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APEX-Regional > REGIONAL-neuraxial block > Flashcards

REGIONAL-neuraxial block Flashcards

1
Q

What are the 4 points of spinal curvature

A
  1. Cervical and lumbar lordosis

2. Thoracic and sacral kyphosis

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2
Q

Which portion of the vertebrae project laterally

A

The 2 transverse processes

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3
Q

Which portion of the vertebrae project posteriorly

A

The spinous process

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4
Q

Which vertebral landmark helps determine midline

A

Spinous process

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5
Q

What distinction differentiates lumbar vertebrae from thoracic and cervical vertebra

A

The orientation of the spinous process

  • Lumbar SP project posteriorly
  • C and T-spine SP angle in caudal direction
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6
Q

How does the difference in spinous process angle of the lumbar vs thoracic vertebra affect epidural access

A

The thoracic SP angle caudally requiring a more cephalad approach with the needle

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7
Q

How does the altered anatomy of C1 and C2 affect function

A

Allows for head rotation at the AO joint

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8
Q

Which vertebra doesn’t have a vertebral body

A

C1 atlas

C2 has a very small vertebral body

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9
Q

Which vertebra has the odontoid process

A

C2 Axis

Also called the dens

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10
Q

Where do spinal nerves exit the vertebral column

A

the intervertebral foramina

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11
Q

What portion of the vertebrae form the posterior border of the intervertebral foramina

A

Facet joints

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12
Q

What alterations reduces the size of the intervertebral foramina
How does this impact the spine

A

Disc degeneration reduces intervertebral foramina size

This can cause nerve compression

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13
Q

What processes form the facet joints

A

Inferior articular process of the top vertebra

Superior articular process of the bottom vertebra

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14
Q 
Name the corresponding posterior surface landmarks for each vertebra
C7
T3
T7
L1
L4
S2
A 
C7 = vertebra prominens
T3 = Spine of scapula (top)
T7 = Inferior angle of scapula
L1 = Rib 12 margin
L4 = Superior aspect of iliac crest
S2 = Posterior superior iliac spine
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15
Q 
Name the corresponding vertebra for each surface landmark
Vertebra prominens=
Spine of scapula=
Inferior angle scapula=
Rib 12 margin=
Superior iliac crest=
PSIS=
A 
Vertebra prominens= C7
Spine of scapula= T3
Inferior angle scapula= T7
Rib 12 margin= L1
Superior iliac crest= L4
PSIS= S2
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16
Q

What is the landmark called that corresponds to the superior aspect of the iliac crest
Correlates with which vertebra

A

Intercristal line aka Tuffier’s line

L4

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17
Q

What do the interspaces above and below the intercristal line correlate with

A 
Above = L3-L4 space
Below = L4-L5 space
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18
Q

In infants up to 1 year, what interspace level does the intercristal line correlate

A

L5 - S1 interspace

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19
Q

4 facts about the sacral hiatus

A
  1. Coincides with S5
  2. Results from incomplete fusion of laminae at S5 (or S4)
  3. Covered by the sacrococcygeal ligament
  4. Entry point to epidural space
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20
Q

2 facts about the sacral cornua

A
  1. Bony nodules that flank the sacral hiatus

2. Result from incomplete development of facets

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21
Q

Where does the spinal cord end in adults vs infant

What is this anatomy called

A

Conus medullaris

Adults = L1-L2
Infant=L3

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22
Q

What is the cauda equina

A

Bundle of spinal nerves extending FROM the conus medullaris to the dural sac

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23
Q

What spinal levels make up the cauda equina

A

Nerves and nerves roots from L2 - S5, coccygeal nerve

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24
Q

Where does the dural sac terminate in adults vs infants

A 
Adult = S2
Infant = S3
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25
Q

What space terminates at the dural sac

A

The subarachnoid space

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26
Q

What is the filum terminale

A

A continuation of pia mater from the conus medullar that extends to the coccyx

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27
Q

What is the function of the filum terminale

A

Anchors the spinal cord to the coccyx

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28
Q

What is the bundle of spinal nerves that extend from the conus medullaris to the dural sac

A

Cauda equina

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29
Q

The filum terminale is fixated at which two points

A

Conus medullaris and coccyx

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30
Q

List the 5 ligaments of the spinal column in order from superficial to deep

A
  1. Supraspinous
  2. Interspinous
  3. Ligamentum flavum
  4. Posterior longitudinal
  5. Anterior longitudinal
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31
Q

List the ligaments the needle passes through when performing a spinal, from superficial to deep

A
  1. Supraspinous ligament
  2. Interspinous ligament
  3. Ligamentum flavum
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32
Q

Which spinal ligaments are not traversed when performing a spinal

A

Posterior longitudinal ligament

Anterior longitudinal ligament

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33
Q

Describe the anatomy of the supraspinous ligament

A

Runs the length of the spin and joins the tips of the spinous processes

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34
Q

4 facts of the ligamentum flavum

A
  1. Two flava run the length of the spinal canal
  2. Form the dorsolateral margin of epidural space
  3. Thickest in the lumbar region
  4. Piercing them contributes to LOR when needle enters the epidural space
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35
Q

What ligament forms the dorsolateral margin of the epidural space

A

Ligamentum flavum

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36
Q

When using the paramedian approach to perform a spinal, which ligaments are traversed
Which ligaments are not traversed

A

Traversed = ligamentum flavum

NOT traversed = supraspinous and interspinous ligaments

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37
Q

When is the paramedian approach for performing a spinal useful

A
  1. Calcified interspinous ligament

2. Pt cannot flex their spine

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38
Q

How is the paramedian approach different from the midline approach

A
  1. 15 degrees off midline
    OR
  2. 1 cm lateral and 1 cm inferior to interspace

