held for 12 hours before regional anesthesia to ensure safety.

405
Q

For therapeutic doses of Unfractionated Heparin (>20,000 U daily), including those for pregnant patients, what is the hold time before regional anesthesia?

a) 4-6 hours
b) 12 hours
c) 18 hours
d) 24 hours

A

Correct Answer: d) 24 hours

Rationale: Therapeutic doses of UFH (>20,000 U daily) should be held for 24 hours to reduce the risk of bleeding complications during regional anesthesia.

406
Q

What platelet count is recommended before performing a central neuraxial block in patients on Unfractionated Heparin therapy for more than 4 days?

a) 50K
b) 75K
c) 100K
d) 125K

A

Correct Answer: c) 100K

Rationale: Patients on UFH therapy for more than 4 days should have a platelet count greater than 100K before a central neuraxial block to reduce the risk of bleeding and hematoma formation.

407
Q

Which factor does low molecular weight heparin (LMWH) primarily inhibit?

A) Factor II
B) Factor VII
C) Factor IX
D) Factor Xa

A

Answer: D) Factor Xa

Rationale: LMWH primarily inhibits Factor Xa, which plays a crucial role in the coagulation cascade, preventing the formation of thrombin and subsequent clot formation.

408
Q

What is the recommended delay after a prophylactic dose of LMWH before performing a block or catheter placement?

A) 4-6 hours
B) 8-10 hours
C) 12 hours
D) 24 hours

A

Answer: C) 12 hours

Rationale: The guidelines recommend a delay of at least 12 hours after a prophylactic dose of LMWH to reduce the risk of bleeding complications during block or catheter placement.

409
Q

In which situations should anti-factor 10a activity be considered for monitoring when using LMWH?

A) In young and healthy individuals
B) In elderly patients or those with renal insufficiency
C) In patients with liver disease
D) In patients with a history of thromboembolism

A

Answer: B) In elderly patients or those with renal insufficiency

Rationale: Monitoring anti-factor 10a activity is particularly important in elderly patients or those with renal insufficiency to ensure proper dosing and to minimize the risk of bleeding.

410
Q

For patients on LMWH for more than 4 days, what additional check should be performed before central neuraxial block?

A) Blood pressure
B) Platelet count
C) Liver function test
D) Electrolyte levels

A

Answer: B) Platelet count

Rationale: A platelet count should be checked in patients on LMWH for more than 4 days to ensure adequate platelet levels and reduce the risk of bleeding during neuraxial procedures.

411
Q

How long should you delay a block/catheter placement after a therapeutic dose of LMWH?

A) 12 hours
B) 18 hours
C) 24 hours
D) 36 hours

A

Answer: C) 24 hours

Rationale: After a therapeutic dose of LMWH, it is recommended to delay the block or catheter placement for at least 24 hours to reduce the risk of bleeding complications.

412
Q

Which vitamin K-dependent clotting factors does Warfarin impair?

A) Factors 1, 3, 5, 8
B) Factors 2, 7, 9, 10
C) Factors 11, 12, 13, 14
D) Factors 2, 4, 6, 8

A

Answer: B) Factors 2, 7, 9, 10

Rationale: Warfarin is a vitamin K antagonist that inhibits the synthesis of vitamin K-dependent clotting factors, specifically factors 2, 7, 9, and 10, which are essential for blood coagulation.

413
Q

How many days should Warfarin be held before regional anesthesia?

A) 2 days
B) 3 days
C) 5 days
D) 7 days

A

Answer: C) 5 days

Rationale: Warfarin should be held for 5 days before regional anesthesia to allow for normalization of INR and reduce the risk of bleeding complications.

414
Q

What is the target INR level for patients on Warfarin before performing a regional block?

A) Greater than 1.5
B) Greater than 2.0
C) Less than 1.5
D) Less than 2.0

A

Answer: C) Less than 1.5

Rationale: The INR should be less than 1.5 to ensure that the blood’s clotting ability is sufficient to reduce the risk of bleeding during and after the procedure.

415
Q

What is the regional anesthesia consideration for patients on thrombolytic agents?

A) Proceed with additional monitoring
B) Absolute contraindication
C) Delay for 12 hours
D) Ensure normal platelet count

A

Answer: B) Absolute contraindication

Rationale: Thrombolytic agents activate plasminogen, leading to the breakdown of clots. This significantly increases the risk of bleeding, making regional anesthesia an absolute contraindication.

416
Q

Which thrombolytic agent activates plasminogen?

A) Heparin
B) Warfarin
C) Streptokinase
D) Clopidogrel

A

Answer: C) Streptokinase

Rationale: Streptokinase is one of the thrombolytic agents that activates plasminogen, converting it to plasmin, which then breaks down fibrin and dissolves clots.

417
Q

What is the recommended time to discontinue Direct Oral Anticoagulants (DOACs) before performing a neuraxial block?

a) 24 hours
b) 48 hours
c) 72 hours
d) 96 hours

A

Answer: c) 72 hours

Rationale: It is recommended to discontinue DOACs at least 72 hours before performing a neuraxial block to ensure that the anticoagulant effect has sufficiently diminished, reducing the risk of bleeding complications during the procedure.

Inhibits factor 10a
Apixaban (Eliquis), Betrixaban (Bevyxxa), Edoxaban (Lixiana), Rivaroxaban (Xarelto), Dabigatran (Pradaxa)

418
Q

If a patient has been on Direct Oral Anticoagulants (DOACs) for less than 72 hours and is scheduled for a neuraxial block, what consideration should be made?

a) Proceed with the block without any additional testing
b) Administer an antidote to reverse the effect of DOACs
c) Consider checking the drug level or anti-factor 10a activity
d) Delay the block for an additional 24 hours

A

Answer: c) Consider checking the drug level or anti-factor 10a activity

Rationale: If the patient has been on DOACs for less than 72 hours, it is prudent to check the drug level or anti-factor 10a activity to assess the extent of anticoagulation and ensure it is safe to proceed with the neuraxial block.

419
Q

What should be the approach to neuraxial anesthesia if a patient is on herbal therapies like Garlic, Ginkgo, or Ginseng, but not on other blood-thinning drugs?

a) Delay the neuraxial block for 24 hours
b) Proceed with neuraxial anesthesia without concern for hematoma
c) Administer a reversal agent for herbal therapies
d) Perform a platelet count before proceeding

A

Answer: b) Proceed with neuraxial anesthesia without concern for hematoma

Rationale: Herbal therapies alone (such as Garlic, Ginkgo, or Ginseng) do not pose a significant risk for hematoma formation when used without other blood-thinning medications. Therefore, it is generally safe to proceed with neuraxial anesthesia in such patients.

420
Q

Which of the following symptoms are associated with postdural puncture headache (PDPH)?

A. Sensitivity to light, double vision, and ringing in the ears
B. High fever and chills
C. Swelling and redness at the injection site
D. Rash and itching

A

A. Sensitivity to light, double vision, and ringing in the ears

Rationale: Symptoms of PDPH include headache that worsens when sitting or standing, sensitivity to light, double vision, and ringing in the ears. These symptoms are due to the decrease in CSF volume and the resultant pressure changes in the brain.

420
Q

What is the primary cause of a postdural puncture headache (PDPH)?

A. Increase in CSF volume
B. Continuous leak of CSF causing an overall reduction in CSF volume
C. Infection at the puncture site
D. Allergic reaction to the anesthesia

A

B. Continuous leak of CSF causing an overall reduction in CSF volume

Rationale: The primary cause of a postdural puncture headache is a continuous leak of cerebrospinal fluid (CSF), which leads to a reduction in CSF volume. This leak decreases the pressure in the brain area, causing the brain to sag slightly and stretch the surrounding membranes, resulting in a headache.

421
Q

Which patient factors increase the risk of postdural puncture headache (PDPH)?

A. Older age, being male, not pregnant
B. Being younger, being female, being pregnant
C. Having a history of hypertension
D. Smoking history

A

B. Being younger, being female, being pregnant

Rationale: Patient factors that increase the risk of PDPH include being younger, being female, and being pregnant. These demographics are associated with a higher likelihood of experiencing PDPH after a dural puncture.

422
Q

Which practitioner factors can increase the risk of postdural puncture headache (PDPH)?

A. Using a needle with a pencil point
B. Using a large diameter needle and positioning the needle perpendicular to the spine’s long axis
C. Using a small diameter needle
D. Ensuring the needle bevel is parallel to the dural fibers

A

B. Using a large diameter needle and positioning the needle perpendicular to the spine’s long axis

Rationale: Practitioner factors that increase the risk of PDPH include using a needle with a cutting tip, using a large diameter needle, using air for loss of resistance (LOR) with epidural, and positioning the needle perpendicular to the spine’s long axis.

423
Q

Which type of needle is associated with a higher incidence of postdural puncture headache (PDPH)?

A. Quincke
B. Whitacre
C. Sprotte
D. Tuohy

A

A. Quincke

Rationale: Quincke needles, which have a cutting tip, are associated with a higher incidence of PDPH compared to pencil point needles like Whitacre, Sprotte, and Tuohy. The cutting tip of the Quincke needle creates a larger and less clean puncture, increasing the likelihood of CSF leak.

424
Q

What is the most effective treatment for severe post-dural puncture headache?

A) Bed rest
B) NSAIDs
C) Caffeine
D) Epidural blood patch

A

Answer: D) Epidural blood patch

Rationale: The most effective treatment for severe PDPH is an epidural blood patch, which involves injecting the patient’s own blood into the epidural space to seal the leak.

425
Q

Which cranial nerves are targeted by the sphenopalatine ganglion block for treating PDPH?

A) CN 6
B) CN 5, V2 portion
C) CN 5 V3 portion, 9, 10
D) CN 5, V1 portion

A

B) CN 5, V2 portion

426
Q

How long should you wait before performing an epidural blood patch after a dural puncture?

A) Immediately
B) Within 24 hours
C) After 48 hours
D) After 72 hours

A

Answer: C) After 48 hours

Rationale: It is recommended to wait at least 48 hours after a dural puncture before performing an epidural blood patch, as this timing has shown to be more effective in sealing the CSF leak.

Try caffeine, bedrest, NSAIDS first

427
Q

What does the procedure of an epidural blood patch involve?

A) Injecting saline into the epidural space
B) Injecting the patient’s own blood into the epidural space
C) Administering NSAIDs intravenously
D) Applying a topical anesthetic patch

A

Answer: B) Injecting the patient’s own blood into the epidural space (10-20mL)

Rationale: An epidural blood patch involves injecting the patient’s own blood into the epidural space to create a clot that seals the CSF leak.

