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Anaesthesiology > Regional 2 > Flashcards

Regional 2 Flashcards

1
Q

Principle site of action of neuraxial techniques?

A

Nerve root
If block posterior root: block somatic and visceral sensation
Anterior: prevent motor and autonomic outflow

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2
Q

Where does sympathetic plexus start and end?

A

T1 to L1

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3
Q

Consequence of blocking sympathetic plexus from t5 downwards? (4)

A

• Decreased vasomotor tone
. Pooling of blood in lower limbs
• decreased bp
• compensatory tachycardia

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4
Q

Consequence of blocking sympathetic plexus t1-t4?

A

Block cardiac accelerator fibres leading to bradycardia and decreased cardiac contractility

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5
Q

How can CvS effects of regional neuraxial anaesthesia be prevented?

A

Volume preload with 10-20 ml/kg iv and early administration vasopressors
If bradycardia develops, treat with atropine

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6
Q

Name 3 indications neuraxial anaesthesia

A

• Lower abdominal surgery
• inguinal, urogenital, rectal procedures
• lower extremity surgery ortho eg arthroplasty

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7
Q

Name 6 absolute contraindications to neuraxial anaesthesia

A

• Patient refusal
• infection at site (risk meningitis), general sepsis
• coagulopathy (risk spinal haematoma)./ bleeding diathesis (platelets <80-100 000/MicroL, INR >1.5, urea >20)
• severe hypovolaemia eg abruptio placenta (risk CVS collapse), hypotensive
• increased ICP (risk herniation)
• severe aortic or mitral stenosis aka fixed cardiac output state, especially if SYMPTOMATIC (can’t compensate for dropped BP)
Umbilical cord prolapse

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8
Q

Name 5 relative contraindications to neuraxial anaesthesia

A

• Sepsis or infection of site
• uncooperative patient
• preexisting neurological deficit
• mild to moderate stenotic valvular lesions
• severe spinal deformity eg scoliosis

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9
Q

Name the layers penetrated in order when performing spinal anaesthesia (8)

A

• Skin
• subcutaneous tissue
• supraspinous ligament
• interspinous ligament
• ligament flavum (first loss resistance)
• epidural space
• dura mater
• arachnoid mater (second loss resistance)

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10
Q

Name 4 agents that can be used for spinal anaesthesia

A

• Bupivacaine 0,5% with or without dextrose: most common. Longest duration.
• procaine 10% . shortest duration
• tetracaine 1 %
• ropivacaine 0,2 -1%

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11
Q

Name 6 early complications spinal anaesthesia

A

Early
• Hypotension: most common due to sympathetic blockade with resultant vasodilation and reflex tachycardia (present as nausea)
• High spinal block: due to excessive doses or volume drug used or high spread of local. Above T4
• severe bradycardia with hypotension: due to block cardiac accelerator fibres t1.-t4. May require intubation and ventilation
• failed spinal
• direct neurological injury: needle in root or cord
Anaphylaxis

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12
Q

Name symptoms post dural puncture headache (5)

A

• Can be anywhere but usually fronto-occipital
• throbbing or constant
• photophobia
• Nausea
• worsen in sitting or standing position, improve with lying down

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13
Q

Treatment postural puncture headache?

A

Simple analgesics, bed rest, caffeine tablets, adequate hydration
If longer than 24 hours, consider epidural patch (pts IV blood 15-20ml slowly injected into epidural space with 18G needle) (only draw blood once sure in epidural space and inject immediately - 2 man job) (better success rate with more attempts, don’t do more than 3)

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14
Q

Define failed spinal and name 5 causes

A

No or incomplete neurological deficit 20 minutes after subarachnoid injection
• Septations
• inadvertent epidural injection
• dry taps
• leakage
• nerve sheath and ligament abnormalities

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15
Q

Which neuraxial technique is better for analgesia?

A

Epidural
Not as effective at anaesthesia

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16
Q

Treatment high spinal? (4)

A

• Hhh
. Airway; RSI, cautious with induction drug if GCS 3
. Breathing: ambubag or ventilate 100% oxygen
• circulation: either sympathetic agonist or parasympathetic antagonist antimuscarinics (atropine)

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17
Q

How recognise spinal epidural haematoma?