Doesn’t traverse supraspinous or interspinous ligaments

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39
Q

What is the order of meningeal layers of the spinal cord from the outside in

A

Dura
Arachnoid
Pia

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40
Q

What are the layers traversed when doing a spinal

A
  1. Skin
  2. SQ tissue
  3. Supraspinous ligament
  4. Interspinous ligament
  5. Ligamentum flavum
  6. Epidural space
  7. Dura mater
  8. Subdural space
  9. Arachnoid mater
  10. Subarachnoid space
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41
Q

What is another name for epidural veins

A

Batson’s plexus

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42
Q

From where do epidural veins drain blood

A

From the spinal cord

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43
Q

What happens to epidural veins with pregnancy and obesity

A

Increased intra-abdominal pressure causes engorgement of epidural veins

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44
Q

What risks are increased when performing an epidural during pregnancy

A

Increased risk of cannulation or injury

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45
Q

What occurs if medication is inadvertently injected into the subdural space when performing a spinal or epidural

A

Spinal dosing = failed spinal

Epidural dosing = high spinal

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46
Q

What space is the target when performing a spinal

A

subarachnoid space

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47
Q

What structures are contained in the subarachnoid space

A

CSF
Nerve roots
Rootlets
Spinal cord

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48
Q

Which meninge is never punctured during spinal anesthesia

A

Pia mater

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49
Q

How many paired spinal nerves are there

A

31

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50
Q

What is the anatomy of each spinal nerve

A

They each have a posterior (dorsal) nerve root or anterior (ventral) nerve root

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51
Q

What information is carried via posterior vs anterior nerve roots

A 
Posterior = sensory
Anterior = motor, autonomic
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52
Q

What is a dermatome

A

An area of skin that’s innervated by a dorsal spinal nerve

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53
Q 
What is the corresponding cutaneous landmark for each nerve root
C6
C7
C8
T4
T6
T10
T12
L4
A 
C6 = thumb
C7 = 2nd/3rd digits
C8 = 4th/5th digits
T4 = Nipple line
T6 = Xiphoid process
T10 = umbilicus
T12 = Pubic symphysis
L4 = Anterior knee
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54
Q

What nerve serves as sensory innervation of the face

A

The 3 branches of cranial nerve V (trigeminal nerve)

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55
Q

What are the 3 branches of cranial nerve V

A 
V1 = ophthalmic
V2 = Maxillary 
V3 = Mandibular
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56
Q 
What spinal nerve roots correspond to the following landmarks
Anterior knee = 
Thumb = 
Umbilicus = 
Nipple line = 
2nd/3rd digit = 
Pubic symphysis = 
4th/5th digits = 
Xiphoid process =
A 
Anterior knee = L4
Thumb = C6
Umbilicus = T10
Nipple line = T4
2nd/3rd digit = C7
Pubic symphysis = T12 
4th/5th digits = C8
Xiphoid process = T6
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57
Q

What 3 surgical procedures require sensory level at T4

Landmark

A
  1. Upper abd surgery
  2. C-section
  3. Cystectomy

Landmark = nipple line

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58
Q

What 2 surgical procedures require sensory level block at T6-T7
Landmark

A
  1. Lower abd surgery
  2. Appendectomy

Landmark = xiphoid process

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59
Q

What 3 surgical procedures require sensory level block at T10
Landmark

A
  1. Total hip arthroplasty
  2. Vaginal delivery
  3. TURP

Landmark = umbilicus

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60
Q

What surgery requires sensory level block at L1 - L3

Landmark

A

LE surgery

Landmark = inguinal ligament

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61
Q

What surgery requires sensory block at L2-L3

A

Foot surgery

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62
Q

What surgery requires sensory block at S2-S5

A

Hemorrhoidectomy

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63
Q

Where is catheter insertion location for thoracic surgeries like thoracotomy or thoracic aneurysm repair
How much local

A

T2 - T6

Local = 5-10 mL

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64
Q

Where is catheter insertion location for upper abdominal surgeries
How much local

A

T6 - L1

Local = 10 - 20 mL

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65
Q

Where is catheter insertion location for LE surgeries like THA or TKA
How much local =

A

L2 - L5

Local = 20 mL

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66
Q

What are 4 key benefits of thoracic epidural vs lumbar epidural

A
  1. Superior analgesia
  2. Minimizes surgical stress response
  3. Reduces incidence of postop pulmonary complications
  4. Can spare LE nerves, allowing for postop ambulation
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67
Q

What are 2 reasona thoracic epidural may be more challenging than a lumbar epidural

A
  1. Spinous processes are more angles in the T-spine

2. The epidural space is small

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68
Q

When an epidural is combined with GA, there can be an increased risk of what 3 cardiopulmonary issues

A
  1. bradycardia
  2. HoTN
  3. Altered airway resistance
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69
Q

Why is bradycardia possible when epidural anesthesia is used with GA

A

The cardioaccelerator nerves are blocked at T1 - T4

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70
Q

Why is HoTN possible when epidural anesthesia is used with GA

A

There’s a decrease in CO and increased vasodilation

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71
Q

What airway changes occur d/t epidural anesthesia in conjunction with GA

A

Epidural anesthesia can increase vagal influence on airways (increased resistance and constriction)

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72
Q

What is the primary site of spinal anesthesia action in the subarachnoid space

A

Myelinated preganglionic fibers of spinal nerve roots

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73
Q

what is the site of action for epidural anesthesia

A
  • Diffusion through the dural cuff to the nerve root

- Leaking into the intervertebral foramen to enter the paravertebral area

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74
Q

How is the spread of local anesthetic controlled with spinal anesthesia (4)

