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Regional Anesthesia > Regional Midterm > Flashcards

Regional Midterm Flashcards

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
Q

Throbolytics

A

Wait (10) days before placing block

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26
Q

Heparin (LMWH)

A

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

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27
Q

Warfarin

A

Wait 4-5 days - check INR

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28
Q

Garlic

A

7 days before block

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29
Q

Ginko

A

36hrs before block

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30
Q

Ginseng

A

24hrs before block

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31
Q

Clopidogrel (Plavix)

A

7 days before block

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32
Q

Ticlopidine (Ticlid)

A

14 days before block

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33
Q

GP IIb/IIIa (ReaPro, Integrilin)

A

8-48hrs before block

34
Q

(4) Processes of Nociceptive Pain

A
  1. Transduction
    2) Transmission
    3) Modulation
    4) Perception
35
Q

Chloroprocaine

A

800mg or 1000mg EPI
9mg/kg or 12mg/kg EPI
Ester: pseudcholinessterase (C>P>T)

36
Q

Procaine

A

400mg or 600mg EPI
7mg/kg or 12mg/kg EPI
Ester: pseudcholinessterase (C>P>T)

37
Q

Tetracaine

A

100mg or 200mg EPI
No weight based
Ester: pseudcholinessterase (C>P>T)

38
Q

Prilocaine

A

500mg no EPI
No weight based
Amide: CYP-450 (P>L>M>R>B)

39
Q

Lidocaine

A

300mg or 500mg EPI
5m/kg or 7mg/kg EPI
Amide: CYP-450 (P>L>M>R>B)

40
Q

Mepivicaine

A

300mg or 500mg EPI
5mg/kg
Amide: CYP-450 (P>L>M>R>B)

41
Q

Ropivicaine

A

300mg no EPI
No weight based
Amide: CYP-450 (P>L>M>R>B)

42
Q

Bupivicaine

A

175mg or 225mg EPI
2.5mg/kg or 3mg/kg EPI
Amide: CYP-450 (P>L>M>R>B)

43
Q

Lipid Rescue

A

500mL of 20% Lipid Emulsion
1.5mL/kg over 1 minute
Max total dose of 10mL/kg

44
Q

Preventing Local Anesthetics Toxicity

A
  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
Q

Cardio-Acceleratory Fibers

A

T1 to T4

46
Q

Most Prominent Vertebra

A

C7

47
Q

Shoulder Blade

A

T7

48
Q

Iliac Crests

A

L4-L5 Interspace - location for Spinal/Epidural

49
Q

Posterior / Superior Iliac Spine

A

S2

50
Q

C-Section Block

A

T6

51
Q

Vaginal Delivery Block

A

T10

52
Q

TURP Block

A

T6

53
Q

Which Nerves are Blocked EASILY?

A
  1. Thinner
  2. Myelinated
  3. Outer Edge of Bundle
54
Q

(6) Factors Affecting SPINAL LEVEL

A
  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
Q

Cutting SPINAL Needles

A

Quinke
Point bevel to the SIDE
if not cuts the longitudinal (up/down) dural fibers

56
Q

Pencil Point SPINAL Needles

A

Sprotte or Whitacre
Separates the dura - not cutting
Less PDPH no mater what position

57
Q

Site of Action of Neuraxial Blockade

A

Spinal Nerve Roots and Dorsal Root Ganglia

Same for Epidural and Spinals

58
Q

Epidural Space

A

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
Q

Addition of Epinephrine

A
  1. Prolongs Duration of Action

2. Decreases Risk of Toxicity

60
Q

Sequence of Blockade

A
  1. B-Fibers: AUTONOMIC
  2. A-Delta & C-Fibers: SENSORY
  3. A-Gamma: MOTOR Weakness
  4. A-Beta & A-Alpha: MOTOR Paralysis
61
Q

Epidural vs. Spinal

(3) Main Differences

A

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
Q

EPIDURAL Needles

A

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
Q

EPIDURAL Test Dose

A

3mL of 1.5% Lidocaine w/ 5mcg/mL epinephrine
INTRAVACULAR: increased HR within 1 minute
INTRATHECAL (Spinal): sacral anesthesia within 3-5minutes

64
Q

(1) Determinante of EPIDURAL Height

A
  1. Volume of Local Anesthetic Given
65
Q

(3) Determinantes of SPINAL Height

A
  1. Baricity
  2. Volume of Local Anesthetic Given
  3. Patient Position
66
Q

Dosing of EPIDURALS

A 
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
Q

Dorsiflex Feet

Motor Assessment

A

S1-S2

68
Q

Flex Toes

Motor Assessment

A

L4-L5

69
Q

Raise Knees

Motor Assessment

A

L2-L3

70
Q

Lift Shoulders

Motor Assessment

A

T6-T12

71
Q

Tense Abdominal Rectus

Motor Assessment

A

T6-T12

72
Q

Dosing of SPINALS

A

1mL for 5ft patient
Add 0.1mL for each inch over 5ft
Ex. 5’06” would get 1.6mL

73
Q

Treatment of Local Anesthetic Toxicity

(5) Steps

A
  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
Q

Sodium Bicarbonate and Locals

A
  1. Adding NaHCO3 raises pH
  2. Increases non-ionized fraction
  3. Increases diffusion
  4. SPEEDS THE ONSET
75
Q

Excitatory Peptide

A

Substance-P
C-fibers - SLOW pain
Binds to Neurokinin (NK-1) receptors
Interacts with 2nd Order Neurons

76
Q

Excitatory Amino-Acid

A

Glutamate
A-Delta - FAST pain
Binds to NMDA and AMPA Receptors
Interacts with 2nd Order Neurons

77
Q

(5) Advantages of EPIDURALS

A
  1. Segmental block
  2. Control of speed of onset
  3. Less Hypotension
  4. Flexible / Indefinite Duration
  5. Less Puncture Headache
78
Q

(4) Disadvantages of EPIDURALS

A
  1. Slow Onset - no good for emergency
  2. Larger Doses = Risk Toxicity
  3. Technically more difficult
  4. Less reliable / less dense blockade
79
Q

Sacral Hiatus

A

S4-S5 - site of caudal block
Due to failure of lamina to fuse
Covered by sacrococcygeal ligament

80
Q

(6) Risk Factors of Puncture Headache (PDPH)

A
  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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