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Basics > Spinal > Flashcards

Spinal Flashcards

1
Q

a-alpha (general info)

A
  • motor
  • myelin
  • size ++++
  • CM ++++
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2
Q

Myelin

A

fat

LA are lipophilic and onset of action and CM is lower with myelin present

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3
Q

CM on periphery nerve fibers

A

minimum concentration of LA needed to stop nerve conduction

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4
Q

A-alpha

A 
thick nerve 
controls movement
need increased LA to block 
greatest in size and CM 
motor response is last to go
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5
Q

a-beta: general info

A
  • light touch, pain, pressure
  • myelin
  • size +++
  • CM +++
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6
Q

a-beta

A

affect occurs before a-alpha

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7
Q

a-gamma - general

A

muscle spindles - proprioception

  • myelin
  • size +++
  • CM ++
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8
Q

a gamma

A

proprioception- ability of pt to know the orientation of different parts of body “legs floating”

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9
Q

a-delta general

A

temp and pain

  • myelin
  • size ++ (smaller)
  • CM +
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10
Q

A- delta

A

warm, pain blocked.

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11
Q

B fibers - general

A

preganglionic sympathetic fibers

  • chemical sympathectomy
  • myelin
  • Size ++
  • CM + (lowest conc- sets up first)
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12
Q

B fibers

A
  • lost first
  • innervate the SNS activity to vasculature
  • arteries and veins blocked –> block SNS –> unopppsed vasodilation –> decreased BP
  • TX- load tank and give vasopressors, see warm tingling in feet
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13
Q

C fibers - general

A

pain, pressure

  • NO myelin
  • Size +
  • CM +++
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14
Q

Nerve distribution

C3-C5

A
  • bad
  • diaphragm, pt stops breathing
  • high spinal
  • no reversal, ABCs, BP will be extremely low
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15
Q

Nerve distribution

T1-T4

A

cardioaccelatory fibers

sympathectomy occurs –> pure vagel activity, decreased HR, cardiac arrest, systole

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16
Q

sympathectomy

A

chemical removal of SNS while under spinal anesthesia

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17
Q

Nerve distribution

T5-L1

A

block here causes vasodilation
higher the block toward T5 > vasodilation > decreased BP
GIVE VOLUME PRIOR TO SPINAL, vasopressors if needed

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18
Q

Expectations on injection

A 
L4-L5 = warm tingling in feel 
B fibers = decreased BP 
A-gamma= legs floating in air 
A- beta= sensory test: push on skin and feel whats normal- absence abeta blocked
A- alpha = unable to move feet
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19
Q

T6

A

intercostal nerves

pt may have difficult time breathing

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20
Q

CV effects with spinal

A
  • preload
  • afterload
  • BP
  • contractility
  • HR
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21
Q

preload effects

A

decreased due to ventilation from B fiber blockade

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22
Q

afterload

A

decreased due to arterial dilation from B fiber blockade

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23
Q

BP

A

1- decreased DT decreased afterload and preload
2- decreased BP is proportional with height of sensory block, degree of hypovolemia, and responsiveness to SNS
3- monitor degree of hypotension as to avoid decreased cardiac and cerebral perfusion
4- b fiber blockade = vasodilation

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24
Q

contractility

A

1- increased in response to decreased BP as form of compensation
2- depressed contractility will occur if the pt is taking B blockers or if the cardioaccelatory fibers are blocked.

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25
Q

HR

A

1- increased in response to decreased BP as form of compensation
2- depressed HR will occur if the pt is taking B blockers or if the cardioaccelatory fibers are blocked.
3- increased HR via baroreceptor reflex

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26
Q

strategies to help minimize CV effects

A
  • achieve sensory block neccessary for procedure
  • administer O2
  • administer IVF
  • Vasopressors PRN
    • administer atropine for bradycardia
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27
Q

Sensory block at T10

A

motor block @ T12
sympathetic block @ T8

Sympathetic block - always 2 higher than sensory
motor block- always 2 lower than sensory

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28
Q

Dermatomes:

C8

A

little finger

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29
Q

Dermatomes:

T4

A

nipples

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30
Q

Dermatomes:

T10

A

umbilicus

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31
Q

LA: Generic Names

Bupivicaine

A

Marcaine

sensorcaine

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32
Q

LA: Generic Names

tetracaine

A

Pontocaine

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33
Q

LA: Generic Names

Lidocaine

A

Xylocaine

34
Q

cauda equina symdrome

A

paresthesias, neurotoxic with lidocaine.

all drugs we put in pts are neurotoxic

35
Q

LA MOA

A

LA binds to lipid or nonlipid and keeps cell from opening (depolarizing)
cell stays repolarized - nerve impulse cannot go thorugh