428
Q

What should you do if paresthesia is encountered during the placement of a needle or catheter?

A. Continue with the procedure as normal.
B. Redirect the needle.
C. Stop the procedure immediately.
D. Increase the dose of anesthetic.

A

Answer: B. Redirect the needle. (IE. pull it out)

Rationale: If paresthesia is encountered, it indicates that the needle may have contacted a nerve, so redirecting the needle can help avoid nerve injury.

429
Q

Which technique has a higher incidence of paresthesia?

A. Single-shot spinal
B. Combined spinal epidural (CSE)
C. Epidural catheter
D. Local infiltration

A

Answer: B. Combined spinal epidural (CSE).

Rationale: The slide notes that CSE techniques have a higher incidence of paresthesia compared to other methods.

430
Q

What is a critical step to take if a patient reports paresthesia during needle placement?

A. Increase the depth of the needle.
B. Document the incident.
C. Withdraw the needle completely.
D. Continue without any changes.

A

Answer: B. Document the incident.

Rationale: Proper documentation is essential for patient safety and legal purposes if paresthesia occurs during needle placement.

431
Q

Which of the following factors can increase the risk of paresthesia during needle or catheter placement?

A. Using a pencil-point needle.
B. A cooperative patient.
C. Noncooperative or moving patient.
D. Midline positioning.

A

Answer: C. Noncooperative or moving patient.

Rationale: A noncooperative or moving patient can increase the risk of paresthesia as it may cause the needle to deviate from its intended path, potentially injuring a nerve.

432
Q

What is the recommended course of action if a spinal block has not set up after 15-20 minutes?

A. Wait an additional 30 minutes.
B. Adjust the patient’s position.
C. Redo the block.
D. Administer a higher dose of anesthetic.

A

Answer: C. Redo the block.

Rationale: If no anesthesia effect is observed after 15-20 minutes, it may be necessary to redo the block to achieve the desired anesthetic effect.

433
Q

What should be considered if a patchy block occurs?

A. Repeat the block immediately.
B. Adjust the patient’s position.
C. Avoid repeating to prevent neurotoxicity.
D. Administer a different type of anesthetic.

A

Answer: C. Avoid repeating to prevent neurotoxicity.

Rationale: Repeating a patchy block may cause neurotoxicity, so it’s better to consider IV sedation or general anesthesia.

434
Q

If a patient experiences a unilateral block, what should be the next step?

A. Administer a higher dose of anesthetic.
B. Adjust the patient’s position.
C. Perform a blood patch.
D. Repeat the block immediately.

A

Answer: B. Adjust the patient’s position.

Rationale: Adjusting the patient’s position can help distribute the anesthetic more evenly and address a unilateral block.

435
Q

What are two potential ways infections can happen after a spinal procedure?

A) Failure to wear gloves and mask
B) Failure to maintain aseptic technique
C) Bacteria in the blood
D) Using expired medications

A

Answer: B) Failure to maintain aseptic technique
C) Bacteria in the blood

Rationale: Infections can occur due to failure to maintain aseptic technique or if the patient has bacteria in their bloodstream.

436
Q

Which bacterium is commonly involved in post-spinal bacterial meningitis?

A) Escherichia coli
B) Staphylococcus aureus
C) Streptococcus viridans
D) Pseudomonas aeruginosa

A

Answer: C.

Rationale: Streptococcus viridans, commonly found in the mouth and on hands, is a typical bacterium involved in post-spinal bacterial meningitis.

437
Q

What are the recommended skin preparation options to prevent post-spinal bacterial meningitis?

A) Alcohol and iodine
B) Iodine and chlorhexidine
C) Alcohol and chlorhexidine
D) Only alcohol

A

Answer: C.

Rationale: The recommended combination for skin preparation is alcohol and chlorhexidine, which is highly effective in preventing bacterial meningitis.

438
Q

Why is it important to let chlorhexidine dry before starting a spinal procedure?

A) To enhance its antiseptic properties
B) To avoid staining the skin
C) To prevent neurotoxicity and arachnoiditis
D) To reduce the smell

A

Answer: C.

Rationale: Chlorhexidine must be allowed to dry before the procedure to prevent neurotoxicity and arachnoiditis.

439
Q

What preventive measures can help reduce the spread of Streptococcus viridans during a spinal procedure?

A) Wearing a mask and gloves
B) Using a larger needle
C) Wearing a gown
D) Applying a sterile drape

A

Answer: A.

Rationale: Wearing a mask and washing hands are essential preventive measures to avoid spreading Streptococcus viridans.

440
Q

Which nerves are affected in Cauda Equina Syndrome?

A) C1-C4
B) T1-T12
C) L2-S5 + coccygeal nerves
D) L1-L5

A

Answer: C) L2-S5 + coccygeal nerves

Rationale: Cauda Equina Syndrome specifically involves the cauda equina, which consists of the lower lumbar, sacral, and coccygeal nerves.

441
Q

What is the primary cause of neurotoxicity in Cauda Equina Syndrome?

A) Infection
B) High concentration of local anesthetics
C) Trauma
D) Genetic predisposition

A

Answer: B) High concentration of local anesthetics

Rationale: Neurotoxicity in Cauda Equina Syndrome is caused by high levels of local anesthetic drugs affecting nerve function, especially when using high concentrations like 5% lidocaine in SAB.

442
Q

Which of the following needles has been associated with Cauda Equina Syndrome?

A) Tuohy 16
B) Quincke 22
C) Whitacre 25/26
D) Sprotte 24

A

Answer: C) Whitacre 25/26

Rationale: Whitacre 25/26 needles have been associated with this syndrome due to their design and usage characteristics.

443
Q

What are the signs and symptoms of Cauda Equina Syndrome?

A) Hearing loss, speech difficulties
B) Bowel and bladder dysfunction, sensory deficits, and back pain
C) Visual disturbances, headaches
D) Nausea, vomiting

A

Answer: B) Bowel and bladder dysfunction, sensory deficits, and back pain

Rationale: Cauda Equina Syndrome presents with serious neurological complications such as bowel and bladder dysfunction, sensory deficits in the legs or feet, back pain, saddle anesthesia, and potential paralysis.

444
Q

Which treatment is recommended if compression (disc, hematoma, etc.) is a factor in Cauda Equina Syndrome?

A) Immediate laminectomy within 6 hours
B) Bed rest and NSAIDs
C) Physical therapy
D) Antidepressants

A

Answer: A) Immediate laminectomy within 6 hours

Rationale: If compression from a disc or hematoma is contributing to Cauda Equina Syndrome, immediate surgical decompression (laminectomy) within 6 hours is crucial to optimize recovery and prevent permanent damage.

445
Q

hy is it not common practice to use 5% lidocaine in spinal anesthesia?

A) Risk of systemic toxicity
B) Insufficient anesthetic effect
C) High risk of neurotoxicity
D) Long duration of action

A

Answer: C) High risk of neurotoxicity

Rationale: The use of 5% lidocaine in spinal anesthesia is avoided due to its high risk of causing neurotoxicity, leading to complications such as Cauda Equina Syndrome.

446
Q

What is a common cause of Transient Neurologic Symptoms (TNS)?

A) High concentration of local anesthetics
B) Improper patient positioning during procedures
C) Early ambulation post-surgery
D) Low dose of local anesthetics

A

Answer: B) Improper patient positioning during procedures

Rationale: TNS can occur due to improper positioning during procedures, which can stretch nerves like the sciatic nerve, leading to symptoms.

447
Q

Which factor increases the risk of TNS?

A) Early ambulation
B) Using 5% lidocaine
C) Low concentration of local anesthetics
D) Proper surgical positions

A

Answer: B) Using 5% lidocaine

Rationale: The use of 5% lidocaine has been associated with a higher incidence of TNS, around 19%.

448
Q

Which surgical position is associated with a higher risk of TNS?

A) Supine position
B) Prone position
C) Lithotomy position
D) Lateral position

A

Answer: C) Lithotomy position

Rationale: Surgical positions like the lithotomy position, which involves hip or knee flexion, are associated with higher risks of TNS.

449
Q

Which of the following is not a factor that increases the risk of TNS?

A) Outpatient surgeries
B) Early ambulation
C) Knee arthroscopy
D) Myofascial strain and spasms

A

Answer: B) Early ambulation

Rationale: Early ambulation does not increase the risk of TNS. Factors like outpatient surgeries and knee arthroscopy do increase the risk.

450
Q

What is the typical timing for the onset of TNS symptoms after surgery?

A) 1 to 2 hours
B) 6 to 36 hours
C) 3 to 5 days
D) 7 to 10 days

A

Answer: B) 6 to 36 hours

Rationale: TNS (Transient Neurologic Symptoms) symptoms usually start within 6 to 36 hours after surgery and can last from 1 to 7 days.

451
Q

What is a common symptom of TNS?

A) Severe radicular pain in the back and buttocks
B) Loss of consciousness
C) Swelling in the limbs
D) Fever and chills

A

Answer: A) Severe radicular pain in the back and buttocks

Rationale: TNS typically involves severe radicular pain in the back and buttocks that spreads down both legs.

452
Q

What is a recommended treatment for TNS?

A) High dose of opioids
B) Bed rest only
C) NSAIDs like ibuprofen
D) Antibiotics

A

Answer: C) NSAIDs like ibuprofen

Rationale: Pain relief with NSAIDs, like ibuprofen, and opioid painkillers can help manage TNS symptoms.

453
Q

What is the recommended technique for removing an epidural catheter to prevent sheering?

a) Remove the catheter first, then the needle

b) Remove the needle first, then the catheter

c) Withdraw the needle and catheter simultaneously

d) Leave the catheter in place for a few minutes before removing the needle

A

Answer: c) Withdraw the needle and catheter simultaneously (I think this is for spinal but its just what his slide said)

Rationale: Simultaneous removal of the needle and catheter helps to prevent the catheter from sheering during the process.

454
Q

If there is resistance when trying to remove an epidural catheter, which of the following is NOT a recommended solution?

a) Applying gentle, continuous pulling

b) Placing the patient in the position they were in during insertion or lateral decubitus

c) Using forceful, quick pulling to overcome resistance

d) Taping the catheter to the skin and gently pulling

A

Answer: c) Using forceful, quick pulling to overcome resistance

Rationale: Forceful pulling can increase the risk of breaking the catheter. Gentle, continuous pulling, appropriate positioning, and tape traction are recommended to safely remove the catheter.

