Principles- Spinal/Epidural Flashcards

Question

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

Answer 1

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

Answer 2

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.

Answer 3

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

Answer 4

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.

Answer 5

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

Answer 6

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.

Answer 7

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.

Answer 8

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.

Answer 9

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.

Answer 10

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

Answer 11

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.

Answer 12

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.

Answer 13

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.

Answer 14

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.

Answer 15

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.

Answer 16

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.

Answer 17

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.

Answer 18

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.

Answer 19

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.

Answer 20

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.

Answer 21

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.

Answer 22

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.

Answer 23

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.

Answer 24

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).

Answer 25

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.

Answer 26

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

Answer 27

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.

Answer 28

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.

Answer 29

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.

Answer 30

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.

Answer 31

Correct Answer: B) Pedicle and lamina Rationale: The pedicle and lamina link the anterior and posterior segments of a vertebra, forming the vertebral arch.

Answer 32

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.

Answer 33

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.

Answer 34

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.

Answer 35

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

Answer 36

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.

Answer 37

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.

Answer 38

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.

Answer 39

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.

Answer 40

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.

Answer 41

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.

Answer 42

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.

Answer 43

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.

Answer 44

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.

Answer 45

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.

Answer 46

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.

Answer 47

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.

Answer 48

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.

Answer 49

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.

Answer 50

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.

Answer 51

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.

Answer 52

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.

Answer 53

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.

Answer 54

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.

Answer 55

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.

Answer 56

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.

Answer 57

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.

Answer 58

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.

Answer 59

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

Answer 60

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.

Answer 61

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.

Answer 62

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).

Answer 63

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.

Answer 64

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.

Answer 65

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.

Answer 66

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.

Answer 67

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.

Answer 68

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.

Answer 69

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.

Answer 70

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.

Answer 71

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

Answer 72

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.

Answer 73

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.

Answer 74

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).

Answer 75

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.

Answer 76

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.

Answer 77

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.

Answer 78

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.

Answer 79

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).

Answer 80

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.

Answer 81

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.

Answer 82

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.

Answer 83

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.

Answer 84

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.

Answer 85

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).

Answer 86

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.

Answer 87

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.

Answer 88

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.

Answer 89

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.

Answer 90

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.

Answer 91

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.

Answer 92

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.

Answer 93

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.

Answer 94

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.

Answer 95

Correct Answer: C) Ligamentum flavum Rationale: Piercing the ligamentum flavum indicates entry into the epidural space during a spinal procedure.

Answer 96

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.

Answer 97

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.

Answer 98

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.

Answer 99

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.

Answer 100

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.

Answer 101

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.

Answer 102

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.

Answer 103

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.

Answer 104

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.

Answer 105

Correct Answer: B) Posterior longitudinal ligament Rationale: The anterior border of the epidural space is lined by the posterior longitudinal ligament along the vertebrae.

Answer 106

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.

Answer 107

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).

Answer 108

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.

Answer 109

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.

Answer 110

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.

Answer 111

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.

Answer 112

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.

Answer 113

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.

Answer 114

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

Answer 115

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

Answer 116

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

Answer 117

Answer: C. Plica mediana dorsalis

Answer 118

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

Answer 119

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.

Answer 120

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.

Answer 121

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.

Answer 122

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.

Answer 123

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.

Answer 124

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.

Answer 125

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.

Answer 126

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.

Answer 127

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.

Answer 128

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

Answer 129

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.

Answer 130

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.

Answer 131

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

Answer 132

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.

Answer 133

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

Answer 134

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.

Answer 135

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.

Answer 136

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

Answer 137

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.

Answer 138

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.

Answer 139

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.

Answer 140

Correct Answer: a) S2-S5 Rationale: The dermatome level S2-S5 is targeted for peri-anal or anal surgery, known as a "saddle block."

Answer 141

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

Answer 142

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

Answer 143

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).

Answer 144

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.

Answer 145

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.

Answer 146

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.

Answer 147

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.

Answer 148

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.

Answer 149

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.

Answer 150

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.

Answer 151

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

Answer 152

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.

Answer 153

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.

Answer 154

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

Answer 155

Correct Answer: b) Mostly spreads cephalad Rationale: In the lumbar region, the local anesthetic mostly spreads cephalad.