A
  1. Baracity
  2. Pt position during and after block placement
  3. Dose
  4. Site of injection
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75
Q

What are 2 non-controllable factors that affect spread of spinal anesthesia

A
  1. Volume of CSF

2. Density of CSF

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76
Q

List 7 factors that do not affect spread of spinal anesthesia

A
  1. Barbotage
  2. Increased intra-abdominal pressure (i.e. cough)
  3. Speed of injection
  4. Orientation of bevel
  5. Addition of vasoconstrictor
  6. Weight
  7. Gender
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77
Q

What is the most reliable factor of intrathecal spread when using hypo- or isobaric solution

A

Dose

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78
Q

What is the most reliable factor of intrathecal spread when using hyperbaric solution

A

Baracity

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79
Q

What are the 2 most reliable determinants of intrathecal spread

A
  1. Dose when hypo- or isobaric

2. Baracity when hyperbaric

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80
Q

What 3 factors significantly affect spread of epidural anesthesia

A
  1. LA volume
  2. Level of injection
  3. LA dose
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81
Q

What are 2 non-controllable factors that significantly affect spread of epidural anesthesia

A
  1. Pregnancy

2. Old age

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82
Q

What are 2 factors that have a small effect on epidural anesthesia spread

A
  1. LA concentration

2. Patient position

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83
Q

What are 3 factors that have a SMALL effect on epidural anesthesia spread

A
  1. Height
  2. Body weight
  3. Pressure in nearby body cavities
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84
Q

What are 3 factors that do NOT affect epidural anesthesia spread

A
  1. Additives
  2. Direction of bevel
  3. Speed of injection
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85
Q

How does the level of injection affect epidural anesthesia spread
Lumbar
Midthoracic
Cervical

A
  1. Spread is mostly cephalad
  2. Spread is equally cephalad and caudad
  3. Spread is mostly caudad
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86
Q

What is the order of blocking fibers with local anesthetic

A
  1. Autonomic fibers
  2. Sensory fibers
  3. Motor neurons
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87
Q

How does neurologic function return as local anesthetic decreases

A
  1. motor neuron
  2. sensory fibers
  3. Autonomic fibers
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88
Q

How are the levels of blockade for autonomic, sensory, and motor fibers distributed with spinal anesthesia

A

Autonomic block is 2-6 levels above sensory

Sensory is 2 levels above motor

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89
Q

How are the levels of blockade for autonomic, sensory, and motor fibers distributed with epidural anesthesia

A

Sensory and SNS block are 2-4 levels above motor

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90
Q

Why are the level of autonomic and sensory blocks higher than motor

A

Because the LA concentration required to block sensory fibers is less than motor
The concentration to block SNS fibers is less then sensory

As the LA anesthetic spreads upward, the concentration is less but still effective as SNS or sensory block

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91
Q

What is the first sensory modality blocked

A

Sense of temperature

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92
Q

How can you test the first portion of differential blockade

A

With an alcohol pad, they won’t feel cold

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93
Q

What is the second sensory modality blocked

A

Pain

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94
Q

How can you test the second portion of differential blockade

A

Pinprick

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95
Q

What is the last sensory modality blocked

A

Sense of light touch or pressure

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96
Q

What is the method of monitoring motor block

A

Modified Bromage Scale to assess the degree of motor block

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97
Q

What does the modified bromage scale assess

A

Motor block of the lumbosacral nerves

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98
Q

What are the levels of the modified bromage scale

A

0=no motor block
1=Cannot raise an extended leg; moves knees/feet
2=Cannot raise an extended leg or move knee; moves feet
3=Complete motor block; no leg, knee, or feet movement

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99
Q

Peripheral nerve fiber velocity greatest to least

A

A alpha = A beta > A gamma = A delta > B > C sympathetic = C dorsal root

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100
Q

Peripheral nerve fiber block onset from first to last

A 
1st = B
2nd = C sympathetic, C dorsal root
3rd = A gamma, A delta
4th = A alpha, A beta
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101
Q

Peripheral nerve fiber myelination from most to least

A

Heavy: A alpha = A beta Medium: A gamma = A delta
Light: B

C fibers = NO myelination

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102
Q

Why are B and C fibers blocked first and second

A

B fibers = preganglionic ANS fibers

C fibers = Postganglionic ANS fibers (then pain/temp/touch)

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103
Q

What structure must be traversed by epidural LAs and what is their primary target?

A

First diffuse through the dural cuff before they can anesthetize the nerve root (target)

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104
Q

What is the primary drug-related determinant of local anesthetic spread in the epidural space

A

The volume of LA

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105
Q

What type of nerve fiber is blocked first after a spinal anesthetic

A

Type B - preganglionic ANS fibers

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106
Q

Function of A alpha fibers

A

Skeletal muscle = motor
Proprioception
(preserved with anterior spinal artery ischemia)

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107
Q

Function of A beta fibers

A

Touch

Pressure

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108
Q

Function of A gamma fibers

A

Skeletal muscle tone

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109
Q

Function of A delta fibers

A
  1. Fast pain
  2. Temperature
  3. Touch
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110
Q

Function of B fiber

A

preganglionic ANS fibers

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111
Q

Function of C sympathetic fibers

A

Postganglionic ANS fibers

112
Q

Function of C dorsal root

A
  1. Slow temp
  2. Temperature
  3. Touch
113
Q

The addition of what solution leads to a hyperbaric solution in spinal anesthetic

A

Dextrose

114
Q 
Spinal dose Bupivacaine 0.5 - 0.75%
Dose T10=
Dose T4=
Onset=
Duration plain=
Duration epi=
A 
Level T10= 10-15 mg
Level T4= 12-20 mg
Onset= 4-8 min
Duration plain= 130-220 min
Duration epi= +20-50%
115
Q 
Spinal dose Levobupivacaine 0.5%
Level T10=
Level T4=
Onset=
Duration plain=
A