455
Q

What should be done if a piece of the catheter breaks off inside the patient?

a) Perform immediate surgery to remove the fragment

b) Inform the patient and monitor them for symptoms

c) Ignore it if the patient does not complain

d) Remove the remaining catheter piece and continue with the procedure

A

Answer: b) Inform the patient and monitor them for symptoms

Rationale: If a catheter breaks inside a patient, the patient should be informed, and they should be monitored for symptoms. Many patients can live safely with the fragment if they do not show any symptoms.

456
Q

In case of catheter breakage, under what circumstance might surgery be needed?

a) If the patient requests it

b) If the catheter piece causes infection

c) If neurological symptoms develop

d) If the catheter piece is visible under the skin

A

Answer: c) If neurological symptoms develop

Rationale: Surgery may be needed to remove the catheter piece if neurological symptoms develop, indicating that the fragment might be causing harm.

457
Q

If blood is in the epidural needle, what is the most likely cause?

A. The needle is too far medial.
B. The needle is too far lateral.
C. The needle is in the correct position.
D. The needle has punctured an artery.

A

Answer: B. The needle is too far lateral.

Rationale: When blood is found in the epidural needle, it often indicates that the needle has gone too far laterally and punctured a vein. Adjusting the needle towards the midline can help avoid this issue.

458
Q

What is the recommended action if blood is found in the epidural catheter during use?

A. Remove the catheter immediately.
B. Push the catheter further in.
C. Slightly pull back the catheter and flush with saline.
D. Continue using the catheter as normal.

A

Answer: C. Slightly pull back the catheter and flush with saline.

Rationale: If blood is found in the catheter, it is advisable to slightly retract the catheter and flush with saline to clear any blood. This can help determine if the catheter can still be used safely without further adjustment.

459
Q

What is a preventive measure to avoid epidural vein cannulation?

A. Avoid using stiff catheters.
B. Inject fluid in the epidural space before placing the catheter.
C. Use a larger needle.
D. Perform the procedure with the patient in a sitting position.

A

Answer: B. Inject fluid in the epidural space before placing the catheter.

Rationale: Pre-injecting fluid into the epidural space can help create a clearer path for catheter placement and prevent the catheter from coiling, thus reducing the risk of puncturing an epidural vein.

460
Q

Which of the following is a risk factor for epidural vein cannulation?

A. Using a flexible catheter
B. Single attempt procedure
C. Pregnancy
D. Patient in supine position

A

Answer: C. Pregnancy

Rationale: Pregnancy increases the risk of epidural vein cannulation due to the engorged epidural veins from increased abdominal pressure and vascular volume. Multiple attempts and the type of catheter (rigid) used are also significant risk factors.

461
Q

How should the catheter be adjusted if blood is found during aspiration?

A. Remove and replace the catheter immediately.
B. Push the catheter further into the epidural space.
C. Slightly pull back the catheter and try flushing with saline.
D. Leave the catheter in place and continue with the procedure.

A

Answer: C. Slightly pull back the catheter and try flushing with saline.

Rationale: This adjustment can help clear the blood and ensure proper catheter placement without the need for complete removal and replacement.

462
Q

What is a common cause of a unilateral epidural block?

A) The catheter has been placed too close to the spinal cord.

B) The catheter may have been inserted too far, exiting the epidural space through the intervertebral foramen.

C) The anesthetic solution is too concentrated.

D) The patient has a high tolerance to anesthetics.

A

Correct Answer: B

Rationale:
A common cause of a unilateral epidural block is that the catheter may have been inserted too far, causing it to exit the epidural space through the intervertebral foramen.

463
Q

What is the recommended solution if a unilateral epidural block occurs due to the catheter being too close to a nerve?

A) Remove the catheter and start over.

B) Inject a higher dose of anesthetic.

C) Adjust the catheter slightly, about 1-2 cm.

D) Increase the infusion rate of the current anesthetic.

A

Correct Answer: C

Rationale:
If the catheter is too close to a nerve, the recommended solution is to adjust the catheter slightly, about 1-2 cm, but ensure at least 3 cm remains in the epidural space.

464
Q

What position should the patient be placed in to help resolve a unilateral epidural block?

A) Supine position with legs elevated.

B) Prone position with a pillow under the abdomen.

C) Lateral decubitus position with the side not feeling numb facing downwards.

D) Sitting position with legs crossed.

A

Correct Answer: C

Rationale:
To help resolve a unilateral epidural block, the patient should be placed in the lateral decubitus position with the side not feeling numb facing downwards.

465
Q

What should be administered if adjusting the catheter and repositioning the patient does not resolve the unilateral epidural block?

A) A higher concentration of local anesthetic.

B) Diluted anesthetic to even out the block.

C) Only opioids to manage pain.

D) Nothing, wait for the block to wear off.

A

Correct Answer: B

Rationale:
If adjusting the catheter and repositioning the patient does not resolve the block, a diluted local anesthetic should be administered to try to even out the block.

466
Q

When is it necessary to replace the catheter during a unilateral epidural block?

A) If the patient complains of severe pain.

B) If the anesthetic has been administered for more than 4 hours.

C) If adjustments and additional anesthetic don’t resolve the issue.

D) If the patient is allergic to the anesthetic.

A

Correct Answer: C

Rationale:
It is necessary to replace the catheter if adjustments and additional anesthetic don’t resolve the unilateral epidural block issue.

467
Q

What is the most common cause of local anesthetic systemic toxicity (LAST)?

A) Allergic reaction to the anesthetic.

B) Inadvertent injection.

C) Overdose of anesthetic.

D) Interaction with other medications.

A

Correct Answer: B. Inadvertent injection

Rationale:
The most common cause of local anesthetic systemic toxicity (LAST) is inadvertent injection, which leads to high plasma concentrations of the anesthetic.

468
Q

What is the most frequent symptom of local anesthetic systemic toxicity?

A) Cardiac arrest

B) Seizure

C) Respiratory depression

D) Hypotension

A

Correct Answer: B. Seizure

Rationale:
The most frequent symptom of local anesthetic systemic toxicity is a seizure. With certain anesthetics like bupivacaine, cardiac arrest may precede a seizure.

469
Q

Which of the following local anesthetics is more likely to cause cardiac arrest before a seizure in the event of toxicity?

A) Lidocaine

B) Bupivacaine

C) Ropivacaine

D) Mepivacaine

A

Correct Answer: B. Bupivacaine

Rationale:
Bupivacaine is more likely to cause cardiac arrest before a seizure in the event of toxicity compared to other local anesthetics.

470
Q

Which scenario is most likely to result in local anesthetic systemic toxicity?

A) Epidural block in labor

B) Peripheral nerve block

C) Local infiltration in minor surgery

D) Topical application for skin numbing

A

Correct Answer: B. Peripheral nerve block

Rationale:
Local anesthetic systemic toxicity is more common in peripheral nerve blocks than in epidural anesthesia.

471
Q

At what plasma concentration of lidocaine do coma and cardiovascular collapse typically occur?

A) 1-5 mcg/mL

B) 5-10 mcg/mL

C) 10-15 mcg/mL

D) >25 mcg/mL

A

Correct Answer: D. >25 mcg/mL

Rationale:
Coma and cardiovascular collapse typically occur at plasma concentrations of lidocaine greater than 25 mcg/mL.

seizures & LOC : 10 -15mcg/mL

472
Q

What factor increases the risk of CNS toxicity from local anesthetics?

A) Hypocarbia

B) Hypercarbia

C) Hypokalemia

D) CNS depressants

A

Correct Answer: B. Hypercarbia

Rationale:
Hypercarbia increases cerebral perfusion, leading to increased drug delivery to the brain, and decreases protein binding, which increases the free fraction of local anesthetics available to enter the brain, thereby increasing the risk of CNS toxicity.

473
Q

Which condition lowers the seizure threshold and increases brain drug retention, thereby increasing the risk of CNS toxicity?

A) Hypercarbia

B) Metabolic acidosis

C) Hyperkalemia

D) Hypocarbia

A

Correct Answer: B. Metabolic acidosis

Rationale:
Metabolic acidosis lowers the seizure threshold and increases brain drug retention through ion trapping, thus increasing the risk of CNS toxicity from local anesthetics.

474
Q

Which of the following is a cardiovascular effect of local anesthetic toxicity?

A) Increased conduction velocity

B) Enhanced myocardial contractility

C) Depressed myocardium by affecting intracellular calcium regulation

D) Increased heart automaticity

A

Correct Answer: C. Depressed myocardium by affecting intracellular calcium regulation

Rationale:
Local anesthetic toxicity can depress the myocardium by affecting intracellular calcium regulation, which is one of the cardiovascular effects.

475
Q

What decreases the risk of CNS toxicity from local anesthetics?

A) Hyperkalemia

B) Hypokalemia

C) Hypercarbia

D) Metabolic acidosis

A

Correct Answer: B. Hypokalemia

Rationale:
Hypokalemia decreases the excitability of neurons and requires larger stimuli for depolarization, thereby reducing the risk of CNS toxicity from local anesthetics.

476
Q

Which local anesthetic has the highest difficulty of cardiac resuscitation in case of toxicity?

A) Lidocaine

B) Levobupivacaine

C) Ropivacaine

D) Bupivacaine

A

Correct Answer: D. Bupivacaine

Rationale:
Bupivacaine has a high affinity to the voltage-sodium channel and a slower dissociation rate from the receptor during diastole, making cardiac resuscitation very difficult in case of toxicity.

477
Q

What is the first step when managing a patient with local anesthetic systemic toxicity (LAST)?

A) Administer epinephrine

B) Ensure adequate airway and administer 100% oxygen

C) Administer lipid emulsion therapy

D) Give benzodiazepines for seizure control

A

Correct Answer: B. Ensure adequate airway and administer 100% oxygen

Rationale:
The first step in managing a patient with LAST is to ensure adequate airway and administer 100% oxygen to prevent hypoxia and support respiratory function.

478
Q

Why should propofol be avoided in large doses during the treatment of seizures in LAST?

A) It is ineffective in controlling seizures.

B) It can lower the seizure threshold.

C) It can weaken the heart in large doses and doesn’t replace lipid therapy.

D) It interferes with oxygen therapy.