Answer 156

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

Answer 157

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

Answer 158

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

Answer 159

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

Answer 160

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

Answer 161

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

Answer 162

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.

Answer 163

e) both b & d rationale: sensory blockade occurs at a lower concentration than that of a motor blockade and autonomic at even lower concentrations.

Answer 164

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.

Answer 165

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.

Answer 166

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.

Answer 167

Correct Answer: b) 2 levels Rationale: The sensory block level is 2 levels higher than the motor block level.

Answer 168

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

Answer 169

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

Answer 170

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

Answer 171

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.

Answer 172

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.

Answer 173

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

Answer 174

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.

Answer 175

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

Answer 176

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

Answer 177

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.

Answer 178

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

Answer 179

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

Answer 180

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

Answer 181

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.

Answer 182

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.

Answer 183

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.

Answer 184

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

Answer 185

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.

Answer 186

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.

Answer 187

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.

Answer 188

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)

Answer 189

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.

Answer 190

Correct Answer: c) Young adults Rationale: Sudden cardiac arrest can be seen in young adults with high parasympathetic tone.

Answer 191

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

Answer 192

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

Answer 193

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.

Answer 194

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.

Answer 195

Correct Answer: b) They constrict blood vessels to maintain blood pressure Rationale: Vasopressors like phenylephrine help maintain blood pressure by constricting blood vessels.

Answer 196

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.

Answer 197

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.

Answer 198

Correct Answer: b) They can overload the circulatory system Rationale: Excessive fluid can overload the circulatory system, especially in patients with heart problems.

Answer 199

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

Answer 200

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.

Answer 201

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

Answer 202

Correct Answer: c) Treatment of bradycardia Rationale: Atropine may be used if the patient is experiencing bradycardia.

Answer 203

Correct Answer: a) Crystalloids Rationale: Crystalloids should be administered first to maintain adequate blood volume.

Answer 204

Correct Answer: b) They can cause renal issues Rationale: Colloids can cause renal issues and should be used cautiously.

Answer 205

Correct Answer: b) Reduced cerebral perfusion Rationale: Using a >20-degree tilt can reduce cerebral perfusion because the tilt can reduce venous brain drainage.

Answer 206

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.

Answer 207

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.

Answer 208

Correct Answer: c) Expiratory reserve volume (ERV) Rationale: The loss of abdominal muscle contribution in forced expiration results in a decrease in ERV.

Answer 209

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.

Answer 210

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.

Answer 211

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)

Answer 212

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.

Answer 213

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

Answer 214

Correct Answer: b) Satiety, distension, and nausea Rationale: Parasympathetic afferent fibers transmit sensations of satiety, distension, and nausea.

Answer 215

Correct Answer: c) Promote tonic contractions, sphincter relaxation, peristalsis, and secretion Rationale: Parasympathetic efferent fibers promote tonic contractions, sphincter relaxation, peristalsis, and secretion.

Answer 216

Correct Answer: c) T5-L2 Rationale: Sympathetic innervation of the GI tract stems from T5-L2.

Answer 217

Correct Answer: a) Transmit visceral pain Rationale: Sympathetic afferent fibers in the GI tract transmit visceral pain.

Answer 218

Correct Answer: b) T8 Rationale: The sympathetic innervation of the stomach originates from the T8 spinal level.

Answer 219

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

Answer 220

Correct Answer: b) Reduces sympathetic tone Rationale: Local anesthetics used in neuraxial blocks decrease the activity of sympathetic nerves, thereby reducing sympathetic tone.

Answer 221

Correct Answer: b) Increases Rationale: With less sympathetic inhibition, the parasympathetic system becomes more dominant, leading to increased parasympathetic activity.

Answer 222

Correct Answer: c) Relaxation of sphincters Rationale: Unopposed vagal tone results in the relaxation of sphincters.

Answer 223

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

Answer 224

Correct Answer: c) As a result of increased parasympathetic activity Rationale: Increased parasympathetic activity leads to increased peristalsis in the GI tract.

Answer 225

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.

Answer 226

Correct Answer: c) Mean arterial pressure (MAP) Rationale: No change in renal blood flow occurs when MAP is maintained.

Answer 227

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

Answer 228

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

Answer 229

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.

Answer 230

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.

Answer 231

Correct Answer: b) Decreases contraction Rationale: Neuraxial anesthesia decreases detrusor muscle contraction.