Level T10= 10-15 mg
Level T4= 12-20 mg
Onset= 4-8 min
Duration plain= 140-230 min

116
Q 
Spinal dose Ropivacaine 0.5-1%
Level T10=
Level T4=
Onset=
Duration plain=
A

Level T10= 12-18 mg
Level T4= 18-25 mg
Onset= 3-8 min
Duration plain= 80-210 min

117
Q 
Spinal dose 2-Chloroprocaine 3% (w/wo dextrose)
Level T10=
Level T4=
Onset=
Duration plain=
A

Level T10= 30-40 mg
Level T4= 40-60 mg
Onset= 2-4 min
Duration plain= 40-90 min

118
Q 
Spinal dose Tetracaine 0.5-1% (with dextrose)
Level T10=
Level T4=
Onset=
Duration plain=
Duration epi=
A 
Level T10= 6-10 mg
Level T4= 12-16 mg
Onset= 3-5 min
Duration plain= 90-120 min
Duration epi= +20-50%
119
Q 
List the following meds from quickest onset to slowest 
Tetracaine
Chloroprocaine
Bupivacaine
Ropivacaine
Levobupivacaine
A

2-Chloroprocaine, Tetracaine, ropivacaine, bupivacaine = levobupivacaine

120
Q 
Duration of the following meds from longest to shortest 
Tetracaine
Chloroprocaine
Bupivacaine
Ropivacaine
Levobupivacaine
A

Levobupivacaine > Bupivacaine > Ropivacaine > Tetracaine > 2-Chloroprocaine

121
Q

Which LA requires the largest dose for spinal anesthesia

A

Chloroprocaine (30-60 mg)

122
Q

Which LA requires the smallest dose for spinal anesthesia

A

Tetracaine (6-16 mg)

123
Q

What is the initial dose for epidural anesthetic

A

1-2 mL per segment to be blocked

124
Q

What is the “top-up” dose for epidural anesthesia

A

50-75% of initial dose

125
Q

When is a “top-up” dose administered

A

Before the block recedes more than 2 dermatomes

126
Q

Why is LA spread greater in the thoracic region vs the lumbar with an epidural

A

The thoracic epidural space is smaller than lumbar

127
Q

What is the primary determinant of epidural block height

A

Volume

128
Q

What is the primary determinant of epidural block density

A

Concentration

129
Q

How is a “walking epidural” achieved

A

Low concentration that provides analgesia but preserves motor function

130
Q

Epidural with 2-Chloroprocaine
Concentration=
Onset=
Duration=

A 
Concentration= 3%
Onset= 5-15 min
Duration= 30-90 min
131
Q

Epidural with Lidocaine
Concentration=
Onset=
Duration=

A 
Concentration= 2%
Onset= 10-20 min
Duration= 60-120 min
132
Q

Epidural with Ropivacaine
Concentration=
Onset=
Duration=

A 
Concentration= 0.1-0.75%
Onset= 15-20 min
Duration= 140-220 min
133
Q

Epidural with Bupivacaine
Concentration=
Onset=
Duration=

A 
Concentration= 0.0625-0.5%
Onset= 15-20 min
Duration= 160-220 min
134
Q

Epidural with levobupivacaine
Concentration=
Onset=
Duration=

A

Concentration= 0.0625-0.5%
Onset= 15-20 min
Duration=150-225 min

135
Q 
What is the onset for the following drugs from fastest to slowest when dosing an epidural
Chloroprocaine
Bupivacaine
Ropivacaine
Levobupivacaine
A

2-Chloroprocaine
Lidocaine
Ropivacaine = Bupivacaine = Levobupivacaine

136
Q 
What is the duration for the following drugs from shortest to longest when dosing an epidural 
Chloroprocaine
Bupivacaine
Ropivacaine
Levobupivacaine
A

2-Chloroprocaine
Lidocaine
Ropivacaine, Levobupivacaine, Bupivacaine

137
Q

Define baricity

A

The density of a LA relative to the CSF

138
Q

Compare the following
Isobaric
Hyperbaric
Hypobaric

A

LA solution compared to CSF
Isobaric = 1 (remain)
Hyperbaric = >1 (sinks)
Hypobaric = <1 (rise)

139
Q

What solutes are added to make the following mixture baracities
Isobaric
Hyperbaric
Hypobaric

A 
Isobaric =  sline
Hyperbaric = dextrose
Hypobaric = water
140
Q

Why is procaine 10% in water hyperbaric

A

because a 10% solution contains a lot of molecules

141
Q

Where do hyperbaric solutions accumulate (i.e. sitting vs supine)

A

The lowest point of spinal canal
Sitting = sinks, causing saddle block
Supine = in the thoracic kyphotic portions (T5-T7, S2)

142
Q

Where do hypobaric solutions accumulate (i.e. sitting vs supine)

A

The highest point of the spinal canal
Sitting = rise towards brain
Supine = Lordotic lumbar region (L3)

143
Q

What physical body alterations can affect spinal LA spread

A

Obesity = excessive lumbar lordosis

Ankylosing spondylosis = spinal fixation w/ lac of normal curve

144
Q

What is the highest point of lordosis in the supine position

A

C5 and L3

145
Q

What are the highest points of kyphosis in the supine position

A

T5-T7 and S2

146
Q

When is bradycardia a concern with neuraxial anesthesia

A

When fibers at T1-T4 are inhibited (cardioaccelerator nerves)