A

Correct Answer: C. It can weaken the heart in large doses and doesn’t replace lipid therapy

Rationale:
Propofol should be avoided in large doses during the treatment of seizures in LAST because it can weaken the heart and it does not serve as a substitute for lipid therapy.

479
Q

What is the recommended caution when using epinephrine in the modified ACLS protocol for LAST?

A) Use in large doses to counteract cardiac depression

B) Use in combination with benzodiazepines

C) Use less than 1 mcg/kg to avoid making resuscitation harder and reducing lipid therapy effectiveness

D) Avoid using epinephrine altogether

A

Correct Answer: C. Use less than 1 mcg/kg to avoid making resuscitation harder and reducing lipid therapy effectiveness

Rationale:
Epinephrine should be used cautiously in the modified ACLS protocol for LAST, with less than 1 mcg/kg, because higher doses can make resuscitation harder and reduce the effectiveness of lipid therapy.

480
Q

How is lipid emulsion therapy administered for a patient weighing over 70 kg according to the 2020 ASRA guidelines?

A) 100 mL bolus for 2-3 minutes, followed by 250 mL infusion over 15-20 minutes

B) 1.5 mL/kg bolus for 2-3 minutes, followed by 0.25 mL/kg/min infusion

C) 100 mL bolus for 5-10 minutes, followed by 200 mL infusion over 10-15 minutes

D) 1 mL/kg bolus for 2-3 minutes, followed by 0.5 mL/kg/min infusion

A

Correct Answer: A. 100 mL bolus for 2-3 minutes, followed by 250 mL infusion over 15-20 minutes

Rationale:
For a patient weighing over 70 kg, the 2020 ASRA guidelines recommend starting with a 100 mL bolus of lipid emulsion for 2-3 minutes, followed by a 250 mL infusion over 15-20 minutes.

Under 70 kg: Start with a 1.5 mL/kg bolus for 2-3 minutes, followed by a 0.25 mL/kg/min infusion. Repeat or double if unstable.

481
Q

What is the proposed mechanism of action (MOA) of lipid emulsion therapy in the treatment of LAST?

A) Increases renal clearance of local anesthetics

B) Acts as a lipid sink to sequester and reduce LA plasma concentration

C) Enhances hepatic metabolism of local anesthetics

D) Inhibits the central nervous system response to local anesthetics

A

Correct Answer: B. Acts as a lipid sink to sequester and reduce LA plasma concentration

Rationale:
The proposed mechanism of action of lipid emulsion therapy in the treatment of LAST is to act as a lipid sink, sequestering and reducing the plasma concentration of local anesthetics.

482
Q

Which weight category and corresponding lipid emulsion therapy regimen are correctly matched according to the 2020 ASRA guidelines?

A) Over 70 kg: 1.5 mL/kg bolus over 2-3 minutes, followed by 0.25 mL/kg/min infusion

B) Under 70 kg: 100 mL bolus over 2-3 minutes, followed by 250 mL infusion over 15-20 minutes

C) Over 70 kg: 100 mL bolus over 2-3 minutes, followed by 250 mL infusion over 15-20 minutes

D) Under 70 kg: 2 mL/kg bolus over 3-4 minutes, followed by 0.5 mL/kg/min infusion

A

Correct Answer: C. Over 70 kg: 100 mL bolus over 2-3 minutes, followed by 250 mL infusion over 15-20 minutes

Rationale:
For patients over 70 kg, the correct lipid emulsion therapy regimen according to the 2020 ASRA guidelines is a 100 mL bolus over 2-3 minutes, followed by a 250 mL infusion over 15-20 minutes.

Under 70 kg: Start with a 1.5 mL/kg bolus for 2-3 minutes, followed by a 0.25 mL/kg/min infusion. Repeat or double if unstable.

483
Q

What should be the approach if a patient with LAST is experiencing seizures?

A) Administer epinephrine immediately

B) Ensure adequate airway and administer benzodiazepines

C) Start with lipid emulsion therapy

D) Use a high dose of propofol

A

Correct Answer: B. Ensure adequate airway and administer benzodiazepines

Rationale:
If a patient with LAST is experiencing seizures, the approach should be to ensure an adequate airway and administer benzodiazepines to control the seizures.

484
Q

What is the advised maximum lipid dose for treating LAST according to the ASRA guidelines?

A) 10 mL/kg

B) 12 mL/kg

C) 15 mL/kg

D) 20 mL/kg

A

Correct Answer: B. 12 mL/kg

Rationale:
The advised maximum lipid dose for treating LAST according to the ASRA guidelines is 12 mL/kg.

485
Q

When is it appropriate to consider cardiopulmonary bypass in the management of LAST?

A) After the first dose of lipid emulsion therapy

B) If the patient does not respond to modified ACLS and lipid therapy

C) Immediately after seizure control

D) Only if the patient is over 70 kg

A

Correct Answer: B. If the patient does not respond to modified ACLS and lipid therapy

Rationale:
Cardiopulmonary bypass should be considered if the patient does not respond to modified ACLS and lipid therapy, as this may be necessary for successful resuscitation.

486
Q

What is the incidence rate of epidural/spinal hematoma?

A) 1:50K

B) 1:100K

C) 1:200K

D) 1:500K

A

Correct Answer: C. 1:200K

Rationale:
The incidence rate of epidural/spinal hematoma is 1:200K, indicating it is a rare occurrence.

487
Q

Which condition is associated with an increased risk of epidural/spinal hematoma?

A) Hypertension

B) Preexisting abnormalities in clotting hemostasis

C) Diabetes

D) Obesity

A

Correct Answer: B. Preexisting abnormalities in clotting hemostasis

Rationale:
Preexisting abnormalities in clotting hemostasis are associated with an increased risk of developing an epidural/spinal hematoma.

488
Q

What is a critical factor for the reversibility of cord ischemia in epidural/spinal hematoma?

A) Early administration of analgesics

B) Performing a laminectomy within 24 hours

C) Performing a laminectomy within 8 hours

D) Immediate cessation of anticoagulants

A

Correct Answer: C. Performing a laminectomy within 8 hours

Rationale:
Cord ischemia can be reversible if a laminectomy is performed within 8 hours, emphasizing the need for prompt surgical intervention.

489
Q

Which symptom is commonly associated with epidural/spinal hematoma and can be confusing due to the use of local anesthetics?

A) Hypertension

B) Tachycardia

C) Numbness and weakness

D) Hyperglycemia

A

Correct Answer: C. Numbness and weakness

Rationale:
Symptoms of numbness and weakness are commonly associated with epidural/spinal hematoma and can be confusing due to the similar effects of local anesthetics.

490
Q

What is the recommended INR level to minimize the risk of epidural/spinal hematoma?

A) Less than 2.0

B) Less than 1.8

C) Less than 1.7

D) Less than 1.5

A

Correct Answer: D. Less than 1.5

Rationale:
To minimize the risk of epidural/spinal hematoma, it is recommended to have an INR level of less than 1.5.

491
Q

What are 2 primary causes of arachnoiditis?

A) Use of non-preservative free solutions

B) Trauma to the spinal cord

C) Nonapproved administration of a drug into the intrathecal or epidural space

D) Infection from surgical procedures

A

Answer: C) Nonapproved administration of a drug into the intrathecal or epidural space
A) Use of non-preservative free solutions

Rationale:
Arachnoiditis is primarily caused by the nonapproved administration of a drug into the intrathecal or epidural space, which is considered a medical error. And Non-preservative free solutions.

492
Q

What is the first sign of arachnoiditis?

A) Severe back pain

B) Fever 2-3 days after the incident

C) Paralysis

D) Loss of sensation in the legs

A

Correct Answer: B. Fever 2-3 days after the incident

Rationale:
The first sign of arachnoiditis is usually a fever that appears 2-3 days after the incident.

493
Q

Which complication is associated with the use of Betadine in the epidural or spinal space?

A) Allergic reaction

B) Neuropathy

C) Contamination leading to arachnoiditis

D) Increased risk of bleeding

A

Correct Answer: C. Contamination leading to arachnoiditis

Rationale:
Betadine contamination, if not wiped off properly, can lead to arachnoiditis, which is the inflammation of the meninges.

494
Q

According to ASA Closed Claims, what percentage of claims since 1990 are related to nerve injury?

A) 10%

B) 19%

C) 25%

D) 30%

A

Correct Answer: B. 19%

Rationale:
According to ASA Closed Claims, 19% of claims since 1990 are related to nerve injury.

495
Q

Which nerve is commonly injured according to the ASA Closed Claims data?

A) Sciatic nerve

B) Radial nerve

C) Ulnar nerve

D) Median nerve

A

Correct Answer: C. Ulnar nerve

Rationale:
The ulnar nerve is commonly injured according to the ASA Closed Claims data, with injuries often occurring due to positioning or spinal cord injury.

496
Q

What are the main causes of the 14 deaths from cardiac-related events after spinal anesthesia according to the ASA Closed Claims data?

A) Overdose of anesthetics and allergic reactions

B) Anesthesia-related issues and undetected respiratory compromise

C) Pre-existing cardiac conditions and surgical complications

D) Blood loss and electrolyte imbalance

A

Correct Answer: B. Anesthesia-related issues and undetected respiratory compromise

Rationale:
The main causes of the 14 deaths from cardiac-related events after spinal anesthesia were anesthesia-related issues, contributing to 54% of the cases, and undetected respiratory compromise along with sympathetic blockade.

497
Q

In which scenarios must you be prepared to perform a general anesthesia conversion during a neuraxial case?

A) Failed block, high spinal, LAST

B) Anaphylaxis, severe CV collapse, prolonged case duration

C) Both A and B

D) Only if the patient requests it

A

Correct Answer: C. Both A and B

Rationale:
You must be prepared to perform a general anesthesia conversion during a neuraxial case in scenarios such as failed block, high spinal, LAST, anaphylaxis, severe CV collapse, and if the case exceeds the duration of the local anesthetic.

498
Q

Which of the following is NOT listed as a common reason for neuraxial anesthesia failure?

A) Wrong dose

B) Wrong location

C) Wrong medication

D) Wrong position

A

Correct Answer: C. Wrong medication

Rationale:
The common reasons for neuraxial anesthesia failure listed are wrong dose, wrong location, and wrong position, not wrong medication.

499
Q

What must be prepared for in every neuraxial anesthesia case?

