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S5 - Principles III - Test 4 > Regional > Flashcards

Regional Flashcards

1
Q

what anesthetic agents can cause neuroapoptosis?

A
  • GABAA agonists (propofol, benzos, volatile agents)
  • NMDA antagonists (ketamine, N2O
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2
Q

what age kids are at risk of neuroapoptosis?

what increases the risk?

A
  • kids < 3 yrs (occurs in utero during 3rd trimester too)
  • increased risk with anesthesia time > 3 hrs and repeated exposure
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3
Q

why is use of neuraxial and regional techniques growing?

A

to avoid GA

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4
Q

T/F: regional techniques are safe and effective for intra-op and post-op analgesia in infants, children, but not in pre-term neonates

A

false - safe for infants, children, and neonates

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5
Q

advantages for using regional/spinals in peds

A
  • opioid related adverse effects avoided
  • promotes spontaneous ventilation and earlier extubation
  • reduces risk of post-op apnea and respiratory dysfunction in high-risk infants
  • airway instrumentation can be avoided
  • enhances hemodynamic stability
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6
Q

advantage of continuous epidural analgesia in peds

A
  • decreases time to extubation
  • promotes return of bowel function
  • decreases metabolic stress response
  • may decrease postoperative sedation needs
  • promotes shorter ICU length of stay
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7
Q

little fact: when combined with GA, regionals decrease intra-op volatiles, opioids and neuromuscular blocking agents

(reduces risk of negative cognitive outcomes)

A

yay

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8
Q

indications for spinals (5)

A
  • lower abdominal procedures (urologic and hernias)
  • lower extremity orthopedics
  • omphalocele
  • exploratory laparotomy
  • myelomeningocele
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9
Q

T/F: there are frequent complications with spinal use in peds, mainly being permanent neurologic injury or death

A

false

“Complications infrequent; no reports of permanent neurological injury or death in children”

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10
Q

what can be added to a spinal to double the duration?

A

clonidine

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11
Q

complex procedures often benefit from a spinal combined with what other technique?

A

caudal catheter

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12
Q

agents commonly used for sedation with spinals?

A

precedex - infusion

fentanyl, midazolam - boluses

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13
Q

difference in conus medullaris in peds vs adults?

when is it the same as adults?

A

conus medullaris more caudal in neonates and infants (L3)

reaches adult level at 1 y/o

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14
Q

level of lumbar puncture in peds vs adults?

why?

A

at L4-L5 or L5-S1 to avoid spinal cord trauma

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15
Q

what approach to a spinal is preferred in peds?

A

midline

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16
Q

difference in sacrum in peds vs adults

A
  • sacrum more narrow and flat
  • access to subarachnoid space from caudal canal more direct (dural puncture more likely)
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17
Q

differnce in ligamentum flavum in peds vs adults?

consideration?

A

less dense in peds

harder to feel loss of resistance

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18
Q

duration of spinal in peds vs adults?

why the difference?

A
  • peds have shorter block duration
  • due to faster CSF turnover rate
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19
Q

in a pediatric patient, how much space is between the skin and the subarachnoid space?

A

1.5 cm

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20
Q

T/F: a spinal eliminates the incidence of post-op apnea in former premies

A

false - decreases but does not eliminate

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21
Q

what agent when given in addition to a spinal causes more apnea than a GA?

A

ketamine

22
Q

what is deafferentation?

A

sedation due to decreased sensory input to RAS from periphery

(can be advantage or disadvantage of SAB)

23
Q

what specific pediatric population is the most common to use spinal techniques on?

A

infants

uncommon past infancy

24
Q

what age group is the most hemodynamically stable after a spinal or epidural anesthetic?

A

infants - more stable than older kids or adults

~and more responsive to hemodynamic meds vs those ppl too

25
Q

who has a bigger impact on their respiratory function with a spinal - infants or children?

why?

A

infants - they rely more on diaphragm for their tidal volume

but most compensate and tolerate well

26
Q

common technique for spinals in peds

A
  • usually sitting position
  • 1% lidocaine
  • midline insertion at L4-L5 or L5-S1 (lower than adults)
  • must remain horizontal to avoid high spinal - no leg raises, toe touches, somersaults, etc.
  • avoid sedation if possible - esp ketamine
27
Q

complications of SAB

A
  • total spinal - apnea, bradycardia
  • post-dural puncture headache
  • spinal cord trauma
  • epidermoid tumors
28
Q

what usually causes epidermoid tumors?