Answer 232

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.

Answer 233

Correct Answer: b) It partially suppresses the neuroendocrine response Rationale: Neuraxial blockade can partially suppress the neuroendocrine response during major invasive surgery.

Answer 234

Correct Answer: b) Lower extremity surgery Rationale: Neuraxial blockade can totally block the neuroendocrine response in lower extremity surgeries.

Answer 235

Correct Answer: c) Before the surgical stimulus Rationale: Maximal benefits occur if the neuraxial blockade occurs before the surgical stimulus.

Answer 236

Correct Answer: b) Renin-angiotensin-aldosterone system Rationale: Elevated levels of these hormones activate the renin-angiotensin-aldosterone system.

Answer 237

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.

Answer 238

Correct Answer: c) Aromatic ring Rationale: The aromatic ring is the lipophilic portion of the local anesthetic molecule.

Answer 239

Correct Answer: c) Cocaine Rationale: Cocaine is an ester local anesthetic that is also metabolized by the liver.

Answer 240

Correct Answer: b) Para-aminobenzoic acid (PABA) Rationale: Ester local anesthetics produce para-aminobenzoic acid (PABA), which can cause allergic reactions.

Answer 241

Correct Answer: b) Esters Rationale: Allergic reactions are more commonly associated with ester local anesthetics.

Answer 242

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.

Answer 243

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.

Answer 244

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.

Answer 245

Correct Answer: d) Weak bases Rationale: Local anesthetic agents are weak bases.

Answer 246

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.

Answer 247

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.

Answer 248

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.

Answer 249

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.

Answer 250

Correct Answer: c) Intravenous Rationale: Intravenous injection of local anesthetics results in the highest blood concentrations.

Answer 251

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.

Answer 252

Correct Answer: d) Sciatic Rationale: Sciatic injections result in lower blood concentrations of local anesthetic compared to paracervical injections.

Answer 253

b) It has better safety profile Safer than bupivicaine, must be injected in vein.

Answer 254

Correct Answer: b) Subcutaneous Rationale: Subcutaneous injection results in the lowest blood concentrations of local anesthetic due to slower absorption.

Answer 255

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).

Answer 256

Correct Answer: c) Isobaric Rationale: An isobaric solution has a baricity of 1, meaning its density matches that of CSF.

Answer 257

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.

Answer 258

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.

Answer 259

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.

Answer 260

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.

Answer 261

Correct Answer: b) C3 and L3 Rationale: The highest points in the spinal column for hyperbaric solutions are C3 and L3.

Answer 262

Correct Answer: c) T6 and S2 Rationale: The lowest points in the spinal column for hyperbaric solutions are T6 and S2.

Answer 263

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)

Answer 264

Correct Answer: b) Bupivacaine Rationale: Bupivacaine has a duration of 130-220 minutes without epinephrine, which is longer than the other local anesthetics listed.

Answer 265

Correct Answer: c) Vascular reabsorption Rationale: Local anesthetics are eliminated by reuptake through vascular reabsorption, primarily via vessels in the pia mater.

Answer 266

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.

Answer 267

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.

Answer 268

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.

Answer 269

Correct Answer: d) 140-230 minutes Rationale: According to the table, levobupivacaine has a duration of action of 140-230 minutes without epinephrine.

Answer 270

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.

Answer 271

Correct Answer: c) 3-8 minutes Rationale: The onset time for ropivacaine is 3-8 minutes according to the table.

Answer 272

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.

Answer 273

Correct Answer: d) Increases by 20-50% Rationale: Adding epinephrine to bupivacaine increases its duration of action by 20-50%.

Answer 274

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.

Answer 275

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.

Answer 276

Correct Answer: b) 80-210 minutes Rationale: Ropivacaine has a duration of action of 80-210 minutes without epinephrine according to the table.

Answer 277

Correct Answer: c) 5 mL

Answer 278

Correct Answer: d) Increasing the duration of anesthesia

Answer 279

Correct Answer: c) 10-25 minutes

Answer 280

Correct Answer: b) Epinephrine

Answer 281

Correct Answer: c) Cardiac arrest

Answer 282

Correct Answer: c) Both cephalad and caudad

Answer 283

Correct Answer: b) To minimize the risk of local anesthetic systemic toxicity

Answer 284

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.

Answer 285

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.

Answer 286

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.