A) A backup supply of local anesthetics

B) The possibility of converting to general anesthesia

C) An alternative surgical procedure

D) Additional pain management techniques

A

Correct Answer: B. The possibility of converting to general anesthesia

Rationale:
In every neuraxial anesthesia case, there must be preparation for the possibility of converting to general anesthesia due to potential complications such as failed block, high spinal, LAST, anaphylaxis, severe cardiovascular collapse, or exceeding the duration of the local anesthetic.

500
Q

What are three common reasons for the failure of neuraxial anesthesia?

A) Inadequate patient preparation, wrong surgical technique, incorrect drug choice

B) Wrong dose, wrong location, wrong position

C) Equipment failure, patient refusal, improper monitoring

D) Allergic reactions, insufficient sedation, surgical complications

A

Correct Answer: B. Wrong dose, wrong location, wrong position

Rationale:
The three common reasons for the failure of neuraxial anesthesia are the wrong dose, wrong location, and wrong position.

501
Q

Which of the following complications requires immediate conversion to general anesthesia during a neuraxial anesthesia procedure?

A) Mild hypotension

B) High spinal block

C) Minor tremors

D) Slight nausea

A

Correct Answer: B. High spinal block

Rationale:
A high spinal block is a serious complication that requires immediate conversion to general anesthesia to ensure patient safety and maintain adequate respiratory and cardiovascular function.

502
Q

What is a major reason for severe cardiovascular collapse during neuraxial anesthesia?

A) Patient anxiety

B) Over-sedation

C) Anaphylaxis

D) Incorrect positioning of the patient

A

Correct Answer: C. Anaphylaxis

Rationale:
Anaphylaxis is a major reason for severe cardiovascular collapse during neuraxial anesthesia, necessitating immediate intervention and possibly conversion to general anesthesia.

503
Q

Why is it essential to be prepared with a general anesthesia setup during neuraxial anesthesia cases?

A) To provide additional comfort to the patient

B) To expedite the surgical procedure

C) To manage any complications that exceed the duration of the local anesthetic

D) To enhance the effectiveness of local anesthetics

A

Correct Answer: C. To manage any complications that exceed the duration of the local anesthetic

Rationale:
It is essential to be prepared with a general anesthesia setup to manage any complications that exceed the duration of the local anesthetic, ensuring continuous patient care and safety.

504
Q

What is the purpose of using a filter needle when drawing up SAB (subarachnoid block) medication?

A) To ensure accurate dosing

B) To prevent contamination

C) To remove particulate matter

D) To facilitate easier injection

A

Correct Answer: C. To remove particulate matter

Rationale:
The filter needle is used to remove particulate matter from the medication, ensuring that only the pure solution is injected.

505
Q

Which types of preparation solutions are typically used for spinal procedures?

A) Alcohol and saline

B) Chlorhexidine and Betadine

C) Hydrogen peroxide and iodine

D) Sterile water and soap

A

Correct Answer: B. Chlorhexidine and Betadine

Rationale:
Chlorhexidine and Betadine are commonly used preparation solutions due to their antiseptic properties, reducing the risk of infection.

506
Q

What concentration of lidocaine is commonly used for skin anesthesia in spinal procedures?

A) 0.5%

B) 1%

C) 2%

D) 5%

A

Correct Answer: B. 1%

Rationale:
A 1% concentration of lidocaine is commonly used for skin anesthesia in spinal procedures, providing effective local anesthesia for the skin prior to deeper injections.

507
Q

What is the typical local anesthetic medication used in spinal anesthesia for a subarachnoid block?

A) Lidocaine

B) Bupivacaine

C) Ropivacaine

D) Mepivacaine

A

Correct Answer: B. Bupivacaine

Rationale:
Bupivacaine is commonly used in spinal anesthesia for subarachnoid blocks due to its long duration of action and effective sensory and motor blockade, making it ideal for lower abdominal, pelvic, and lower extremity surgeries​

507
Q

What is the purpose of using a stylet in the spinal anesthesia needle?

A) To increase the flexibility of the needle

B) To prevent the formation of micro clots

C) To enhance the penetration power of the needle

D) To reduce patient discomfort

A

Correct Answer: B. To prevent the formation of micro clots

Rationale:
The 3.5 inch stylet is used to prevent the formation of micro clots within the needle by keeping it free of tissue and blood until it is ready for the anesthetic injection.

508
Q

How can you determine the bevel position of the spinal anesthesia needle?

A) By checking the stylet length

B) By examining the needle hub

C) By looking at the introducer

D) By measuring the needle’s diameter

A

Correct Answer: B. By examining the needle hub

Rationale:
The position of the bevel can be determined by looking at the needle hub. If the hub is up, then the bevel is also up, which is the most common position for the needle.

509
Q

What is the role of the introducer in spinal anesthesia?

A) To inject the local anesthetic

B) To guide the spinal needle into the correct position

C) To measure the depth of needle insertion

D) To maintain sterility during the procedure

A

Correct Answer: B. To guide the spinal needle into the correct position

Rationale:
The introducer is used to guide the spinal needle into the correct position, ensuring accurate placement and minimizing tissue trauma during the procedure.

510
Q

Which of the following spinal needles is classified as a cutting needle?

A) Sprotte

B) Whitacre

C) Quincke

D) Gertie Marx

A

Correct Answer: C. Quincke

Rationale:
The Quincke needle is a cutting type of spinal needle, designed to cut through tissue for easier insertion. This type of needle is often associated with a higher incidence of post-dural puncture headache (PDPH) compared to non-cutting needles.

511
Q

What is a key characteristic of non-cutting spinal needles like the Sprotte and Whitacre?

A) They are less sharp than cutting needles.

B) They have a pencil-point tip that separates rather than cuts tissue.

C) They require a larger gauge to be effective.

D) They are more likely to cause nerve damage.

A

Correct Answer: B. They have a pencil-point tip that separates rather than cuts tissue.

Rationale:
Non-cutting spinal needles, such as the Sprotte and Whitacre, have a pencil-point tip designed to separate rather than cut the dura and other tissues, reducing the incidence of post-dural puncture headaches and other complications.

512
Q

What is a significant advantage of using non-cutting spinal needles over cutting needles?

A) Increased ease of insertion

B) Reduced risk of PDPH

C) Faster onset of anesthesia

D) Lower cost

A

Correct Answer: B. Reduced risk of PDPH

Rationale:
Non-cutting spinal needles, such as the Whitacre and Sprotte, reduce the risk of post-dural puncture headache (PDPH) because they cause less trauma to the dura by separating rather than cutting the fibers.

513
Q

What is a tactile feature of using a pencil-point needle in spinal anesthesia?

A) Resistance is felt throughout insertion

B) No sensation is felt when passing through tissues

C) A “click” or “pop” can be sensed as the needle passes through the dura

D) Continuous smooth passage with no feedback

A

Correct Answer: C. A “click” or “pop” can be sensed as the needle passes through the dura

Rationale:
When using a pencil-point needle, a distinct “click” or “pop” can be felt as the needle passes through the dura, providing tactile feedback to the anesthesiologist that the correct space has been reached​ (American Nurse)​​ (NYSORA)​.

514
Q

How do pencil-point needles minimize contamination during spinal anesthesia?

A) They have a built-in filter

B) They are coated with antibiotics

C) They drag fewer contaminants into subnormal tissue

D) They are used with a sterile sheath

A

Correct Answer: C. They drag fewer contaminants into subnormal tissue

Rationale:
Pencil-point needles are designed to drag fewer contaminants into subnormal tissue during insertion, reducing the risk of infection compared to cutting needles​ (American Nurse)​​ (NYSORA)​.

515
Q

What is the approximate failure rate associated with pencil-point needles in spinal anesthesia?

A) 1%

B) 3%

C) 5%

D) 10%

A

Correct Answer: C. 5%

Rationale:
Pencil-point needles are associated with a failure rate of about 5% in spinal anesthesia procedures​ (American Nurse)​​ (NYSORA)​.

516
Q

What is a key benefit of using pencil-point needles over cutting needles in terms of patient outcomes?

A) Lower cost

B) Reduced procedural time

C) Less post-procedural pain

D) Less than 1% risk of post-dural puncture headache (PDPH)

A

Correct Answer: D. Less than 1% risk of post-dural puncture headache (PDPH)

Rationale:
The use of pencil-point needles is associated with less than a 1% risk of post-dural puncture headache (PDPH), making them preferable for minimizing this common complication​ (American Nurse)​​ (NYSORA)​.

517
Q

What is the first step to be taken before initiating a spinal procedure?

A) Position the patient

B) Insert the spinal needle

C) Timeout to check ID, consent, allergies, and site

D) Sterile prep with 3 sponges

A

Correct Answer: C. Timeout to check ID, consent, allergies, and site

Rationale:
The first step before initiating a spinal procedure is to perform a timeout to verify the patient’s identity, consent, allergies, and the correct procedure site. This step ensures patient safety and compliance with protocols.

518
Q

What position is commonly used for the patient during a spinal procedure?

A) Supine

B) Mad cat

C) Prone

D) Trendelenburg

A

Correct Answer: B. Mad cat

Rationale:
The “Mad cat” position is commonly used during spinal procedures. This position involves the patient arching their back to help open the intervertebral spaces, making it easier to access the subarachnoid space.

519
Q

What should be done immediately after traversing the dura with the spinal needle?

A) Inject the local anesthetic

B) Withdraw the stylet and watch for CSF flow

C) Rotate the needle 360 degrees

D) Place the introducer

A

Correct Answer: B. Withdraw the stylet and watch for CSF flow

Rationale:
After traversing the dura, the stylet should be withdrawn, and the provider should watch for cerebrospinal fluid (CSF) flow to confirm correct placement of the needle in the subarachnoid space.

520
Q

Why is it important to rotate the needle 360 degrees during a spinal procedure?

A) To ensure even distribution of the local anesthetic

B) To verify the needle’s sharpness

C) To prevent contamination

D) To confirm proper placement by observing CSF flow

A

Correct Answer: D. To confirm proper placement by observing CSF flow

Rationale:
Rotating the needle 360 degrees helps ensure that the needle is correctly positioned within the subarachnoid space and allows for consistent observation of CSF flow, confirming proper placement.

521
Q

What is the purpose of laying the patient flat and repositioning the patient within the first 5 minutes after injecting the SAB local anesthetic?

A) To reduce the risk of hypotension

B) To enhance the onset of anesthesia

C) To prevent high spinal block

D) To allow for better absorption of the anesthetic

A

Correct Answer: C. To prevent high spinal block

Rationale: when Lying a patient flat the spinal can move as high as T6 so it is important to utilize semi-fowlers position to prevent a high spinal.