147
Q

What effects does neuraxial anesthesia have on the respiratory system

A

Negligible effect on Vm, Vt, RR, Vds, & ABG

148
Q

How are respiratory muscles affected by neuraxial anesthesia

A
  • Accessory muscle function is reduced

- Impaired intercostal and abd muscles decrease pulm reserve

149
Q

What 2 effects does neuraxial anesthesia have on the GI tract

A
  1. relaxation of sphincters

2. Increased peristalsis

150
Q

What is the primary mechanism of HoTN during neuraxial anesthesia

A

Block of pre-ganglionic B fibers in the sympathetic chain

151
Q

What are 4 additional reasons HoTN occurs with neuraxial anesthesia

A
  1. Decreased catecholamine output from adrenals
  2. Skeletal muscle paralysis
  3. Direct effects of LA on systemic circulation
  4. Decreased preload d/t venous dilation
152
Q 
What effect does neuraxial anesthesia have on the following:
Preload
Afterload
Cardiac output
HR
A

Preload = decreased
Afterload = decreased
Cardiac output = variable
HR = variable

153
Q

Why is neuraxial anesthetic effect on cardiac output variable

A

d/t 2 competeing changes

  1. decreased VR => decreased SV => decreased CO
  2. decreased SVR => INC CO
154
Q

Why is neuraxial anesthetic effect on HR variable

A

Competing HR effects

  1. HoTN => baroreceptor reflex activation => increased HR
  2. Preganglionic block of cardioaccelerator fibers => relative INC PNS tone
155
Q

What pts can have pulmonary problems with neuraxial anesthesia

A

COPD pts

156
Q

Rationale for apnea in the following neuraxial aneshtesia

A

Result of brainstem hypoperfusion

157
Q

What mechanism can cause drowsiness with neuraxial anesthesia

A

Reduced sensory input to reticular activating system

158
Q

How does neuraxial anesthesia decreased surgical stress response

A
  1. Inhibits afferent traffic from surgical site

2. Reduces circulating catecholamines, renin, angiotensin, glucose, TSH, growth hormone

159
Q

Which spinal nerves provide sympathetic innervation to the GI tract

A

T5 - L2

160
Q

Which nerve provides parasympathetic innervation to the GI tract

A

CN 10 (vagus nerve)

161
Q

What reflex contributes to asystole that occurs with spinal anesthesia

A

Bezold-Jarisch reflex

-The heart slows to allow it adequate time to fill

162
Q

Where do neuraxial opioids inhibit afferent pain transmissions

A

Substantia gelatinosa (lamina 2 of dorsal horn)

163
Q

What 3 mechanisms reduce neurotransmission with neuraxial opioids

A
  1. Decreased cAMP
  2. Decreased Ca++ conductance
  3. Increased K+ conductance
164
Q

What effect do neuraxial opioids have when combined with local anesthetics

A

They create a denser block

165
Q

Describe the CSF spread of hydrophilic neuraxial opioids (3)

A
  1. Extensive spread
  2. Wide band of analgesia
  3. Most rostral spread toward brain
166
Q

Describe the CSF spread of lipophilic neuraxial opioids (3)

A
  1. Minimal
  2. Narrow band of analgesia
  3. Less rostral spread
167
Q

Where is the site of action of hydrophilic neuraxial opioids

A

Rexed laminae 2 and 3

168
Q

What is the onset of hydrophilic vs lipophilic neuraxial opioids

A 
Hydrophilic = 30 - 60 min (DELAYED)
Lipophilic = 5 - 10 min (FAST)
169
Q

What is the duration of hydrophilic vs lipophilic neuraxial opioids

A 
Hydrophilic = 6-24 hrs (LONGER)
Lipophilic = 2-4 hrs (SHORTER)
170
Q

How does systemic absorption of hydrophilic vs lipophilic neuraxial opioids differ

A 
Hydrophilic = less systemic absorption
Lipophilic = more absorption
171
Q

Describe the effect of hydrophilic neuraxial opioids on respirations

A

Biphasic respiratory depression

Early <6 hrs (from minimal systemic absorption)
Late >6 hours (from action on the brainstem)

172
Q

Compare the incidence of N/V and pruritis with hydrophilic vs lipophilic neuraxial opioids

A

The incidence of N/V and pruritis is much higher with hydrophilic opioids

173
Q

How do opioids injected in the epidural space exert their action

A
  1. Diffuses in the epidural tissue

2. Diffuses across the dural cuff into the CSF to the spinal cord

174
Q

Sufentanil dosing:
Intrathecal =
Epidural =
Infusion =

A 
Intrathecal = 5-10 mcg
Epidural = 25 - 50 mcg
Infusion = 10-20 mcg/hr
175
Q

Fentanyl dosing:
Intrathecal =
Epidural =
Infusion =

A 
Intrathecal = 10-20 mcg
Epidural = 50-100 mcg
Infusion = 25-100 mcg/hr
176
Q

Hydromorphone dosing:
Intrathecal =
Epidural =
Infusion =

A 
Intrathecal = NONE
Epidural = 0.5-1 mg
Infusion = 0.1-0.2 mg/hr
177
Q

Meperidine dosing:
Intrathecal =
Epidural =
Infusion =

A 
Intrathecal = 10 mg
Epidural = 25-50 mg
Infusion = 10-60 mg/hr
178
Q

Morphine dosing:
Intrathecal =
Epidural =
Infusion =

A 
Intrathecal = 0.25-0.30 mg
Epidural = 2-5 mg
Infusion = 0.1-1 mg/hr
179
Q

What are 4 common side effects of neuraxial opioid administration. Which is the most common

A
  1. Pruritis (most common)
  2. Respiratory depression
  3. Urinary retention
  4. N/V
180
Q