A

Persistent neurological fallout beyond expected length of neuraxial blockade > 6 hours.
Initial reports of failure to regain motor function and bladder / bowel control
Severe pain in lumbar nerve distribution- back and thigh pain

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18
Q

Pathogenesis of spinal epidural haematoma and complications

A

• Caused by coagulopathy and or traumatic spinal tap or epidural
• haematoma compress distal spinal cord /cauda equina resulting in fallout
• if not relieved, will cause permanent nerve damage and paralysis

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19
Q

Name 4 complications epidural anaesthesia

A

• Unintentional dural puncture and CSF leak
• epidural haematoma or abscess
• infection
• catheter transection / kinking during manipulation

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20
Q

Size of spinal needle that should be used?

A

No larger than 22G! Preferable 25/26G

21
Q

What is caudal block and what Is It used for?

A

• form of epidural. needle inserted through sacral hiatus into sacral epidural space
• used for paediatrics
About 4 hours analgesia

22
Q

Name the spinal needles picture 56

A

A: quincke
B: whitacre
C: sprotte (pencil point)

23
Q

Which needle used for epidural?

A

Larger gauge than spinal
Touhy needle

24
Q

Which anaesthetic and dose is used for Bier’s block?

A

30-40ml of 0,5% lignocaine IV injection
Because has safest CVS profile of local anaesthetics so is the only one that can be administered IV

25
Q

What is Bier’s block used for?

A

Surgery on extremities

26
Q

Which type of drugs are used to treat the cause of local anaesthetic toxicity?

A

Intra-lipids to bind the local anaesthetic (definitive management)

27
Q

What is equipment is picture 67 used for?

A

Epidural.
A = 16G spinal needle
B= epidural catheter

28
Q

What is equipment is picture 68 used for?

A

Spinal block

29
Q

Which spinal needle has lowest incidence PDPH?

A

pencil point needle (sprotte)

30
Q

Which regional block is best for hysterectomy

A

Transverse abdominis plane (tap) block

31
Q

Define neuraxial block

A

La injected into intrathecal space (spinal) or epidural space

32
Q

Name the steps of spinal anaesthesia

A
  1. Measure NIBP, set cuff to read at 1 min intervals. Monitor ECG and oximetry.
  2. If preload not done in ward, give 5ooml ringers while doing spinal
  3. Draw up drugs: adrenaline-free hyperbaric bupivacaine with dextrose 0.5% 9mg (1.8ml); fentanyl 10 microg/0.01 mg (0.2 ml) for total volume 2ml
    4 Position in sitting (slouched with arms up) or lateral position
  4. Median or paramedian approach. Identify PSIS and follow to L3L4. Make mark with fingernail in space.
  5. Scrub and clean - sterile technique
  6. Localise with 2-3 ml lignocaine with small gauge blue needle in subcutaneous
  7. Insert 25-26 6 pencil point spinal needle
  8. Insert introducer and advance into spinal space, confirm by aspirate Csf
  9. Inject over 10-20 seconds
    11 patient lie down. If pregnant, insert wedge under R hip (left tilt) and pillow under head
  10. Monitor NIBP every minute and check level of spinal block prior to incision
  11. If pregnant - when baby delivered, oxytocin 2.5 u IV over 1 minute and 17.5 u in 1L Ringers over 8 hours
33
Q

Name 7 late complications spinal block

A

• meningitis or arachnoiditis: contamination
• backache
• postdural puncture headache: common with big gauge black Quincke needle inserted with bevel upwards instead of sideways, due to CSF leak
• systemic toxicity: if inject into blood vessel (last)
Haematoma
Urine retention
Nerve injury

34
Q

How do bier block? (10)

A
  1. Insert Iv line as far peripheral as possible
  2. Place double-pneumatic tourniquet on proximal limb
  3. Elevate arm to allow passive exsanguination for 1 minute
  4. Inflate proximal cuff to 50-100 mmHg above the systolic bp
  5. Confirm absence of radial pulse
  6. Inject 30-50 ml 0.5% lignocaine
  7. Remove cannula and apply pressure to prevent bleeding
  8. Can start procedure about 5-10 minutes later
  9. About 20-30 minutes after injection pt will complain of tourniquet pain. Inflate distal cuff and deflate proximal.
  10. Don’t deflate tourniquet before 20 minutes or more than 45 minutes after infusion
35
Q

Name 5 contraindications to bier block

A

• Local anaesthetic allergy/anaphylax
• open #
• severe ht SBP > 175
• severe crush injury or compromised circulation
• sickle cell disease

36
Q

Indication spinal?