Answer 287

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.

Answer 288

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.

Answer 289

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

Answer 290

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.

Answer 291

Correct Answer: b) 1 mEq Rationale: The typical amount of NaHCO3 added to 10 mL of local anesthetic for alkalinization is 1 mEq.

Answer 292

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

Answer 293

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.

Answer 294

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.

Answer 295

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.

Answer 296

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.

Answer 297

Correct Answer: b) Bupivacaine & d) Levobupivacaine

Answer 298

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.

Answer 299

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.

Answer 300

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.

Answer 301

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.

Answer 302

Correct Answer: d) Epinephrine Rationale: Epinephrine is listed as a vasopressor, not as an investigative agent. Investigative agents include neostigmine, magnesium, ketamine, and versed.

Answer 303

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.

Answer 304

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.

Answer 305

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.

Answer 306

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.

Answer 307

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.

Answer 308

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.

Answer 309

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.

Answer 310

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.

Answer 311

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.

Answer 312

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.

Answer 313

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.

Answer 314

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.

Answer 315

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.

Answer 316

Correct Answer: d) Morphine Rationale: Morphine is administered intrathecally at doses of 0.25 - 0.30 mg for effective pain relief.

Answer 317

Correct Answer: b) 25 - 100 mcg/hr Rationale: Fentanyl, when used as an epidural infusion, is typically dosed at 25 - 100 mcg/hr.

Answer 318

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.

Answer 319

Correct Answer: b) Fentanyl Rationale: According to the slide, fentanyl's intrathecal dose range is 10-20 mcg.

Answer 320

Correct Answer: c) 2-5 mg Rationale: The slide indicates that the epidural dose range for morphine is 2-5 mg.

Answer 321

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)

Answer 322

Correct Answer: c) Hydromorphone Rationale: The slide does not provide an intrathecal dose for hydromorphone, only epidural and epidural infusion doses are listed.

Answer 323

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.

Answer 324

Correct Answer: b) 25-50 mcg Rationale: The slide indicates that the epidural dose range for Sufentanil is 25-50 mcg.

Answer 325

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.

Answer 326

a) Sufentanil

Answer 327

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.

Answer 328

Correct Answer: c) Hydromorphone Rationale: The slide indicates that the epidural dose range for Hydromorphone is 0.5-1 mg.

Answer 329

Correct Answer: b) 10 mg Rationale: The slide specifies that the intrathecal dose for Meperidine is 10 mg.

Answer 330

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.

Answer 331

Answer: b) 30-100% Rationale: Pruritus is a troublesome side effect with a high incidence range of 30-100%, as highlighted on the slide.

Answer 332

Answer: b) Naloxone Rationale: Naloxone 0.1 mg IV is considered the best treatment for pruritus in this context.

Answer 333

Answer: c) 25-50 mg IV Rationale: Benadryl is recommended at a dose of 25-50 mg IV for treating pruritus.

Answer 334

Answer: b) 4 mg IV Rationale: Ondansetron 4 mg IV is used for prophylaxis against pruritus.

Answer 335

Answer: c) Mixed agonist/antagonist Rationale: Buprenex is a mixed agonist/antagonist, which is effective in treating pruritus.

Answer 336

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.

Answer 337

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.

Answer 338

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

Answer 339

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.

Answer 340

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.

Answer 341

Correct Answer: c) < 300 mcg

Answer 342

Correct Answer: b) Ondansetron

Answer 343

Correct Answer: c) 30-40%

Answer 344

Correct Answer: c) Fentanyl/Sufentanil + Morphine

Answer 345

Correct Answer: c) Phenergan

Answer 346

Correct Answer: a) Clonidine and Dexmedetomidine

Answer 347

Correct Answer: b) Intensifies and prolongs the block aprox 1 hour

Answer 348

Correct Answer: b) 1 hour

Answer 349

Correct Answer: b) Hypotension, bradycardia, and sedation

Answer 350

b) 15-45 mcg

Answer 351

Correct Answer: b) 3 mcg Tubog says he typically uses 5-10 mcg

Answer 352

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.

Answer 353

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.

Answer 354

Correct Answer: c) Profound increase in duration Rationale: Adding epinephrine to tetracaine results in a profound increase in the duration of the anesthetic effect.

Answer 355

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%.

Answer 356

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.

