Regional Flashcards by Samina Chowdhury Gilani

Order of differential neuroaxial blockade from least to most dense?

SANS < temp & pinprick < pain (sensory) < motor

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BENIGN radicular irritation associated with spinal lidocaine, obesity, lithotomy position, and ambulatory surgery with early ambulation. No sensory or motor changes; only back pain with radiation butt, thighs, hips, and calves. Symptoms last 1-3 days and resolve spontaneously.

TNS

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Only scenario in which lovenox can be restarted WITH neuroaxial catheter in place

ONCE daily prophylactic dosing; Can restart lovenox after 6-8 hours

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How long to wait after stopping Lovenox for neuroaxial puncture?

12 hours with dosing < 10,000U

24 hours with dosing > 10,000

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Do not place neuroaxial if PTT = ? or INR = ?

PTT > 40

INR > 1.5

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How long to wait before neuroaxial puncture after stopping Tirofiban/Eptifibatide?

8 hours

“Elliptical for 8 hours”

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How long to wait before neuroaxial puncture after stopping Dalteparin?

12 hours if prophylactic dose

24 hours if full treatment dose

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How long to wait before neuroaxial puncture after stopping Fondaparinux?

2 days if prophylactic dose
3 days if full treatment dose

“Fondue party in 2-3 days”

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How long to wait before neuroaxial puncture after stopping argatroban, bivalirudin, or lepirudin?

PTT < 40

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How long to wait before neuroaxial puncture after stopping Abciximab?

2 days

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How long to wait before neuroaxial puncture after stopping Dabigatran?

3 days if renal function intact and no other risk factors for bleeding (Cr clearance > 80 mL/min)

otherwise, 5 days

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How long to wait before neuroaxial puncture after stopping clopidogrel?

7 days

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How long to wait before neuroaxial puncture after stopping Alteplase?

10 days

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How long to wait before neuroaxial puncture after stopping ticlopidine?

14 days

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Normal kyphosis limits spinals to what level?

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Decreased CSF volume in following states?

pregnancy (2/2 epidural vein engorgement and progesterone), ascites, advanced age, severe kyphoscoliosis

*NOT OBESITY

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Opioids that cross dura quickly therefore less epidural spread (narrow band of analgesia) and short duration

lipophilic opioids like fentanyl and sufentanil

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Opioids that cross dura slowly therefore more time to travel rostrally and longer duration of action

lipophobic opioids like morphine

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Purpose of epinephrine in neuroaxial blocks?

Prolongs duration
Adds density to spinals
No added density to epidural

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Attenuates neuroaxial opioids except butorphanol?

Chlorprocaine

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Artery located (inferiorly) in line with interscalene roots/trunks in ultrasound image?

vertebral artery

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Vessels located medial to interscalene roots/trunks (and in line with superficial cervical plexus) on ultrasound image?

Internal Jugular and carotid artery between anterior scalene muscle and sternocleidomastoid muscle

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less risk of phrenic nerve block with interscalene or supraclavicular?

supraclavicular but remains very common

phrenic nerve is blocked 100% of the time with interscalene block

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less risk of pneumothorax with interscalene or supraclavicular block?

interscalene

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landmarks of femoral nerve?

inguinal ligament superior adductor longus medial sartorius lateral

oculocardiac reflex mediated by?

V1 via ciliary ganglion IN | X (vagus) OUT

artery located in ultrasound image of supraclavicular trunks/divisions directly above 1st rib?

subclavian artery

Bezold-Jarisch Reflex

PANS reflex!! Bradycardia and decreased contractility mediated by stretch R's in left ventricle in response to acute drop in preload (thought to allow additional filling time)

nerves covered by TAP block

subcostal, intercostal, iliohypogastric, and ilioinguinal T9-L1

interscalene block for shoulder surgery also covers which other nerve via spillover?

supraclavicular nerve of superficial cervical plexus

Maximum lidocaine dose plain versus lidocaine with epinephrine?

5 mg/kg 7 mg/kg

Maximum bupivicaine dose plain vs. bupivicaine with epinephrine?

2.5 mg/kg 3 mg/kg

maximum dose of ropivicaine?

3 mg/kg

Maximum dose of chlorprocaine?

12 mg/kg

Local anesthetic absorption from highest to lowest...think ICPEBaLLS

IV > tracheal | intercostal > caudal > paracervical > epidural > brachial plexus > lower legs > subcutaneous

Dose for 20% lipid emulsion if treating LAST?

2.5 mL/kg over 1 minute followed by 0.25 mL/kg/min infusion (may incr to 0.5 mL/kg/min)

ACLS dose of epinephrine in LAST

decreased to < 1 mcg/kg

Avoid which drugs in LAST?

beta blockers, calcium ch blockers, vasopressin, and local anesthetics DOC for ventricular arrhythmias? amiodarone

DOC for ventricular arrhythmias in LAST?

amiodarone

Sensory innervation to nasal mucosa, hard palate and lacrimal glands?

Sphenopalatine ganglion (V2 - maxillary branch of trigeminal nerve)

Sensation to medial forearm?

medial antebrachial cutaneous nerve

sensation to dorsal hand?

radial nerve

nerve that allows wrist flexion?

medial nerve

nerve that allows wrist extension?

radial nerve

sensation to palm of hand?

