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Regional Anesthesia > Regional Midterm > Flashcards

Regional Midterm Flashcards

(80 cards)

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1
Q

C-4

Dermatome

A

Chest Surgery

C4 = Clavicle

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2
Q

T4-T5

Dermatome

A

Upper Abdomen, C-Section

T4-T-5 = Nipples

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3
Q

T6-T8

Dermatome

A

Appendectomy, OBGYN, Renal

T6-T8 = Xiphoid Process

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4
Q

T8

Dermatome

A

Abdomen

T8 = Lower Edge of Ribcage

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5
Q

T10

Dermatome

A

TURP, Hip, Vaginal

T10 = Umbilicus

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6
Q

L1

Dermatome

A

TURP, Lower Limb

L1 = Inguinal Ligament

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7
Q

L2-L3

Dermatome

A

Foot Surgery

L2-L3 = Knee & Bellow

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8
Q

S2-S5

Dermatome

A

Anal, Perineal

S2-S5 = Perineal

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9
Q

Supraspinous Ligament

A

1st Ligament Passed
C7 to Sacrum
Thickest & Broadest in Upper Lumbar
Connects SPINOUS PROCESSES (adjacent)

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10
Q

Interspinous Ligament

A 
2nd Ligament Passed 
Feels "Gritty" 
Full Length of Cord 
Thickest & Broadest in Lumbar Region 
Connects SPINOUS PROCESSES (adjacent) 
***Seat Epidural Needle and Attach Syringe***
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11
Q

Ligamentum Flavum

A 
Yellow Ligament 
Formen Magnum to Sacral Hiatus 
Thickest in Midline and Furthest from Midline 
Connects LAMINAs (superior to inferior) 
Limits Forward Flexion 
Last Ligament before EPIDURAL SPACE
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12
Q

Layers to EPIDURAL Space

A

1) Skin
2) Subcutaneous Tissue
3) Supraspinous Ligament
4) Interspinous Ligament
5) Ligamentum Flavum
6) Epidural Space = STOP / No CSF / +Loss of Resistance

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13
Q

Layers to SUBARACHNOID / SPINAL Space

A

1) Skin
2) Subcutaneous Tissue
3) Supraspinous Ligament
4) Interspinous Ligament
5) Ligamentum Flavum
6) Epidural Space
7) Dura Mater
8) Arachnoid Mater
9) Subarachnoid Space = POP / +CSF

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14
Q

EPIDURAL Block Level

A 
Sympathetic & Sensory Block Same Level 
Motor Block is (4) Segments LOWER 
Examples: 
T6 Sympathetic AND Sensory 
T10 MOTOR
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15
Q

SPINAL Block Level

A

Sympathetic is (2-6) Segments HIGHER than Sensory
Sensory is (2) Segments HIGHER than MOTOR
Examples:
T4 Sympathetic
T6 Sensory
T8 Motor

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16
Q

SYMPATHETIC Block

A

1st blockade is SYMPATHETIC
B-fibers (myelinated)
3um diameter
Preganglionic Autonomic

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17
Q

SENSORY Block

Pain & Temperature

A 
2nd blockade is SENSORY 
LOSS of PAIN & TEMP 
C-fibers (unmyelinated*) 0.3-1.5um
A-Delta (myelinated) 3-5um 
SAD: Sensory, Afferent, Dorsal
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18
Q

SENSORY Block

Touch & Pressure

A 
3rd blockade is SENSORY 
LOSS of TOUCH & PRESSURE  
C-fibers (unmyelinated*) 0.3-1.5um
A-Delta (myelinated) 3-5um 
SAD: Sensory, Afferent, Dorsal
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19
Q

MOTOR Block

Weakness

A

4th blockade is MOTOR
MOTOR WEAKNESS
A-Gamma (myelinated) 12-20um
MEV: Motor, Efferent, Ventral

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20
Q

MOTOR Block

Paralysis

A 
5th blockade is MOTOR 
PARALYSIS 
A-Beta > A-Alpha 
(myelinated) 12-20 and 5-15um 
MEV: Motor, Efferent, Ventral
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21
Q