What is the mechanism of neuraxial opioid induced pruritis

A

Stimulation of opioid receptors in the trigeminal nucleus

NOT by mast cell degranulation (it is NOT a histamine reaction)

181
Q

How is neuraxial opioid induced pruritis treated

A

Opioid antagonist i.e. naloxone

182
Q

What medication does not treat neuraxial opioid induced pruritis

A

Diphenhydramine

183
Q

What 6 factors increase respiratory depression with neuraxial opioids

A
  1. High opioid dosing
  2. Co-administration of sedatives
  3. Low lipid solubility
  4. Advanced age
  5. Opioid naivety
  6. Increased intrathoracic pressure
184
Q

What are 3 facts of urinary retention r/t neuraxial opioid administration

A
  1. Most common in young males
  2. More common wit neuraxial opioids vs IV/IM injection
  3. Can be reversed with naloxone
185
Q

What is the mechanism of neuraxial opioid induced urinary retention

A

Inhibition of sacral parasympathetic tone

Causes bladder detrusor muscle relaxation and urinary sphincter contraction

186
Q

Activation at which 2 areas causes neuraxial opioid induced N/V

A

Activation of opioid receptors in the:

  1. Area postrema of medulla
  2. Vestibular apparatus
187
Q

Which LA can reduces the efficacy of epidural opioids

A

2-Chloroprocaine

188
Q

Which neuraxial opioid most commonly causes sedation

A

Sufentanil

189
Q

Why do neuraxial opioids have an antidiuretic effect

A

By increasing vasopressin release

190
Q

What is an absolute contraindication to neuraxial anesthesia

A

Patient refusal

191
Q

What are 11 relative contraindications of neuraxial anesthesia

A
  1. Coagulopathy
  2. Increased ICP
  3. Sepsis
  4. Infection at puncture site
  5. Severe hypovolemia
  6. Valve lesions with fixed stroke volumes (AS)
  7. Scoliosis, spinal fusions
  8. Difficult airway
  9. Full stomach
  10. Peripheral neuropathy
  11. MS
192
Q

Why is coagulopathy a relative contraindication for neuraxial anesthesia

A

d/t risk of spinal or epidural hematoma

193
Q

At what lab levels are neuraxial blocks contraindicated

A

Plt < 100,000 mm3

PT, aPTT, bleeding time > 2x normal

194
Q

Why is increased ICP a relative contraindication for neuraxial anesthesia

A

It can increase the chance of brain herniation with sudden change in CSF pressure

195
Q

Why is sepsis a relative contraindication for neuraxial anesthesia

A
  1. Can introduce contaminated blood beyond BBB

2. Worsening of HoTN

196
Q

Why is hypovolemia a relative contraindication for neuraxial anesthesia

A

Hypovolemia can worsen HoTN d/t sympathectomy

197
Q

Which valve lesions can be considered a relative contraindication for neuraxial anesthesia

A

Severe aortic and mitral stenosis

Hypertrophic cardiomyopathy

198
Q

Why is a h/o scoliosis, arthritis, or spinal fusion a relative contraindication to neuraxial anesthesia

A

These conditions make neuraxial techniques more technically difficult and less reliable

199
Q

Why is MS a relative contraindication for spinal anesthesia

A

There is a small risk of possible symptom exacerbation

Demyelination could increase susceptibility to LA-induced neurotoxicity so use lower dose

200
Q

Which spina bifida defects are at greatest risk for complications d/t neuraxial anesthesia

A

Severe neural tube defects

Tethered cord

201
Q

What are the categories of spinal needles

A
  1. Cutting Type
  2. Non-cutting type
    - pencil point
    - rounded bevel
202
Q

Which needles are pencil point

A

Sprotte
Whitacre
Pencan

203
Q

Which needle is a cutting point

A

Quincke

Pitkin

204
Q

What are 4 benefits of using a non-cutting tip spinal needle

A
  1. Lower risk of PDPH
  2. More tactile feel
  3. Needle less likely to deflect
  4. Less likely to injure the cauda equina
205
Q

What are 4 drawbacks of using a cutting tip spinal needle

A
  1. Higher risk of PDPH
  2. Less tactile feel
  3. Needle more easily deflected
  4. More likely to injure cauda equina
206
Q

What is a benefit of using a cutting tip spinal needle

A

Requires less force

207
Q

What is a drawback of the non-cutting tip spinal needles

A

Requires more force

208
Q

How is the risk of needle deflection minimized when using a spinal needle <22g

A

By placing an introducer in the interspinous ligament

209
Q

What are 3 types of epidural needles

A

Crawford
Hustead
Tuohy

210
Q

How does the needle angle compare between epidural needles

A 
Crawford = 0 degree
Hustead = 15 degree
Tuohy = 30 degree
211
Q

What are the benefits of the increased needle of an epidural needle

A

Minimizes the risk of dural puncture

212
Q

What are the benefits of using a Tuohy needle

A

The 30-degree curvature and blunt tip minimizes dural puncture risk

213
Q

What is the distance of the epidural space from skin
Adults =
Pregnant/obese=

A 
Adults = 3-5 cm
Pregnant/obese= >5 cm up to 9 cm
214
Q

What is the approximate distance from the ligamentum flavum to the dura

A

~7 mm

Range = 2 mm - 2.5 cm

215
Q

What is the optimal depth of catheter inside the epidural space

A

3 - 5 cm

216
Q

What are the risks of not advancing the epidural catheter enough OR too much

A

Too shallow = higher incidence of inadequate analgesia (epidural failure)

Too deep = Cath may enter an epidural vein or exit an intervertebral foramen

217
Q

Where should the epidural catheter be secured at the skin (length) if LOR is at 4 cm