522
Q

What should be done if there is a weak flow CSF when spinning the needle 360 degrees during a spinal procedure?

A) Proceed with injecting the local anesthetic

B) Withdraw the needle slightly and try repositioning

C) Administer a higher dose of anesthetic

D) Advance the needle a little further

A

answer: D) Advance the needle a little further

523
Q

What is indicated by resistance during the injection of local anesthetic in a spinal procedure?

A) Correct placement of the needle

B) Needle blockage or misplacement

C) Adequate dose of anesthetic

D) High pressure in the subarachnoid space

A

Correct Answer: B. Needle blockage or misplacement

Rationale:
Resistance during the injection of local anesthetic indicates that the needle might be blocked or misplaced. It suggests that the needle may not be in the correct position, and adjustments are necessary.

524
Q

What should be done if paresthesia is felt by the patient during the spinal procedure?

A) Increase the dose of the anesthetic

B) Stop and remove needle

C) Continue with the injection

D) Reposition the patient

A

B) Stop and remove needle

525
Q

How should the “swirl” of SAB local anesthetic be checked?

A) At the beginning of the injection

B) Continuously throughout the injection

C) Halfway through the injection

D) At the end of the injection

A

C) Halfway through the injection

Rationale:
The “swirl” of the SAB local anesthetic should be checked halfway throughout or at various intervals throughout the injection to ensure proper mixing and distribution of the anesthetic within the cerebrospinal fluid, indicating correct needle placement.

526
Q

What is the purpose of the Tuohy needle in an epidural kit?

A) To inject medication into the bloodstream

B) To aspirate cerebrospinal fluid

C) To introduce the epidural catheter into the epidural space

D) To suture the insertion site

A

Correct Answer: C. To introduce the epidural catheter into the epidural space

Rationale:
The Tuohy needle, typically 17 or 18 gauge, is designed with a curved tip to facilitate the placement of an epidural catheter into the epidural space, which allows for continuous administration of anesthetics.

527
Q

Why is 1.5% lidocaine with 1:200,000 epinephrine used as a test dose in epidural anesthesia?

A) To provide long-lasting anesthesia

B) To test for correct placement and avoid intravascular injection

C) To reduce inflammation at the injection site

D) To promote quicker onset of anesthesia

A

Correct Answer: B. To test for correct placement and avoid intravascular injection

Rationale:
The combination of 1.5% lidocaine with 1:200,000 epinephrine is used as a test dose to help verify the correct placement of the catheter and to ensure the solution is not being administered intravascularly. The presence of epinephrine helps detect accidental intravascular injection by causing noticeable cardiovascular effects.

528
Q

What is the function of the loss of resistance syringe in the epidural kit?

A) To inject the local anesthetic into the epidural space

B) To confirm entry into the epidural space by detecting a loss of resistance

C) To measure the pressure in the epidural space

D) To aspirate cerebrospinal fluid

A

Correct Answer: B. To confirm entry into the epidural space by detecting a loss of resistance

Rationale:
The loss of resistance syringe, either plastic or glass, is used to confirm entry into the epidural space. When the needle enters the epidural space, there is a noticeable loss of resistance to injection, indicating correct placement.

529
Q

What is the role of the filter needle in the epidural kit?

A) To ensure accurate dosing

B) To prevent contamination

C) To remove particulate matter from the medication

D) To facilitate easier injection

A

Correct Answer: C. To remove particulate matter from the medication

Rationale:
The filter needle is used to remove any particulate matter from the medication before it is administered, ensuring that only a pure solution is injected.

530
Q

What is the primary advantage of using a Tuohy needle for epidural anesthesia?

A) It has the smallest gauge, reducing patient discomfort.

B) It has the most curvature, making it less likely to puncture the subarachnoid space.

C) It is the cheapest option available.

D) It provides the quickest onset of anesthesia.

A

Correct Answer: B. It has the most curvature, making it less likely to puncture the subarachnoid space.

Rationale:
The Tuohy needle, with its 30-degree curvature and blunt tip, is less likely to puncture the subarachnoid space. This makes it the most common needle used for epidural anesthesia.

531
Q

Which epidural needle is preferred for difficult catheter placement or when the angle is steep, such as in thoracic epidurals?

A) Tuohy

B) Hustead

C) Crawford

D) Weiss

A

Correct Answer: C. Crawford

Rationale:
The Crawford needle, which has 0 degrees of curvature, is preferred for difficult catheter placements or when the angle is steep, such as in thoracic epidurals. The straight design aids in navigating challenging anatomical conditions.

532
Q

What is the degree of curvature for the Hustead needle used in epidural anesthesia?

A) 0 degrees

B) 15 degrees

C) 30 degrees

D) 45 degrees

A

Correct Answer: B. 15 degrees

Rationale:
The Hustead needle has a 15-degree curvature, which is a moderate angle compared to the Tuohy needle’s 30-degree curvature and the Crawford needle’s 0 degrees.

533
Q

Which needle is described as having “wings” and a 15-degree curve?

A) Tuohy

B) Hustead

C) Crawford

D) Weiss

A

Correct Answer: D. Weiss

Rationale:
The Weiss needle is described as having a 15-degree curve and is unique for its “wings,” which aid in handling and stabilization during the procedure.

534
Q

What is a common characteristic of the Tuohy, Hustead, and Weiss needles that differentiates them from the Crawford needle?

A) They all have some degree of curvature.

B) They are all used exclusively for lumbar epidurals.

C) They are all single-use only.

D) They have a larger gauge than the Crawford needle.

A

Correct Answer: A. They all have some degree of curvature.

Rationale:
The Tuohy, Hustead, and Weiss needles all have some degree of curvature, which helps in guiding the catheter into the epidural space. In contrast, the Crawford needle has 0 degrees of curvature, making it straight.

535
Q

What gauge is typically used for an epidural needle styleted (typically a Touhy)?

A) 16 or 17 gauge

B) 17 or 18 gauge

C) 18 or 19 gauge

D) 19 or 20 gauge

A

Correct Answer: B. 17 or 18 gauge

Rationale:
Epidural needles are usually 17 or 18 gauge, providing the right balance between ease of insertion and maintaining a sufficient lumen for catheter placement.

536
Q

What does each mark on the epidural needle represent?

A) 0.5 cm

B) 1 cm

C) 2 cm

D) 1.5 cm

A

Correct Answer: B. 1 cm

Rationale:
Each mark on the epidural needle represents 1 cm, allowing the clinician to gauge the depth of needle insertion accurately.

537
Q

At what depth is the “window” on the epidural needle?

A) 12cm

B) 11cm

C) 10cm

D) 9cm

A

C) 10cm

538
Q

Why is the direction of the Tuohy needle opening important?

A) To ensure proper drug administration

B) To minimize patient discomfort

C) To avoid puncturing the subarachnoid space

D) To facilitate correct catheter placement

A

Correct Answer: D. To facilitate correct catheter placement

Rationale:
The direction of the Tuohy needle opening is crucial for proper catheter placement. The marker helps the clinician orient the needle correctly to guide the catheter into the epidural space effectively. (typically oriented cephalic)

539
Q

What is the function of the stylet in an epidural needle?

A) To administer the local anesthetic

B) To measure the pressure in the epidural space

C) To prevent the needle from becoming clogged

D) To help locate the epidural space

A

Correct Answer: C. To prevent the needle from becoming clogged

Rationale:
The stylet is used to prevent the epidural needle from becoming clogged with tissue or blood during insertion. It is removed once the needle is correctly positioned to allow for catheter placement or anesthetic administration.

540
Q

What is the optimal length/depth for placing an epidural catheter within the epidural space?

A) 1-2 cm

B) 2-4 cm

C) 3-5 cm

D) 4-6 cm

A

Correct Answer: C. 3-5 cm

Rationale:
The optimal length/depth for placing an epidural catheter within the epidural space is 3-5 cm. This ensures proper distribution of the anesthetic and minimizes the risk of catheter migration.

541
Q

What is a key advantage of using multi-orifice epidural catheters?

A) Lower cost compared to single-orifice catheters

B) Higher incidence of inadvertent intravascular placement

C) Better distribution of local anesthesia, leading to a lower incidence of inadequate anesthesia

D) Easier insertion

A

Correct Answer: C. Better distribution of local anesthesia, leading to a lower incidence of inadequate anesthesia

Rationale:
Multi-orifice epidural catheters provide better distribution of local anesthesia, which reduces the incidence of inadequate anesthesia and ensures more effective pain relief.

542
Q

What is a potential downside of using multi-orifice epidural catheters?

A) Higher cost

B) Increased risk of breakage

C) Higher incidence of inadvertent intravascular placement

D) More difficult to insert

A

Correct Answer: C. Higher incidence of inadvertent intravascular placement

Rationale:
Multi-orifice epidural catheters have a higher incidence of inadvertent intravascular placement compared to single-orifice catheters, which can complicate the procedure and potentially cause complications.

543
Q

Why are coil-reinforced catheters often preferred?

A) They are more expensive

B) They are easier to see on imaging

C) They are stronger and less likely to shear when removed or placed

D) They provide faster onset of anesthesia

A

Correct Answer: C. They are stronger and less likely to shear when removed or placed

Rationale:
Coil-reinforced catheters are stronger and less likely to shear when removed or placed, providing added safety and reliability during epidural procedures.

544
Q

What is the purpose of using catheters with softer tips?

A) To reduce the cost of the catheter

B) To decrease the risk of inadvertent subarachnoid block (SAB) placement

C) To enhance the speed of catheter insertion

D) To improve patient comfort

A

Correct Answer: B. To decrease the risk of inadvertent subarachnoid block (SAB) placement

Rationale:
Catheters with softer tips help reduce the risk of inadvertent subarachnoid block (SAB) placement, enhancing the safety and accuracy of the epidural procedure.

545
Q

What is a characteristic of plastic epidural catheters that makes them easier to use?

A) More flexible

B) Easier to thread

C) Higher cost

D) Less risk of inadvertent SAB puncture

A

Correct Answer: B. Easier to thread

Rationale:
Plastic epidural catheters are stiffer than other types, making them easier to thread through the epidural needle and into the epidural space.

546
Q

What is a potential risk associated with using plastic epidural catheters?

A) Lower efficacy of anesthesia

B) Increased incidence of infections

C) Possibility of inadvertent subarachnoid block (SAB) puncture

D) Higher cost

A

Correct Answer: C. Possibility of inadvertent subarachnoid block (SAB) puncture

Rationale:
Plastic epidural catheters are stiffer, which can sometimes lead to inadvertent puncture of the subarachnoid space (SAB), potentially causing complications.

