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N610 Anesthesia Concepts > Regional Anesthesia > Flashcards

Regional Anesthesia Flashcards

0
Q

What layers does your needle travel through for epidural and spinal blocks?

A

Skin, subcutaneous tissue, supraspinous ligament, interspinous ligament, ligamentum flavum, epidural space (destination of epidural blocks), dura, subdural space, arachnoid, subarachnoid space (destination of spinal block).. Pia mater is the innermost layer, we do not go that far in blocks though

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1
Q

What space is occupied with CSF?

A

subarachnoid space

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2
Q

Dermatomes: what landmark is T4, T6, T8, and T10?

A

T4 nipple
T6 xiphoid
T8 last rib
T10 umbilicus

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3
Q

Dermatome: which nerve innervates the hand (multiple nerves, which part of the hand). If the pt starts feeling numbness/tingling of the hand during spinal/epidural, what interventions should be done?

A

pinky: C8
middle finger: C7
Index, thumb: C6
If the pt starts to feel numbness/tingling here, put pt in reverse trendelenberg

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4
Q

When doing a spinal, you hope to block which nerves?

A

Not above T1, when the block starts to spread to fingers, it can continue to spread to phrenic nerve (C3-C5) then the patient may loose ability to breathe on their own (“total spinal”)

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5
Q

CSF: How much of it is in the subarachnoid space? What is its specific gravity?

A

150 mL

1.004-1.008

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6
Q

It is expected that sensory, motor, and autonomic functioning will be blocked during spinal/epidural. What is the consequence of blocking autonomic functions in a spinal vs. epidural (on the heart)?

A

Epidural: BP will drop within 8 min
Spinal: BP will drop within 1 min, more profound
Along with BP dropping, C.O. drops 10% (give bolus before procedure), HR drops and SVR drops

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7
Q

Contraindications to regional blocks

A

Pt refusal, infection/cyst at injection site, increased ICP (for spinal), clotting defects/anticoags, hemorrhaging/hypovolemia, CNS disease/meningitis (for spinal), inability to remain still, bacteremia/septicemia, nerve damage/palsy (for peripheral)

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8
Q

Side effects of neuroaxial drugs (due to autonomic block)

A

MAP, HR, C.O., SVR decrease
hyperparistalsis, urinary retention, N/V
If high block, respiratory effects (phrenic nerve)
Blocks stress response, shivering

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9
Q

Sprotte vs. Quincke vs. Whitacre spinal needles, what size needle?

A

25g needle
Sprotte/ Whitacre are pencil point, more tip strength, feel “pop” when entering the dura
Quincke is cutting, make sure bevel to the side, less likely to feel “pop”, increased risk of postdural headache

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10
Q

Landmarks for spinal/epidural block

A

ileac crest and L4 vertebrae is palpated

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11
Q

Spinal block procedure order: Midline approach

A
  1. identify landmarks, 2. sterile field, prep solution, 3. fenestrated drape, wipe iodine away with sterile gauze, 4. skin wheal with 25g needle, 5. advance 17g introducer angled cephalad, stop in interspinous ligament, advance selected needle through ligamentum flavum, feel “pop”, 6. through dura to subarachnoid space, 7. aspirate CSF (confirm by rotating 90 degrees x4) 8. inject drug, pull out needle
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12
Q

What is an epidural headache, why does it occur? Treatment?

A

If dura is punctured, CSF can leak for a day, give pt extra fluids, bedrest
Epidural Blood Patch can be done, give pt 10-20 mL of their blood (IV) back into CSF

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13
Q

What is the Touhy needle used for?

A

Epidural placement, catheterized needle with markings every sonometer

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14
Q

What is the LOR technique

A

LOR: loss of resistance technique for correct epidural placement, when needle hits ligamentum flavum, stylet is removed and syringe with air is tapped and slowly advanced until a sudden loss of resistance

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15
Q

After getting the epidural in the correct location, how is the catheter placed?

A

Advance catheter 2-3 cm into epidural space

Advance catheter 4-6 cm into the epidural space in parturients (pregnant women)

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16
Q

Baracity of local anesthetic drugs with CSF: Hyperbaric, hypobaric, isobaric

A

Hyperbaric solution: has higher specific gravity, like dextrose, solution will “sink” and block lower
Hypobaric solution: has lower specific gravity, like sterile water, solution will “rise” and block higher
Isobaric solution: specific gravity 1.004-1.008, mix with CSF

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17
Q

Indications for caudal blocks

A

pediatric patients post op pain, landmark is sacral hiatus

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18
Q

Epidural Hematoma is a rare complication, what must be done if this occurs and what are signs/symptoms?