A

Surgery below t10. Eg cs, LL

37
Q

Name 4 techniques of brachial plexus block

A

• Interscalene block (block roots- cover shoulder upper arm, elbow : spares ulnar nerve! )
• supraclavicular (block trunks and proximal divisions, cover whole arm)
• infraclavicular (block cords/terminal branches, cover forearm wrist hand)
•axillary block (block terminal branches, cover forearm wrist hand ) - easiest

38
Q

Name 4 complications interscalene brachial plexus block

A

• phrenic nerve palsy
• Horner’s syndrome
• subarachnoid/epidural injection
• vertebral artery injection

39
Q

Name 3 complications supraclavicular brachial plexus block

A

• Highest pneumothorax incidence
• phrenic nerve palsy
• Horner’s syndrome

40
Q

Name 3 complications infraclavicalar brachial plexus block

A

•intravascular injection
• pneumothorax
• painful in awake patient

41
Q

Name 2 complications axillary brachial plexus block

A

• Haematoma
• intravascular injection
(Often spares musculocutaneous nerve)

42
Q

Name 6 steps of preparation for spinal in obstetrics

A

• History and examination, exclude contraindications for spinal
• premedication: sodium citrate 30ml orally, 0-30 minutes pre-op
• good iv access, urinary catheter, nb to preload with 500 ml ringers to prevent hypotension
• prepare theatre: check anaesthetic machine, air way equipment, pillow for intubation, wedge for left lateral tilt
• draw up essential drugs: ephedrine/ etilephrine, phenylephrine, adrenaline
• check that these drugs are in theatre in case; propofol, suxamethonium, atropine

43
Q

Name 5 causes cardiac arrest immediately following spinal

A

• severe hypotension
• vasovagal event
• high spinal block
• amniotic fluid/air embolism
• anaphylactic reaction

44
Q

Management hypotension after spinal? (6)

A

• Make sure pt awake, maintaining airway, is breathing and has pulse (ABC)
• exclude high spinal
• give fluid bolus (5-10 ml/kg ringers, may be repeated)
• if hr > 60: phenylephrine
• hr <60: ephedrine or etilephrine
• if pep or ephedrine doesn’t increase bp within 1 min, give adrenaline

45
Q

Name 4 advantages epidural

A

• Gradual onset of action
• better for cardiac lesions
• can be titrated slowly (graded epidural)
• can be topped up throughout procedure
• can be left in situ after procedure for continuous analgesia

46
Q

Why is an epidural not ideal for c section? (2)

A

• Not great motor and sensory block. Great analgesic but not anaesthetic
• not as dense as spinal so must use very high dose for surgery → local anaesthetic systemic toxicity

47
Q

What sensory level loss must patient have with spinal before surgery

A

T4-T6

48
Q

Name 6 signs and symptoms high spinal before unconsciousness

A

• Anxiety
• nausea and or vomiting
• arm/hand dysaesthesia or paralysis , can’t touch nose
• weak hand grip strength
• ineffective cough and progressive dyspnoea (dropping sats)
• hypotension initially without bradycardia, later with
• late: unable to speak, apnoea

49
Q

Name 6 risk factors high spinal

A

Drug factors
• high dose local
• hyperbaric solution eg not used with dextrose
•prior epidural, especially recent top up

Patient factors
• high BMI - may reduce thecal volume
• spinal canal abnormality
• increased intraabdominal pressure eg pregnancy

Technique factors
• high lumbar injection
• immediate supine positioning
• cephalad direction of needle hole

Anaesthesiology (24 decks)

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