547
Q

Why might plastic epidural catheters be preferred in some clinical settings?

A) They provide a longer duration of anesthesia

B) They are less likely to break

C) They are less expensive

D) They have a softer tip

A

Correct Answer: C. They are less expensive

Rationale:
Plastic epidural catheters are generally less expensive than other types, making them a cost-effective choice in various clinical settings.

548
Q

Which feature of plastic epidural catheters can be a disadvantage during insertion?

A) Increased flexibility

B) Higher cost

C) Stiffer structure

D) Lower visibility under imaging

A

Correct Answer: C. Stiffer structure

Rationale:
The stiffer structure of plastic epidural catheters, while making them easier to thread, can also be a disadvantage as it increases the risk of inadvertent subarachnoid puncture.

549
Q

How do you determine the distance from the skin to the epidural space using the epidural needle?

A) Measure the visible length of the needle and multiply by 2

B) Measure the visible length of the needle and subtract it from the total length of the needle

C) Measure the total length of the needle and add the visible length

D) Measure the total length of the needle and subtract half of the visible length

A

Correct Answer: B. Measure the visible length of the needle and subtract it from the total length of the needle

Rationale:
To determine the distance from the skin to the epidural space, you measure the visible length of the needle outside the skin and subtract this from the total length of the needle. This gives the depth at which the epidural space is located.

550
Q

What is the optimal epidural catheter depth in the epidural space?

A) 1-2 cm

B) 2-4 cm

C) 3-5 cm

D) 4-6 cm

A

Correct Answer: C. 3-5 cm

Rationale:
The optimal epidural catheter depth in the epidural space is 3-5 cm. This ensures effective distribution of the anesthetic and reduces the risk of the catheter migrating out of the epidural space.

551
Q

If the total length of the epidural needle is 9 cm and 4 cm of the needle is visible after reaching the epidural space, what is the distance from the skin to the epidural space?

A) 3 cm

B) 4 cm

C) 5 cm

D) 6 cm

A

Correct Answer: C. 5 cm

Rationale:
If the total length of the needle is 9 cm and 4 cm is visible, the distance from the skin to the epidural space is 5 cm (9 cm - 4 cm = 5 cm).

552
Q

How should the epidural catheter be secured at the skin if the depth to the epidural space is 5 cm and the optimal catheter depth is also 5 cm?

A) At 8 cm

B) At 9 cm

C) At 10 cm

D) At 11 cm

A

Correct Answer: C. At 10 cm

Rationale:
The catheter should be secured at 10 cm at the skin (5 cm depth to the epidural space + 5 cm optimal catheter depth = 10 cm).

553
Q

Why is the epidural space considered a potential space?

A) It is always filled with cerebrospinal fluid

B) It can be expanded to accommodate the catheter and injectate

C) It is a solid space filled with tissue

D) It cannot change its volume or accommodate any additional material

A

Correct Answer: B. It can be expanded to accommodate the catheter and injectate

Rationale:
The epidural space is considered a potential space because it can be expanded to accommodate the catheter and the injectate (e.g., anesthetic solution) during the epidural procedure. The concept of “loss of resistance” is used to identify this space during the procedure.

554
Q

What is the main concern associated with performing an epidural on a patient with a lumbar tattoo?

A) Increased risk of infection

B) Potential for tattoo ink to be carried into the spine causing inflammation (chemical arachnoiditis)

C) Difficulty in needle insertion

D) Prolonged procedure time

A

Correct Answer: B. Potential for tattoo ink to be carried into the spine causing inflammation (chemical arachnoiditis)

Rationale:
The primary concern with performing an epidural through a lumbar tattoo is the risk of tattoo ink being carried into the spine, which could potentially cause inflammation known as chemical arachnoiditis.

555
Q

What has been the general outcome of cases reported since the 2002 article regarding epidurals performed on patients with lumbar tattoos?

A) Increased neurological complications

B) Higher infection rates

C) Most cases have shown no neurological problems

D) Shorter duration of anesthesia

A

Correct Answer: C. Most cases have shown no neurological problems

Rationale:
Since the 2002 report, most cases have demonstrated that epidurals performed on patients with lumbar tattoos do not cause neurological problems.

556
Q

What is one of the recommendations for performing an epidural on a patient with a lumbar tattoo?

A) Always avoid the tattooed area

B) Ensure the tattoo is more than 2 years old

C) Try to avoid placing the needle through tattooed skin and, if needed, avoid “nicking” the skin

D) Use only a specific type of needle

A

Correct Answer: C. Try to avoid placing the needle through tattooed skin and, if needed, avoid “nicking” the skin

Rationale:
It is recommended to try to avoid placing the needle through tattooed skin, and if it is necessary, to avoid “nicking” the skin to reduce the risk of ink being carried into the epidural space.

557
Q

For safety, when is it best to perform an epidural in relation to the time of tattoo application?

A) Immediately after tattoo application

B) 1 month after tattoo application

C) 3 months after tattoo application

D) 5 months after tattoo application

A

Correct Answer: D. 5 months after tattoo application

Rationale:
It is recommended to wait at least 5 months after the application of a tattoo before performing an epidural to ensure the skin has adequately healed and to reduce the risk of complications.

558
Q

What is the correct orientation of the bevel opening of the Tuohy needle when performing an epidural procedure?

A) Downward

B) Upward

C) Lateral

D) Medial

A

Correct Answer: B. Upward

Rationale:
The Tuohy needle’s bevel opening should be pointed upward (cephalad) during an epidural procedure to facilitate the correct placement of the catheter and to ensure optimal anesthetic distribution.

559
Q

Why is a test dose of 1.5% lidocaine with epinephrine used during an epidural procedure?

A) To provide immediate anesthesia

B) To ensure the catheter is not placed intrathecally or intravascularly

C) To increase the duration of anesthesia

D) To decrease patient discomfort

A

Correct Answer: B. To ensure the catheter is not placed intrathecally or intravascularly (3cc)

Rationale:
The test dose with 1.5% lidocaine and epinephrine is used to ensure that the epidural catheter is not inadvertently placed in the intrathecal or intravascular space. The presence of epinephrine helps detect unintentional vascular injection by causing noticeable cardiovascular effects.

560
Q

What important numbers should be recorded during an epidural procedure?

A) Blood pressure and heart rate

B) Total volume of anesthetic administered

C) Depth to the epidural space, catheter marking at the skin, and catheter depth/length in the epidural space

D) Patient’s weight and height

A

Correct Answer: C. Depth to the epidural space, catheter marking at the skin, and catheter depth/length in the epidural space

Rationale:
It is essential to record the depth to the epidural space (distance from the skin to the epidural space), the catheter marking at the skin, and the catheter depth/length in the epidural space to ensure accurate placement and securement of the catheter.

561
Q

What differentiates an epidural procedure from a spinal procedure?

A) The type of anesthetic used

B) The use of the Tuohy needle

C) The application of a test dose

D) The position of the patient

A

Correct Answer: C. The application of a test dose

Rationale:
One significant difference between an epidural and a spinal procedure is the application of a test dose in the epidural procedure to ensure proper catheter placement and to prevent inadvertent intrathecal or intravascular injection.

562
Q

What are two methods used to identify the epidural space?

A) Digital palpation and ultrasound guidance

B) Loss of resistance (LOR) and hanging drop method

C) MRI and CT scan

D) Fluoroscopy and X-ray

A

Correct Answer: B. Loss of resistance (LOR) and hanging drop method

Rationale:
The two common methods to identify the epidural space are the loss of resistance (LOR) technique, which uses air, saline, or both, and the hanging drop method, where a drop of saline is placed at the needle hub and the needle is advanced until the drop is sucked in by negative pressure.

563
Q

How is the hanging drop method performed?

A) By injecting air into the epidural space and observing the resistance

B) By placing a saline drop at the needle hub and advancing the needle until the drop is sucked into the needle

C) By using ultrasound to visualize the epidural space

D) By palpating the spine and identifying the epidural space manually

A

Correct Answer: B. By placing a saline drop at the needle hub and advancing the needle until the drop is sucked into the needle

Rationale:
In the hanging drop method, a saline drop is placed at the hub of the needle, and the needle is advanced without a syringe. The epidural space is identified when the drop is “sucked” into the needle due to negative atmospheric pressure.

564
Q

Why might the hanging drop method be considered less precise?

A) It requires additional equipment

B) It is dependent on the patient’s position

C) It relies on the negative atmospheric pressure, which can vary

D) It requires the use of air instead of saline

A

Correct Answer: C. It relies on the negative atmospheric pressure, which can vary

Rationale:
The hanging drop method is considered less precise because it relies on the negative atmospheric pressure to draw the saline drop into the needle, and this pressure can vary, making it less reliable compared to other methods.

565
Q

What is a key difference between the hanging drop method and the loss of resistance technique?

A) The hanging drop method uses a syringe, while the LOR technique does not

B) The hanging drop method is more precise than the LOR technique

C) The hanging drop method relies on visual observation, while the LOR technique relies on tactile feedback

D) The hanging drop method uses air, while the LOR technique uses saline

A

Correct Answer: C. The hanging drop method relies on visual observation, while the LOR technique relies on tactile feedback

Rationale:
The hanging drop method relies on visual observation of the saline drop being sucked into the needle due to negative pressure. In contrast, the LOR technique relies on tactile feedback when advancing the needle and feeling the loss of resistance.

566
Q

What is the primary purpose of administering a test dose during an epidural procedure?

A) To provide immediate pain relief

B) To identify unintentional intravascular or subarachnoid placement

C) To reduce the risk of infection

D) To confirm the patient’s identity

A

Correct Answer: B. To identify unintentional intravascular or subarachnoid placement

Rationale:
The test dose is used to detect unintentional intravascular or subarachnoid placement of the epidural catheter, which can prevent serious complications by allowing for immediate corrective action.

567
Q

What composition is typically used for the epidural test dose?

A) 3 mL of 0.5% bupivacaine with epinephrine

B) 3 mL of 2% lidocaine without epinephrine

C) 3 mL of 1.5% lidocaine mixed with epinephrine (1:200,000)

D) 3 mL of 0.25% ropivacaine with epinephrine

A

Correct Answer: C. 3 mL of 1.5% lidocaine mixed with epinephrine (1:200,000)

Rationale:
The typical composition of the epidural test dose is 3 mL of 1.5% lidocaine mixed with epinephrine (1:200,000). This combination helps identify intravascular or subarachnoid placement through noticeable physiological responses.