A

Weak/numbness in lower extremeties, neurosurgery consult immediately, usually caused by coagulation defect (LMWH must be held 12 hours before and 12 hours after surgery)

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19
Q

Risks of peripheral nerve blocks

A

LA (local anesthetic) toxicity, permanent nerve damage (from toxicity, usually nerve will repair), allergic response, incomplete blocks (convert to general), discomfort of positioning

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20
Q

2 classes of local anesthetics

A

esters: (one eyed ester, has one “i”) metabolized by cholinesterase, more likely to have allergic reaction
amides: metabolized by hepatic processes

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21
Q

Rate of absorption from max to min for nerve blocks

A

Intercostals, caudal, epidural, brachial plexus, sciatic, lumbar plexus, femoral

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22
Q

Signs of local anesthetic toxicity

A
  1. CNS toxicity: tongue numb, lightheaded, dizzy, tinnitus, disoriented, seizures, then CNS depression
  2. respiratory depression and arrest
  3. CV instability
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23
Q

Sciatic nerve block, which roots, where does this block

A

L4-S3, blocks posterior leg, foot, and below the knee

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24
Q

Landmarks for sciatic nerve block

A

Draw a line from posterior superior iliac spine to greater trochanter, then from greater trochanter to sacral hiatus, halfway through the second line is where the needle gets inserted

25
Q

How much local is injected for each lower peripheral nerve block: femoral, popliteal, ankle, and sciatic

A

Femoral: 25mL, popliteal: 20-30mL, ankle: 5 sites x5mL=25mL, sciatic: 20-30
(about 25 for each)

26
Q

Femoral nerve block landmarks, what does femoral nerve innervate

A

nerve is lateral to artery/vein, between psoas and iliacus, passes under inguinal ligament
innervates anterior thigh, knee, and hip joints, and small part of medial foot (via the saphenous branch)

27
Q

Femoral nerve block: needle size and direction needle is inserted

A

needle 22g 50mm (5cm), B bevel (short angle) insulated needle, insert perpendicular to the skin, then advance 45 degree angle cephaldad, inject 25-35 mL

28
Q

Peripheral nerve block complications

A

hematoma, IV injection- toxicity, nerve injury

29
Q

Popliteal block landmarks, where is the needle inserted?

A

popliteal fossa crease, bicep femoris, semimembranosis, semitendonosis
needle inserted 7cm above the crease, midline (slightly lateral)

30
Q

Ankle blocks: key point about drugs and stimulator

A

NEVER use epi, no nerve stimulator is necessary

31
Q

Ankle blocks: what needle is used?

A

one source: 23-25g, 1 inch

other source: 22g, 38mm, B bevel

32
Q

Ankle blocks: steps of blocking each nerve

A
  1. tibial- hit posterior tip of medial malleolus and post tib artery is in front of the nerve
  2. sural- behind lateral malleolus, between that and calcaneous
  3. deep peroneal- at ankle level, feel anterior tibial artery and extensor hallucis longus, needle lateral to artery or in groove of tendon
  4. “fan” the needle toward medial malleolus to block saphenous nerve
  5. fan the needle toward lateral malleolus to block superficial peroneal
33
Q

What is an induced sympathectomy?

A

A benefit of regional anesthesia, causes intraop less blood loss and postop improved perfusion
VASODILATE, BETTER PERFUSION

34
Q

Regional anesthesia set up/preparation

A

MSMAID: Monitors, Suction, Means of PPV (ambu bag), Airway (intubation equipment), IV access, Drugs

35
Q

3 ways to tell if you are near the nerve

A

Ultrasound, nerve stimulator, illicit paresthesia (hit the nerve, not ideal)

36
Q

Brachial plexus blocks will block sensory to all of the arm except for what?

A

Posterior shoulder innervated by cervical plexus

37
Q

What are the roots for Musculocutaneous, Axillary, Radial, Median, and Ulnar?

A 
Musculocutaneous: C5-C7
Axillary: C5-C6
Radial: C5-T1
Median: C5-T1
Ulnar: C8-T1
38
Q

Radial nerve vs. Median nerve motor function

A

Radial: Supinators and EXtenders
Median: Pronators and Flexors

39
Q

Black vs. Red on nerve stimulator: placement and +/-?

A

Red is positive, placed proximal

Black is negative, placed distal

40
Q

A bevel vs B bevel

A

B bevel is shorter with a larger angle

41
Q

Indications for interscalene approach of brachial plexus block: where does it block?