Answer 357

Correct Answer: a) Patients on anticoagulants

Answer 358

Correct Answers: a) Lower extremity weakness and numbness, c) Low back pain, d) Bowel and bladder dysfunction

Answer 359

Correct Answer: b) Surgical decompression within 8 hours

Answer 360

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.

Answer 361

Correct Answer: c) Within 8 hours

Answer 362

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.

Answer 363

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.

Answer 364

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.

Answer 365

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.

Answer 366

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.

Answer 367

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

Answer 368

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.

Answer 369

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.

Answer 370

Correct Answer: a) Carotid endarterectomy and head and neck surgeries Rationale: Carotid endarterectomy and head and neck surgeries are considered intermediate cardiac risk procedures.

Answer 371

Correct Answer: c) Do not need to routinely hold NSAIDs Rationale: For low-risk procedures, it is generally not necessary to routinely hold NSAIDs.

Answer 372

Correct Answer: c) No additional precautions needed Rationale: For central neuraxial blocks, no additional precautions are required regarding NSAID use.

Answer 373

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.

Answer 374

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.

Answer 375

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.

Answer 376

Answer: d) Both a and c Rationale: Tirofiban and Eptifibatide both require holding for 4-8 hours before regional anesthesia.

Answer 377

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.

Answer 378

Answer: False Rationale: Tirofiban should be held for 4-8 hours before regional anesthesia.

Answer 379

Answer: False Rationale: Eptifibatide requires 4-8 hours, while Abciximab requires 24-48 hours before regional anesthesia.

Answer 380

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.

Answer 381

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.

Answer 382

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.

Answer 383

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.

Answer 384

Answer: c) Blocks ADP transferase Rationale: Thienopyridine derivatives inhibit platelet aggregation by blocking ADP transferase, thus preventing the formation of platelet clumps.

Answer 385

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)

Answer 386

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.

Answer 387

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.

Answer 388

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.

Answer 389

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.

Answer 390

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.

Answer 391

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.

Answer 392

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.

Answer 393

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.

Answer 394

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.

Answer 395

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.

Answer 396

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.

Answer 397

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.

Answer 398

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.

Answer 399

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.

Answer 400

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)

Answer 401

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.

Answer 402

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.

Answer 403

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.

Answer 404

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.

Answer 405

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.

Answer 406

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.

Answer 407

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.

Answer 408

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.

Answer 409

B) CN 5, V2 portion

Answer 410

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

Answer 411

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.

Answer 412

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.

Answer 413

Answer: B. Combined spinal epidural (CSE). Rationale: The slide notes that CSE techniques have a higher incidence of paresthesia compared to other methods.

Answer 414

Answer: B. Document the incident. Rationale: Proper documentation is essential for patient safety and legal purposes if paresthesia occurs during needle placement.

Answer 415

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.

Answer 416

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.

Answer 417

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.

Answer 418

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.

Answer 419

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.

Answer 420

Answer: C. Rationale: Streptococcus viridans, commonly found in the mouth and on hands, is a typical bacterium involved in post-spinal bacterial meningitis.

Answer 421

Answer: C. Rationale: The recommended combination for skin preparation is alcohol and chlorhexidine, which is highly effective in preventing bacterial meningitis.

Answer 422

Answer: C. Rationale: Chlorhexidine must be allowed to dry before the procedure to prevent neurotoxicity and arachnoiditis.

Answer 423

Answer: A. Rationale: Wearing a mask and washing hands are essential preventive measures to avoid spreading Streptococcus viridans.

Answer 424

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.

Answer 425

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.

Answer 426

Answer: C) Whitacre 25/26 Rationale: Whitacre 25/26 needles have been associated with this syndrome due to their design and usage characteristics.

Answer 427

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.

Answer 428

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.

Answer 429

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.

Answer 430

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.

Answer 431

Answer: B) Using 5% lidocaine Rationale: The use of 5% lidocaine has been associated with a higher incidence of TNS, around 19%.

Answer 432

Answer: C) Lithotomy position Rationale: Surgical positions like the lithotomy position, which involves hip or knee flexion, are associated with higher risks of TNS.

Answer 433

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.

Answer 434

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.

Answer 435

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.

Answer 436

Answer: C) NSAIDs like ibuprofen Rationale: Pain relief with NSAIDs, like ibuprofen, and opioid painkillers can help manage TNS symptoms.