A

7 - 9 cm at skin

218
Q

What are the areas blocked by a caudal approach to the epidural space

A

Sacral, lumbar, and lower thoracic dermatomes

219
Q

What procedural level is a caudal block useful

A

Sensory block up to T10

220
Q

Why are caudal blocks infrequently used in adolescence or adults

A
  1. Sacral anatomy is more difficult to identify

2. Lumbar approach to epidural space is easier to perform

221
Q

What are 3 absolute contraindications for caudal anesthesia

A
  1. Spina bifida
  2. Meningomyelocele of the sacrum
  3. Meningitis
222
Q

What are 5 relative contraindications for caudal anesthesia

A
  1. Pilonidal cyst
  2. Abnormal superficial landmarks
  3. Hydrocephalus
  4. Intracranial tumor
  5. Progress degenerative neuropathy
223
Q

What are the landmarks for performing a caudal block

A

Posterior superior iliac spines

Sacral hiatus

224
Q

At what angle is a caudal block approached

A

45* angle aiming cephalad

225
Q

Technique for preforming a caudal block

A
  1. Position laterally or prone
  2. Identify landmarks (PSIS - sacral hiatus)
  3. Sterilize injection site
  4. Using 22 or 25 g needle, bevel up through sacral hiatus at 45* aiming cephalad
  5. Once pop felt, drop angle and advance further into the epidural space
226
Q

When performing a caudal block, what does the “pop” signifiy

A

Getting into the epidural space after passing through the sacrococcygeal ligament

227
Q

How is the risk for dural puncture with a caudal block increased

A

Passing the needle tip beyond S2-S3

228
Q

What are 3 assessments that should be done while performing a caudal block

A
  1. Aspirate for blood or CSF
  2. Palpate skin during injection to r/o SQ infiltration
  3. Resistance = tip in subperiosteal area
229
Q

Is air used for LOR when performing a caudal block

A

No, d/t the risk of air embolism

230
Q

What adjunct can increase caudal block duration. Mechanism of action

A

Epinephrine 1:200,000 (5 mcg/mL)

MOA: reduced vascular uptake of LA

231
Q

What adjunctive medication can be used in place of an opioid in a caudal block

A

Clonidine 1 mcg/kg provides analgesia equal to epidural opioid

232
Q

How is the height of a caudal block determined

A

By the volume of LA (similar to epidural)

233
Q

Pediatric caudal block dosing level
Sacral=
Sacral to low thoracic (T10)=
Sacral to mid thoracic=

A

Sacral= 0.5 mL/kg
Sacral to low thoracic (T10)= 1 mL/kg
Sacral to mid thoracic= 1.25 mL/kg

234
Q

Adult caudal block dosing level:
Sacral=
Sacral to low thoracic (T10)=
Sacral to mid thoracic=

A

Sacral= 12-15 mL
Sacral to low thoracic (T10)= 20-30 mL
Sacral to mid thoracic= N/A

235
Q

What is the max dose of LA for pediatric caudal block

A

2.5 - 3.0 mg/kg of any concentration of bupivacaine, levobupivacaine, or ropivacaine

236
Q

5 Procedural Indications for caudal block in children

A
  1. Circumcision
  2. Hypospadias repair
  3. Anal surgery
  4. Inguinal herniorrhaphy
  5. Low thoracic surgery
237
Q

Why is there a risk for epidural hematoma with concurrent use of anticoagulant medication and neuraxial anesthesia

A

Epidural blood can accumulate between the dura and the bone

The accumulation of blood in the epidural space can compress the spinal cord, causing ischemia and permanent neurological dysfunction

238
Q

What are 4 presenting symptoms of epidural hematoma

A
  1. LE weakness
  2. LE numbness
  3. Low back pain
  4. Bowel and bladder dysfunction
239
Q

What intervention must be performed within what timeframe if an epidural hematoma occurs following neuraxial anesthesia

A

Surgical decompression

Within 8 hours

240
Q

Neuraxial management when patient takes NSAIDs or ASA

A

Assess coagulation status appears normal

No added risk, proceed

241
Q

Neuraxial management when patient takes glycoprotein IIb/IIIa antagonist
Drug examples
Hold time
Restart time

A

Examples: Tirofiban, Eptifibatide, Abciximab

Avoid neuraxial until plt function is recovered:
Hold = 4-8 hrs (tirofiban, eptifibatide)
Hold = 24-48 hrs (abciximab)

Do NOT restart within 4 weeks of neuraxial

242
Q

Neuraxial management when patient takes thienopyridine derivative
Drug examples
Hold times
Restart time

A

Ex: clopidogrel, prasugrel, ticlopidine

Pre block
Hold 5-7 d (clopidogrel)
Hold 7-10 d (prasugrel)
Hold 10 d (Ticlopidine)

Restart = 24 hrs postop

243
Q 
Neuraxial management when patient takes unfractionated heparin
Drug examples
Hold times
Restart time
Cath removal
A

Ex: Heparin

Clinical assessment of coag status normal?