A

Shoulder/upper arm surgery because it blocks upper brachial plexus roots and trunks plus lower cervical plexus

42
Q

Pt position and landmarks for interscalene approach

A

Supine with head turned away
The brachial plexus lays between the anterior and middle scalene
Clavicular head of sternocleidomastoid, clavicle, C6 (find cricoid cartilage), EJ vein, use “sniffing” technique to help identify these landmarks

43
Q

Absolute contraindications to interscalene approach?

Relative contraindications?

A

Absolute: contralateral recurrent laryngeal nerve palsy, phrenic palsy
Relative: Preexisting nerve injury, brachial plexus pathology, impaired pulmonary function

44
Q

Steps of interscalene approach with nerve stimulator

A
  1. identify landmarks, 2. clean with antiseptic, 3. insert needle slightly caudad while aspirating, 4. turn on nerve stim at 1mA, 5. continue until you see twitches below 0.5mA, 6. aspirate and inject 5mL at a time, give a total of 20-30mL 7. evaluate block
45
Q

Ways to evaluate brachial plexus blocks, after local has been given

A

Have the pt PUSH, PULL, CLOSE hand, and OPEN hand
This is for arm extension-radial nerve, arm flexion-musculocutaneous, median nerve (close or pinch index finger), and ulnar nerve (open or pinch pinky)

46
Q

Complications to interscalene approach

A

IV injection, subarachnoid injection, pneumothorax, phrenic nerve block, RLN block, and Horner’s syndrome (ptosis-eye droop, myosis-dilated eyes, anihydrosis- lack of sweating)
Interscalene doesn’t block ulnar nerve

47
Q

Cervical plexus block indications and where does it block?

A

Done for unilateral surgery of the neck, it blocks C6 level, usually done with deep cervical plexus block of C2-C4 for carotid endarterectomy
Block is done at the posterior border of SCM

48
Q

Supraclavicular approach to brachial plexus block will block where? What are landmarks?

A

Blocks trunks and divisions of brachial plexus, blocks hand, forearm, upper arm
Lateral border of SCM, right above the clavicle, groove between scalene muscles, aim needle caudally

49
Q

Contraindications to supraclavicular block?

A

Contralateral phrenic paralysis, recurrent nerve paralysis, contralateral pneumothorax

50
Q

Supraclavicular block complications?

A

Pneumothorax, Horner’s syndrome, phrenic nerve block, recurrent laryngeal nerve paralysis, neuropathy

51
Q

Infraclavicular approach: landmarks, where does it block

A

Medial clavicular head and coracoid process, needle inserted below clavicle, pointed laterally (as needle advances, pectoral twitches may happen first)
Blocks elbow, forearm, hand

52
Q

Axillary block indications, positioning, and landmarks

A

indications: procedures below the elbow, this will block the terminal branches (musculocutaneous may need an extra stick)
positioning: supine, arm extended, forearm flexed 90 degrees
landmarks: axillary artery, median nerve is superior, ulnar nerve is inferior, radial nerve is posterior (transarterial technique with this block is possible, but not best due to risk of hematoma)

53
Q

Absolute contraindications specific to axillary block

A

lymphangitis

54
Q

What are the landmarks for “touchup” nerve blocks of the brachial plexus (except axillary)?

A

Musculocutaneous: coracobrachialis
Median: medial to brachial artery
Ulnar: ulnar groove between medial epicondyle and olecranon process
Radial: lateral to brachioradialis and biceps tendon

55
Q

Bier block

A

40 mL IV give local anesthetic with double tourniquette/cuff, lasts up to 2 hours, patient discomfort is possible

56
Q

What effects the spread of spinal injection

A

baracity, position, concentration, level of injection

57
Q

How do you position a patient for femoral nerve block? For popliteal nerve block?

A

Femoral: supine, slight external rotation of the femur
Popliteal: prone with operative leg slightly flexed

58
Q

Landmarks of interscalene block?

A

Posterior border of SCM at C6, then roll fingers posterior to groove between anterior and middle scalene
To accentuate the landmarks, have patient sniff

59
Q

What are the advantages to regional anesthesia? (peripheral)

A

Induced sympathectomy (intraop reduction in blood loss, postop improvement in perfusion - vasodilates), reduced N/V, preemptive analgesia, and can avoid general anesthesia

60
Q

What part of the brachial plexus do these techniques block… interscalene, supraclavicular, infraclavicular, axillary?

A

Interscalene: roots and trunks
Supraclavicular: trunks and divisions
Infraclavicular: cords
Axillary: branches

61
Q

What are 3 reasons to have an emergency set up with you during a regional technique?

A
  1. LA toxicity
  2. allergic reaction
  3. conversion to general

N610 Anesthesia Concepts (4 decks)

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