Regional and Neuraxial

Question 0

Sympathetic chain levels

Cardioaccelerator fiber levels

Answer 0

T1-L2

T1-T4

Question 1

Nerve fibers A-alpha, A-delta, and C

Answer 1

A-alpha: motor, thick myelinated
A-delta: pain/temp, thin myelinated
C: pain/temp, small, unmyelinated

Question 2

ASRA Neuraxial Guidelines:
SQH
Enoxaparin
Clopidogrel

Answer 2

Heparin:
Placement okay anytime, start heparin (any dose) 1 hr after

Enoxaparin:
QD DVT ppx: okay 12 hrs after dose, restart 6 hrs after SS S/E
BID tx high dose: okay 24 hrs after dose, restart 24 hrs after SS S/E
Epidural catheter: not suggested to use lovenox, pull 12 hrs after dose, restart 2-4 hrs after removal

Clopidogrel:
7 days off for block

Question 3

Factors associated with decreased CSF volume (higher spinal block)

Answer 3

Pregnancy, ascites, advanced age, kyphoscoliosis (sometimes)

Question 4

Intrathecal Morphine
Typical dose?
Rostral spread?
Respiratory depression?
Peak effect?
DOA?

Answer 4

Typical dose: less than 300 mcg (Mittman uses 500 usually)
Rostral spread: thoracic or potentially higher, but slow, most spread of any opioid d/t hydrophilicity
Respiratory depression: 2 peaks, early and late, early is right away and late is 6 hours
Onset: slow
Peak effect: 6-12 hours
DOA: 24 hours

Question 5

Treatment for intrathecal opioid mediated itching

Answer 5

Ondansetron, naloxone, nalbuphine, propofol
NOT diphenhydramine (not histamine mediated)

Question 6

LA that interferes with epidural opioid mediated analgesia? How is it metabolized?

Answer 6

Chloroprocaine

Pseudocholinesterase