568
Q

What is an indicator of accidental intravascular placement of the epidural catheter?

A) A sudden decrease in heart rate

B) A jump in heart rate by 20% or more

C) Onset of mild sedation

D) A decrease in blood pressure

A

Correct Answer: B. A jump in heart rate by 20% or more

Rationale:
A jump in heart rate by 20% or more after administering the test dose indicates probable intravascular placement, necessitating the replacement of the catheter to avoid complications.

569
Q

What symptom indicates an accidental spinal injection during an epidural procedure?

A) Mild headache within 10 minutes

B) Dense motor block within 5 minutes of a test dose

C) Gradual increase in heart rate

D) Nausea and vomiting

A

Correct Answer: B. Dense motor block within 5 minutes of a test dose

Rationale:
A dense motor block within 5 minutes of administering the test dose is indicative of an accidental spinal injection, which requires immediate attention and replacement of the catheter.

570
Q

When should the test dose be administered in pregnant women to obtain clearer results?

A) Before labor begins

B) During a contraction

C) After a contraction ends

D) After delivery

A

Correct Answer: C. After a contraction ends

Rationale:
In pregnant women, the test dose should be administered after a contraction ends to obtain clearer results and avoid misinterpreting physiological changes caused by the contraction.

Patients on Heart Medications: A big increase in blood pressure (>20 mm Hg) could also mean the needle is in a blood vessel.

571
Q

If a lumbar epidural is started at L4-L5, how many mL of anesthetic are needed to reach the T10 level for surgery?

A) 2-4 mL

B) 4-6 mL

C) 6-12 mL

D) 12-18 mL

A

Correct Answer: C. 6-12 mL

Rationale:
To achieve anesthesia up to the T10 level from an epidural started at L4-L5, 6 segments need to be covered (L3, L2, L1, T12, T11, T10). We consider starting at L4 and do not count that level. The recommended dose is 1-2 mL per segment, totaling 6-12 mL.

572
Q

How should the initial dose of epidural anesthetic be administered?

A) All at once

B) In 10 mL increments

C) In 5 mL increments with aspiration checks in between

D) In 1 mL increments

A

Correct Answer: C. In 5 mL increments with aspiration checks in between

Rationale:
The initial dose should be administered in 5 mL increments, with aspiration for blood or CSF between doses to ensure the catheter is not intravascular or intrathecal.

573
Q

What is the purpose of giving a “top-up” dose before “two-segment regression”?

A) To reduce the patient’s pain

B) To maintain adequate anesthesia

C) To decrease the risk of infection

D) To ensure the catheter is properly placed

A

Correct Answer: B. To maintain adequate anesthesia

Rationale:
The “top-up” dose is given before two-segment regression occurs to maintain adequate anesthesia levels and prevent the block from becoming inadequate.

574
Q

What is the recommended practice for monitoring the patient after an initial epidural dose is administered?

A) Monitor for 10 minutes

B) Monitor for 30 minutes

C) Allow the patient to leave immediately

D) Only monitor if there are complications

A

Correct Answer: B. Monitor for 30 minutes

Rationale:
Best practice includes closely monitoring the patient for 30 minutes after administering the initial dose to check for hypotension and unexpected dermatome spread.

575
Q

What should be done if a significant increase in blood pressure (>20 mm Hg) is observed after administering the epidural test dose in a patient on heart medications?

A) Continue with the procedure as planned

B) Administer an additional test dose

C) Consider that the needle may be in a blood vessel and reassess placement

D) Ignore the increase in blood pressure

A

Correct Answer: C. Consider that the needle may be in a blood vessel and reassess placement

Rationale:
A significant increase in blood pressure after administering the test dose may indicate intravascular placement, especially in patients on heart medications. It is essential to reassess the placement of the needle.

576
Q

What is the recommended “top-up” time for lidocaine from the initial dose during an epidural procedure?

A) 45 minutes

B) 60 minutes

C) 90 minutes

D) 120 minutes

A

Correct Answer: B. 60 minutes

Rationale:
The recommended “top-up” time for lidocaine is 60 minutes from the initial dose to maintain adequate anesthesia.

577
Q

How long after the initial dose should a “top-up” dose of bupivacaine be administered?

A) 45 minutes

B) 60 minutes

C) 90 minutes

D) 120 minutes

A

Correct Answer: D. 120 minutes

Rationale:
Bupivacaine and ropivacaine have longer durations of action, with a recommended “top-up” time of 120 minutes from the initial dose.

578
Q

Which local anesthetic has the shortest recommended “top-up” time from the initial dose?

A) Lidocaine

B) 2-Chloroprocaine

C) Mepivacaine

D) Bupivacaine

A

Correct Answer: B. 2-Chloroprocaine

Rationale:
2-Chloroprocaine has the shortest recommended “top-up” time of 45 minutes from the initial dose, making it the fastest-acting among the listed anesthetics.

579
Q

For maintaining an epidural, what are the two primary methods of dosing?

A) Continuous infusion and bolus dose

B) Continuous infusion and intermittent dosing

C) Bolus dose and single large dose

D) Single large dose and intermittent dosing

A

Correct Answer: A. Continuous infusion and bolus dose

Rationale:
The two primary methods of maintaining an epidural are through continuous infusion or bolus dosing, which helps manage and sustain the anesthesia level.

580
Q

What is the recommended “top-up” time for mepivacaine from the initial dose during an epidural procedure?

A) 45 minutes

B) 60 minutes

C) 90 minutes

D) 120 minutes

A

Correct Answer: B. 60 minutes

Rationale:
The recommended “top-up” time for mepivacaine is 60 minutes from the initial dose, similar to lidocaine, to maintain adequate anesthesia.

581
Q

What is a common complication encountered during epidural procedures characterized by the accidental puncture of the dura mater?

A) Paresthesia

B) Positive test dose

C) CSF “wet tap”

D) Aspiration of blood

A

Correct Answer: C. CSF “wet tap”

Rationale:
A CSF “wet tap” occurs when the epidural needle punctures the dura mater, causing cerebrospinal fluid to leak into the epidural space.

582
Q

What should be done if blood is aspirated during the epidural procedure?

A) Proceed with the injection

B) Stop and replace catheter to new position or intervertebral level

C) Increase the dose of anesthetic

D) Ignore and continue with the procedure

A

B) Stop and replace catheter to new position or intervertebral level

Rationale:
Aspirating blood indicates that the needle is in a blood vessel.

583
Q

What could cause a “false” positive test dose during an epidural procedure?

A) Injecting during a contraction

B) Using saline instead of air

C) Incorrect needle placement

D) Aspiration of CSF

A

Correct Answer: A. Injecting during a contraction

Rationale:
Injecting during a contraction can cause a temporary increase in heart rate, leading to a “false” positive test dose.

584
Q

What is a sign that the epidural catheter might be against the plica or not in the epidural space?

A) Can’t thread catheter

B) CSF “wet tap”

C) Resistance with injection

D) Paresthesia

A

A) Can’t thread catheter

585
Q

What is the first step in locating the epidural space during a combined spinal-epidural (CSE) procedure?

A. Use the spinal needle to find the epidural space.
B. Use the Tuohy needle to find the epidural space and use loss of resistance (LOR) technique.
C. Use a syringe to inject saline into the epidural space.
D. Use an introducer needle to find the epidural space

A

Answer: B. Use the Tuohy needle to find the epidural space and use loss of resistance (LOR) technique.

Rationale: The Tuohy needle is specifically designed to find the epidural space using the loss of resistance (LOR) technique, which helps to ensure accurate placement of the needle in the epidural space.

586
Q

After locating the epidural space with the Tuohy needle, what is the next step in the CSE procedure?

A. Inject the spinal anesthetic through the Tuohy needle.
B. Introduce the spinal needle through the Tuohy needle and advance it until a “pop” is felt.
C. Thread the epidural catheter through the Tuohy needle.
D. Remove the Tuohy needle and insert the spinal needle directly.

A

Answer: B. Introduce the spinal needle through the Tuohy needle and advance it until a “pop” is felt.

Rationale: The “pop” sensation indicates that the spinal needle has punctured the dura, which is a critical step before injecting the spinal anesthetic.

587
Q

What should be done after the spinal needle punctures the dura and before injecting the spinal anesthetic?

A. Thread the epidural catheter through the Tuohy needle.
B. Inject saline to confirm the placement.
C. Remove the stylet from the spinal needle to observe cerebrospinal fluid (CSF) flow.
D. Pull back the spinal needle slightly.

A

Answer: C. Remove the stylet from the spinal needle to observe cerebrospinal fluid (CSF) flow.

Rationale: Observing CSF flow confirms that the spinal needle is correctly placed in the subarachnoid space, ensuring safe injection of the spinal anesthetic.

588
Q

What follows the injection of the spinal anesthetic/analgesic in the CSE procedure?

A. Remove the Tuohy needle and insert the spinal needle directly.
B. Thread the epidural catheter through the Tuohy needle.
C. Inject more anesthetic through the Tuohy needle.
D. Withdraw the spinal needle completely.

A

Answer: B. Thread the epidural catheter through the Tuohy needle.

Rationale: After injecting the spinal anesthetic, the next step is to thread the epidural catheter through the Tuohy needle to establish continuous epidural anesthesia.

589
Q

Why is it important to perform the CSE procedure quickly after injecting the spinal anesthetic?

A. To prevent the patient from experiencing pain.
B. To ensure the spinal anesthetic does not set up in the sacral area without spreading cephalad.
C. To allow time for the anesthetic to take effect.
D. To minimize the risk of infection.

A

Answer: B. To ensure the spinal anesthetic does not set up in the sacral area without spreading cephalad.

Rationale: Performing the procedure quickly helps ensure the anesthetic spreads appropriately within the subarachnoid space to provide effective anesthesia.

590
Q

What potential issue should be monitored for when threading the epidural catheter during a CSE procedure?

A. Ensuring the catheter does not get contaminated.
B. Ensuring the catheter does not enter the dural puncture site.
C. Ensuring the catheter does not bend.
D. Ensuring the catheter is placed deeply enough.

A

Answer: B. Ensuring the catheter does not enter the dural puncture site.

Rationale: If the catheter enters the dural puncture site, it can cause complications such as an unintentional subarachnoid block or other issues with the delivery of anesthesia.