Spinal Vertebrae

A

(7) Cervical
(12) Thoracic
(5) Lumbar
(5) Sacral - fused
(4) Coccygeal - fused
Total (33) Vertebrae

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22
Q

Spinal Nerves

A

(31) Pairs of Spinal Nerves
Cervical Nerves (8) exit at Same Vertebrae
All other Nerves exit BELOW Vertebrae

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23
Q

Heparin (SubQ)

A

Delay 1-2hrs AFTER Block

No problems with REMOVAL

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24
Q

Heparin (IV)

A

Delay 1hr AFTER Block
Place block 2-4hrs after STOPPING Heparin
Remove 2-4hrs after STOPPING - Check PTT

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25
Throbolytics
Wait (10) days before placing block
26
Heparin (LMWH)
Place 10-12hrs after LAST DOSE Wait 6-8hrs for NEXT dose after placing block REMOVAL 10-12hrs after LAST dose or 2-4hrs BEFORE next dose
27
Warfarin
Wait 4-5 days - check INR
28
Garlic
7 days before block
29
Ginko
36hrs before block
30
Ginseng
24hrs before block
31
Clopidogrel (Plavix)
7 days before block
32
Ticlopidine (Ticlid)
14 days before block
33
GP IIb/IIIa (ReaPro, Integrilin)
8-48hrs before block
34
(4) Processes of Nociceptive Pain
1. Transduction 2) Transmission 3) Modulation 4) Perception
35
Chloroprocaine
800mg or 1000mg EPI 9mg/kg or 12mg/kg EPI Ester: pseudcholinessterase (C>P>T)
36
Procaine
400mg or 600mg EPI 7mg/kg or 12mg/kg EPI Ester: pseudcholinessterase (C>P>T)
37
Tetracaine
100mg or 200mg EPI No weight based Ester: pseudcholinessterase (C>P>T)
38
Prilocaine
500mg no EPI No weight based Amide: CYP-450 (P>L>M>R>B)
39
Lidocaine
300mg or 500mg EPI 5m/kg or 7mg/kg EPI Amide: CYP-450 (P>L>M>R>B)
40
Mepivicaine
300mg or 500mg EPI 5mg/kg Amide: CYP-450 (P>L>M>R>B)
41
Ropivicaine
300mg no EPI No weight based Amide: CYP-450 (P>L>M>R>B)
42
Bupivicaine
175mg or 225mg EPI 2.5mg/kg or 3mg/kg EPI Amide: CYP-450 (P>L>M>R>B)
43
Lipid Rescue
500mL of 20% Lipid Emulsion 1.5mL/kg over 1 minute Max total dose of 10mL/kg
44
Preventing Local Anesthetics Toxicity
1. Addition of Epinephrine 10-15mcg 2. Ultrasound for placement 3. Incremental Doses of 3-5mL 4. Aspiration prior to injection 5. Use less potent locals and lowest doses
45
Cardio-Acceleratory Fibers
T1 to T4
46
Most Prominent Vertebra
C7
47
Shoulder Blade
T7
48
Iliac Crests
L4-L5 Interspace - location for Spinal/Epidural
49
Posterior / Superior Iliac Spine
S2
50
C-Section Block
T6
51
Vaginal Delivery Block
T10
52
TURP Block
T6
53
Which Nerves are Blocked EASILY?
1. Thinner 2. Myelinated 3. Outer Edge of Bundle
54
(6) Factors Affecting SPINAL LEVEL
1. Baricity of Solution 2. Position of Patient 3. Drug Dose / Volume 4. CSF Volume - inversely related 5. Extremes in Height 6. Age - decreases with advancing age
55
Cutting SPINAL Needles
Quinke Point bevel to the SIDE if not cuts the longitudinal (up/down) dural fibers
56
Pencil Point SPINAL Needles
Sprotte or Whitacre Separates the dura - not cutting Less PDPH no mater what position
57
Site of Action of Neuraxial Blockade
Spinal Nerve Roots and Dorsal Root Ganglia | Same for Epidural and Spinals
58
Epidural Space