PreBlock
Hold 4-6 hrs = low dose
Hold 12 hrs = Up to 20,000 U/day
Hold 24 hrs = high-dose >20,000 U/d

Restart heparin:
1 hr post block placement
1 hr post cath removal

Cath removal:
Hold 4-6 hr post SQ dose or IV infusion dc’d

244
Q 
Neuraxial management when patient takes low molecular weight heparin:
Drug examples
Hold times
Restart time
Cath removal
A

Ex: enoxaparin, dalteparin, tinzaparin

Clinical assessment of coag status normal? Get plt count

Preblock:
Prophylactic dose = Hold for 12 hrs then block
Therapeutic dose = hold 24 hrs then block

Restart LMWH
12 hrs post cath insertion
24 hrs post cath removal

Cath removal:
Remove before initiating preferably
12 hrs post last dose

245
Q

How long should LMWH be held after epidural catheter removal

A

4 hrs

246
Q

Neuraxial management when patient takes anti-vitamin K drugs
Drug examples
Hold times
Cath removal

A

Ex: warfarin

Preblock hold
5 days
Verify INR normal

Cath removal:
Verify INR <1.5

247
Q

What should the INR be prior to epidural catheter removal

A

<1.5

248
Q

Neuraxial management when patient takes oral anti-factor 10a agents
Drug examples
Hold times
Restart time

A

Ex: apixaban, betrixaban, edoxaban, rivaroxaban

Preblock:
D/c 3 d prior to block
Check anti-factor 10a activity if <73 hrs

Cath removal:
6 hrs before 1st postop dose

249
Q

Neuraxial management when patient takes thrombolytic agents

Drug examples

A

Ex: T-Pa, streptokinase, alteplase, urokinase

ABSOLUTE contraindication to neuraxial anesthesia

250
Q

Neuraxial management when patient takes herbal therapies that inhibit plt aggregation
Drug examples

A

Ex: garlic, ginkgo, ginseng

Proceed with neuraxial if pt isn’t taking other blood thinners

251
Q

What 3 etiologies explain a post-dural puncture headache

A
  1. CSF leaks from the subarachnoid space via the dural puncture
  2. As CSF pressure is lost, the cerebral vessels dilate
  3. Meninges are stretched, pulling on tentorium, d/t brainstem sagging into foramen magnum
252
Q

What are 6 classic symptoms of a post-dural puncture headache

A
  1. Fronto-occipital HA
  2. N/V
  3. Photophobia
  4. Diplopia
  5. Tinnitus
  6. Worse when upright
253
Q

What position relieve PDPH

A

supine

254
Q

What 3 patient factors increase risk of PDPH

A
  1. Younger age
  2. Female
  3. Pregnancy
255
Q

What are 4 practitioner factors that increase the risk of PDPH

A
  1. Use of cutting tip needle
  2. Using large diameter needle
  3. Use of air for LOR with epidural
  4. Needle perpendicular to long-axis of neuraxis
256
Q

What are 5 practitioner factors that lower risk of PDPH

A
  1. non-cutting tip needle use
  2. Smaller diameter needle
  3. Using fluid for LOR
  4. Needle parallel to long-axis of neuraxis
  5. Continuous spinal catheter after wet tap
257
Q

What are the 5 indicated treatments for PDPH

A
  1. Bed rest
  2. NSAIDs
  3. Caffeine (cerebral vasoconstriction)
  4. Epidural blood patch)
  5. Sphenopalatine ganglion block
258
Q

What is the definitive treatment for PDPH

A

Epidural blood patch

259
Q

How is a blood patch performed

A

Using sterile technique, 10-20 mL of venous blood is drawn then reintroduced into the epidural space

When pressure is sensed in her legs, buttocks, or back the injection is complete

260
Q

What are 2 useful reasons to employ blood patch following PDPH

A
  1. Compresses the epidural and SA space, increasing CSF pressure
  2. Acts as a plug, preventing further leaks
261
Q

How is a sphenopalatine ganglion block performed

A
  1. LA soaked cotton-tipped applicator
  2. Sniff position
  3. Insert applicator in each nare until nasopharynx is encountered
  4. Leave applicator for 5-10 minutes
262
Q

Why does a 5-HT3 antagonist minimize spinal-induced HoTN

A

The Bezold-Jarisch reflex is likely mediated by 5-HT3 receptors in the vagus nerve and ventricular myocardium

263
Q

What is the most effective method of hydrating with spinal blocks

A

Co-load with 15 ml/kg just after performing the block

264
Q

What causes cauda equina syndrome

A

Neurotoxicity is the result of exposure to high concentration of LA

265
Q

What factors increase the risk of cauda equina syndrome

A
  1. 5% lidocaine

2. spinal microcatheters (focus LA on a small area of the SC)

266
Q

What are 4 s/sx of cauda equina syndrome

A
  1. Bowel/bladder dysfunction
  2. Sensory deficits
  3. Weakness
  4. Paralysis
267
Q

Treatment for cauda equina syndrome

A

Supportive

268
Q

What is the cause of transient neurologic symptoms

A

Patient positioning, stretching of the sciatic nerve, myofascial strain, and muscle spasm

269
Q

What are 4 factors that increase the risk of TNS

A
  1. Lidocaine
  2. Lithotomy position
  3. Ambulator surgery
  4. Knee arthroscopy
270
Q

4 factors that do NOT increase risk of TNS

A
  1. Early ambulation
  2. LA concentration
  3. Baricity
  4. Glucose concentration
271
Q

What are the s/sx of transient neurologic symptoms

A
  1. Severe back and butt pain radiating to both legs

2. Develops w/in 6-36 hrs and persists 1-7 days

272
Q

Treatment for transient neurologic symptoms

A

NSAIDs
Opioid analgesics
Trigger point injections

273
Q

What is the reason blood is in an epidural needle

A

Needle was inserted to laterally

Redirect the needle towards midline

274
Q

What to do is blood is aspirated in an epidural catheter

A

Pull back catheter a little and flush with saline

Repeat until no blood is aspirated or not enough cath is in epidural space

275
Q

How is the risk of venous cannulation with epidural catheter reduced

A

Injecting fluid in the epidural space before threating the catheter
Use of wire reinforced catheter

276
Q

What are 5 risks of epidural vein cannulation with catheter

A
  1. Multiple insertion attempts
  2. Pregnancy (venous engorgement)
  3. Sitting position
  4. Using stiff catheter
  5. Trauma to epidural vein during block placement

APEX-Regional (3 decks)

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