A

when needle used without the stylet

29
Q

effects of prolonged amide infusions in infants and young children

A
  • variable pharmacokinetics
  • increased risk of LAST
30
Q

which LA is starting to have a resurgence for epidural anesthesia?

how is it metabolized?

A

2-chloroprocaine

metabolized by plasma esterases in seconds to minutes

31
Q

*theoretically can epidurals in peds be the sole anesthetic?

A

yes - but usually combined with GA

32
Q

most common regional technique in children — in some places

A

caudals

33
Q

are caudal blocks used ase the sole anesthetic?

A

nope, always used with GA

34
Q

landmarks for a caudal block

A
  • posterior iliac spine
  • sacral cornu
35
Q

T/F: a caudal block requires sterile technique

A

false - aseptic*

36
Q

is a caudal block a type of spinal or type of epidural?

A

epidural

37
Q

technique for a caudal block

A
  1. after induction, turn lateral or prone
  2. palpate landmarks
  3. insert small gauge needle, angiocath, or Crawford needle at 45°angle
  4. after “pop”, drop to angle parallel to back and advance into caudal canal
  5. for continuous, insert catheter
  6. test dose while watching EKG & BP
  7. inject local over approx. 2 minutes - injection should be easy
  8. watch for sub-cu infiltration
38
Q

how long to inject local over for a caudal block

A

over 2 minutes

39
Q

for a continuous caudal epidural, how far does the catheter need to be advanced?

A

mid-level of surgical incision

40
Q

fun facts on back side :)

A
  • some ppl use ultrasound to confirm catheter placement of caudal epidural catheter
  • these need “meticulous dressing for catheter placement”
41
Q

the dose needed for a caudal block depends on what two factors?

A
  • desired dermatome level
  • volume

not concentration

42
Q

common volume per kg and drug given for a T4-T6 sensory caudal block

A

0.5-1 mL/kg of 0.2% ropivacaine

(or can use 0.25% bupivacaine but its more toxic)

~~idk if saying we won’t dose on exam was we don’t need to know them, or if we just wont have to calculate

43
Q

what is a common drug to administer with a caudal block to prolong the block?

what dose of this drug is associated with increased apnea?

A

common: clonidine 1 mcg/kg

2 mcg/kg increases apnea

~~idk if saying we won’t dose on exam was we don’t need to know them, or if we just wont have to calculate

44
Q

dose that can be used for post-op pain control with a caudal epidural catheter?

considerations if little babe?

A

max: 0.4 mg/kg/hr (of what? unclear)

if < 6 months reduce by 30%

~~idk if saying we won’t dose on exam was we don’t need to know them, or if we just wont have to calculate

45
Q

contraindications to a caudal block

A
  • parents refuse consent
  • surgeon preference
  • allergy to local anesthetics
  • skin infection/diaper rash in sacral area
  • VP shunt in place
  • history of spinal abnormality or surgery (relative)
  • sacral “dimple” (relative)
46
Q

when we look at our little baby patient’s booty, we see a cute lil booty dimple.

what can this indicate?

is this an absolute contraindication to a caudal block?

A
  • can indicate spinal structures behind due to some malformation
  • only a relative contraindication, not absolute
47
Q

post caudal complications

which is most common?

A
  • most common: catheter displacement/malfunction
  • IV or IO injection → CV arrest
  • epidural abscess (emergent)
  • meningitis
  • epidural hematoma
  • urinary retention
  • neuronal injury (rare)
48
Q

what are some common fascial blocked used as an adjunct to GA?

*ones that we would do

A
  • TAP block
  • quadratus lumborum block (QLB)
  • serratus anterior plane block (SAPB)
  • erector spinae block (ESB)
49
Q

what are some common blocks done by the surgeon as an adjunct to GA?

A
  • rectus sheath
  • inguinal
  • penile
  • intercostal
  • paravertebral
50
Q

is it safe to administer regional to an anesthetized child?

A

yep

here’s some obvious reasons why:

  • maintains stillness
  • avoids uncooperative and distressed patient
  • immobility helps avoid accidental needle displacement/puncture of vital structures

negative - any advantages of patient feedback are lost with children who are unable to communicate usefully

S5 - Principles III - Test 4 (7 decks)

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