Median (first 3.5 fingers) and ulnar nerve (last 1.5 fingers)

nerve that allows hand closure and thumb adduction

ulnar nerve

Which orbital block additionally blocks the levator palpabrae?

peribulbar block

nerve that allows eversion and dorsiflexion?

common peroneal nerve | L5-S1

Nerve that allows plantar flexion and inversion?

Tibial nerve

What regional anesthesia is necessary for lateral wall bladder surgery?

spinal anesthesia plus obturator nerve to prevent adductor muscle jerk reflex -OR- GA plus paralysis

The 3-in-1 block often misses?

the obturator nerve

where to inject for lateral femoral cutaneous nerve block?

2-2.5 cm medial and inferior to ASIS. Distribute LA above and below fascia lata

where to inject for obturator nerve block?

sensory portion is between adductor longus muscle and adductor brevis muscle. this is the anterior branch of the nerve. muscles superficial to deep: ALABAMa - adductor longus, adductor brevis, adductor magnus

lumbar plexus block also known as psoas compartment block spares which nerve?

Sciatic nerve Reliably blocks lateral femoral cutaneous, femoral and obturator nerves (VENTRAL RAMI T12-L4)

Which blocks to render eye immobile?

Retrobulbuar/peribulbar plus facial nerve to target orbiculares oculi muscle

Non-cutting spinal needles?

Whitacre or Sprotte

Interscalene blocks the brachial plexus where?

At nerve roots and trunks

Supraclavicular blocks the brachial plexus where?

trunks and origin of divisions

infraclavicular blocks the brachial plexus where?

Cords

Axillary blocks the brachial plexus where?

Nerve BRANCHES

How does adding bicarb to lidocaine help?

increases pH so decreased pain on injection increases the UNionized portion of the local anesthetic which speeds time of onset **Don't mix bicarb with ropi or levobupivicaine because much less soluble so precipitation will form

Allergy to esters likely due to what? (procaine, benzocaine, tetracaine)

Hypersensitivity to PABA (a metabolite of esters)

Allergy to amides due to?

methylparaben (which is metabolized to PABA) **Allergy to amides rarer than esters

Which is more common? allergy to amides or esters?

ESTERS

landmarks to infragluteal sciatic nerve block

ischial tuberosity, greater trochanter, and sciatic groove | sciatic groove is between femur and long head of biceps femoris

Innervation of lateral skin on nose, cheek and upper lip?

infraorbital nerve (derived from maxillary branch of trigeminal nerve v2)

where to inject for TAP block?

between internal oblique and transverses abdominus

entrapment of lateral femoral cutaneous nerve following prolonged labor is called? (causes anterolateral thigh burning pain)

meralgia parasthetica

redirect needle in which direction during interscalene block if there is a diaphragmatic response (coughing, hiccups or gasping)?

posteriorly

Redirect needle in which direction during femoral nerve block if there is only a sartorius twitch?

lateral and deeper - endpoint of femoral nerve stimulation should be patellar twitch +/- sartorius twitch

Nerves that must be blocked for awake intubation?

(1) glossopharyngeal n. via soaked pledget @ the base of palatoglossal fold (2) RLN via transtracheal injection (3) SLN by injection at horn of the hyoid or pledget in the piriform sinus (4) mandibular br. of trigeminal nerve via topical anesthesia

The musculocutaneous nerve provides sensory innervation to?

lateral forearm

Radicular symptoms associated with spinal lidocaine, obesity, lithotomy position, and ambulatory surgery with early ambulation

TNS

Ultrasound image of medial forearm - identify labels

A: flexor carpi ulnaris tendon and muscle B: ulnar nerve C: ulnar artery

Coadministering liposomal bupivicaine with ____ will cause a disruption in the drug delivery system?

Any local anesthetics other than plain bupivicaine; delay administration at least 20 minutes following lidocaine administration in the same area also WET chlorhexadine or povidone iodine solutions will disrupt the drug delivery system

Important landmark for blocking LFCN?

ASIS - 2.5 centimeters medial and inferior to ASIS -- inject above and below fascia lata

Risk factors for cauda equina syndrome?

Small bore spinal catheters, spinal stenosis, patient positioning due to maldistribution of local anesthetic.

Methylene blue is beneficial in which pathophysiology other than methemoglobinemia?

Vasoplegia syndrome (profoundly decr in SVR that is refractory to fluids and vasopressors AFTER cardiopulmonary bypass). This works by preventing nitric oxide-induced vasodilation.

Which local anesthetic has the strongest vasodilator effect?

Procaine due to its degradation product: dimethylaminoethanol (DEAE)

What level is the cervical plexus block needed for CEA?

C2-C4: both superficial and deep blocks required

Maximum dose of plain bupivicaine vs bupivicaine with epinephrine?

2.5 mg/kg vs. 3 mg/kg

Maximum dose of plain ropivicaine vs ropivicaine with epinephrine?

3 mg/kg vs 3.5 mg/kg

Maximum dose of plain mepivicaine vs mepivicaine with epinephrine?

5 mg/kg vs. 7 mg/kg

brachial plexus nerves located where in relation to axillary artery?

3 o'clock: ulnar nerve 6 o'clock: radial nerve (always closest to humerus) 10 o'clock: median nerve

Factors that decrease the rate of intravenous placement of epidural catheters?

lateral position (2ndry to a decrease in venous engorgement) fluid administered through the epidural needle prior to catheter insertion use of wire-embedded catheters having 6cm or less of catheter in epidural space using single-orifice catheters (but inferior pain control)