Foreman Magnum to Coccyx (sacrococcygeal ligament) Posterior Border - Ligamentum Flavum Anterior Border - Spinal Meninges or Dura Mater Access to Epidural Space via Interlaminar Space 1.5mm Cervical; 3-5mm Thoracic; 5-6mm Lumbar
59
Addition of Epinephrine
1. Prolongs Duration of Action | 2. Decreases Risk of Toxicity
60
Sequence of Blockade
1. B-Fibers: AUTONOMIC 2. A-Delta & C-Fibers: SENSORY 3. A-Gamma: MOTOR Weakness 4. A-Beta & A-Alpha: MOTOR Paralysis
61
Epidural vs. Spinal | (3) Main Differences
EPIDURALS: 1. Sympathetic block is slower less abrupt 2. Sensory is SAME LEVEL as Sympathetic 3. Motor is (4) LOWER than Sensory/Sympathetic SPINALS: 1. Sympathetic is FAST and ABRUPT changes 2. Sensory is (4-6) LOWER than Sympathetic 3. Motor is (2) LOWER than SENSORY
62
EPIDURAL Needles
Larger 17-18g Tuohy is Most Common - blunt tip Leave 3-5cm of cather in epidural space Crawford Needle: front end is open and sharp Weiss Modification: has side wings for hanging drop
63
EPIDURAL Test Dose
3mL of 1.5% Lidocaine w/ 5mcg/mL epinephrine INTRAVACULAR: increased HR within 1 minute INTRATHECAL (Spinal): sacral anesthesia within 3-5minutes
64
(1) Determinante of EPIDURAL Height
1. Volume of Local Anesthetic Given
65
(3) Determinantes of SPINAL Height
1. Baricity 2. Volume of Local Anesthetic Given 3. Patient Position
66
Dosing of EPIDURALS
``` 2mL per segment needing blocking 2mL per segment Pregnancy reduces doses by 1/3 Re-Dose with 1/2 or 1/3 of Initial dose Always aspirate before dosing ```
67
Dorsiflex Feet | Motor Assessment
S1-S2
68
Flex Toes | Motor Assessment
L4-L5
69
Raise Knees | Motor Assessment
L2-L3
70
Lift Shoulders | Motor Assessment
T6-T12
71
Tense Abdominal Rectus | Motor Assessment
T6-T12
72
Dosing of SPINALS
1mL for 5ft patient Add 0.1mL for each inch over 5ft Ex. 5'06" would get 1.6mL
73
Treatment of Local Anesthetic Toxicity | (5) Steps
1. Airway management - always #1 for CRNAs 2. Oxygen 3. Seizures: versed, propofol, suc 4. ACLS: for cardiac arrest 5. LIPID Rescue: for Bupivicaine toxicity,
74
Sodium Bicarbonate and Locals
1. Adding NaHCO3 raises pH 2. Increases non-ionized fraction 3. Increases diffusion 4. SPEEDS THE ONSET
75
Excitatory Peptide
Substance-P C-fibers - SLOW pain Binds to Neurokinin (NK-1) receptors Interacts with 2nd Order Neurons
76
Excitatory Amino-Acid
Glutamate A-Delta - FAST pain Binds to NMDA and AMPA Receptors Interacts with 2nd Order Neurons
77
(5) Advantages of EPIDURALS
1. Segmental block 2. Control of speed of onset 3. Less Hypotension 4. Flexible / Indefinite Duration 5. Less Puncture Headache
78
(4) Disadvantages of EPIDURALS
1. Slow Onset - no good for emergency 2. Larger Doses = Risk Toxicity 3. Technically more difficult 4. Less reliable / less dense blockade
79
Sacral Hiatus
S4-S5 - site of caudal block Due to failure of lamina to fuse Covered by sacrococcygeal ligament
80
(6) Risk Factors of Puncture Headache (PDPH)
1. Young Age 2. Skinnier patients 3. Larger Needles >20g - epidural needles 4. Bevel orientation 5. Needle type - cutting = quincke 6. Repeated sticks

Regional Anesthesia (2 decks)

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