Answer 437

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.

Answer 438

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.

Answer 439

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.

Answer 440

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.

Answer 441

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.

Answer 442

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.

Answer 443

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.

Answer 444

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.

Answer 445

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.

Answer 446

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.

Answer 447

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.

Answer 448

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.

Answer 449

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.

Answer 450

Correct Answer: C Rationale: It is necessary to replace the catheter if adjustments and additional anesthetic don't resolve the unilateral epidural block issue.

Answer 451

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.

Answer 452

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.

Answer 453

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.

Answer 454

Correct Answer: B. Peripheral nerve block Rationale: Local anesthetic systemic toxicity is more common in peripheral nerve blocks than in epidural anesthesia.

Answer 455

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

Answer 456

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.

Answer 457

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.

Answer 458

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.

Answer 459

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.

Answer 460

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.

Answer 461

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.

Answer 462

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.

Answer 463

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.

Answer 464

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.

Answer 465

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.

Answer 466

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.

Answer 467

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.

Answer 468

Correct Answer: B. 12 mL/kg Rationale: The advised maximum lipid dose for treating LAST according to the ASRA guidelines is 12 mL/kg.

Answer 469

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.

Answer 470

Correct Answer: C. 1:200K Rationale: The incidence rate of epidural/spinal hematoma is 1:200K, indicating it is a rare occurrence.

Answer 471

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.

Answer 472

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.

Answer 473

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.

Answer 474

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.

Answer 475

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.

Answer 476

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.

Answer 477

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.

Answer 478

Correct Answer: B. 19% Rationale: According to ASA Closed Claims, 19% of claims since 1990 are related to nerve injury.

Answer 479

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.

Answer 480

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.

Answer 481

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.

Answer 482

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.

Answer 483

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.

Answer 484

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.

Answer 485

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.

Answer 486

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.

Answer 487

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.

Answer 488

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.

Answer 489

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.

Answer 490

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.

Answer 491

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

Answer 492

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.

Answer 493

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.

Answer 494

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.

Answer 495

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.

Answer 496

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.

Answer 497

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.

Answer 498

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).

Answer 499

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).

Answer 500

Correct Answer: C. 5% Rationale: Pencil-point needles are associated with a failure rate of about 5% in spinal anesthesia procedures (American Nurse) (NYSORA).

Answer 501

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).

Answer 502

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.

Answer 503

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.

Answer 504

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.

Answer 505

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.

Answer 506

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.

Answer 507

answer: D) Advance the needle a little further

Answer 508

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.

Answer 509

B) Stop and remove needle

Answer 510

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.

Answer 511

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.

Answer 512

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.

Answer 513

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.

Answer 514

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.

Answer 515

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.

Answer 516

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.

Answer 517

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.

Answer 518

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.

Answer 519

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.

Answer 520

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.

Answer 521

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.

Answer 522

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)

Answer 523

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.

Answer 524

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.

Answer 525

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.

Answer 526

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.

Answer 527

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.

Answer 528

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.

Answer 529

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.

Answer 530

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.

Answer 531

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.

Answer 532

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.

Answer 533

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.

Answer 534

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.

Answer 535

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).

Answer 536

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).

Answer 537

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.

Answer 538

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.

Answer 539

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.

Answer 540

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.

Answer 541

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.

Answer 542

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.

Answer 543

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.

Answer 544

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.

Answer 545

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.

Answer 546

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.

Answer 547

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.

Answer 548

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.

Answer 549

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.

Answer 550

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.

Answer 551

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.

Answer 552

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.

Answer 553

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.

Answer 554

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.

Answer 555

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.

Answer 556

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.

Answer 557

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.

Answer 558

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.

Answer 559

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.

Answer 560

Correct Answer: B. 60 minutes Rationale: The recommended "top-up" time for lidocaine is 60 minutes from the initial dose to maintain adequate anesthesia.

Answer 561

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.

Answer 562

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.

Answer 563

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.

Answer 564

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.

Answer 565

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.

Answer 566

B) Stop and replace catheter to new position or intervertebral level Rationale: Aspirating blood indicates that the needle is in a blood vessel.

Answer 567

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.

Answer 568

A) Can't thread catheter

Answer 569

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.

Answer 570

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.

Answer 571

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.

Answer 572

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.

Answer 573

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.

Answer 574

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.