36
Q

How LA wears off

A
  • drug molecules in Na+ channels on nerves in SA space not
  • not all molecules occupy a receptor –> they are entrained into vasculature = venous system within SA space –> central circulation and metabolized.
37
Q

properties that determine LA effects

A

potency
onset of action
duration of action

38
Q

properties that determine LA effects

- Potency

A

proportional to degree of lipiid solubility
more lipid soluble = more potent
decreased potency = decreased strength

39
Q

properties that determine LA effects

- onset of action

A

pka- pH of drug when 50% is ionized and 50% is nonionizedneeds both ionized and nonionized to work
closer pka is to body pH 7.35-7.45 = works faster

40
Q

properties that determine LA effects

- duration of action

A

protein binding
receptors are protein
increased protein binding = Increased duration

41
Q

Bupivicaine

A 
marcaine 
Amide 
Benzine ring 
lipid solubility- ++++ (more toxic, increased potency, increased duration, increased toxicity) 
pka - 8.1 
protein binding ++++
42
Q

lidocaine

A 
xylocaine 
amide
benzine ring 
lipid solubility ++ 
pka 7.8 (sets up faster) 
protein binding ++ (shorter duration)
43
Q

tetracaine

A 
pontocaine 
ester
lipid solubility ++++ 
pka 8.2
protein binding +++
44
Q

amide metabolism

A

broken down in the liver

45
Q

ester metabolism

A

pseudocholinesterase

46
Q

amide allergic reactions

A

rare but DT allergy to methylparaben- preservative for multiuse vials)
all LA will be MPF (methylparaben free)
methylparaben - Increased risk for toxicity

47
Q

Ester allergic reactions

A

Dt paba- metabolite occurs with ester breakdown
metabolite can cause allergic rxn
metabolite = Paba

48
Q

Signs and Symptoms of LA toxicity

A 
1- circumoral numbness
2- tongue parestheisas - tingling 
3- tinnitus 
4- metallic taste 
5- dizzyness 
6- blurred vision 
7- restlessness 
8- altered LOC 
9 -seizures 
10- resp arrest --> cardiac arrest

“come to the most dazzling ball right at 7 and die”

49
Q

Local toxicity

A

neurological symptoms first –> cardiac

50
Q

Bupiv LA toxicity

A

increased danger DT increased potency
leads to nonrescusitable cardiac arrest
TX- give lipids in blood
always have lipids available with 1-epidurals and 2- regional nerve blocks

51
Q

CSF produced per day

A

500cc

52
Q

CSF present in spinal SA space

A

30-80cc

53
Q

density of a solution =

A

the weight in grams of 1cc of solution

g/ml, at a specific temp

54
Q

CSF density

A

1.0000- 1.0006g/cc at 37degrees C

55
Q

the greatest factors affecting LA spread in the SA space

A

baricity

positioning of the patient

56
Q

baricity

A

comparing the density of the LA to the the density of the CSF

57
Q

positioning of the pt

A

during and immediately after placement

58
Q

hyperbaric solution

A

density > CSF
solution baricity > 1.0015
sinks with gravity in CSF
in Supine position this will rest at low points - T5, S2
EX- C-section - give less drug DT increased pressure
total right hip- lay pt on right side

59
Q

preparing a hyperbaric solution

A

mix solution with 5-10% dextrose preservative free

60
Q

hypobaric solution

A 
density < 0.9990
tends to rise against gravity 
floats to least dependent areas 
rests at high point C5, L3
EX- total right hip - turn on left side
not used often
61
Q

preparing a hypobaric solution

A

mix LA with sterile preservative free Water

62
Q

Isobaric solution

A

density apx = CSF
solution baricity apx 1.0000
does not spread with positioning, tends to stay in area where injected.

63
Q

preparing an isobaric solution

A

LA needs to be mixed with preservative free NS or CSF

- positioning has no effect on distribution and no effect on level of anesthesia

64
Q

C- Section

A

T4 block = nipple line

hyperbaric solution

65
Q

epidural vs spinal dosing and toxicity

A

epidural- increased risk for neurotoxicity, increased volume, moves up and down
- give 2% at least 10-14cc
20mg= 200-280mg = increased toxicity risk

Spinals - 5% 2cc= 100mg

66
Q

CSF and nerves

A

put LA into CSF where nerve roots are bathed –> uptaking the med resulting in anesthetic affect we want

67
Q

Other factors affecting baricity:

pt characteristics

A 
age 
height 
weight 
gender 
intraabdominal pressure 
anatomic configuration of spinal column 
position
68
Q

Other factors affecting baricity:
pt characteristics
- AGE

A
  • increased age nerves can be more vulnerable and have decreased CSF
  • decrease dose with spinal in elderly
  • not a big clinical difference
69
Q

Other factors affecting baricity:
pt characteristics
- HEIGHT

A

extremes 6’8 and 4’3 make a difference,

adjust dose

70
Q

Other factors affecting baricity:
pt characteristics
WEIGHT AND GENDER

A

no difference

71
Q

Other factors affecting baricity:
pt characteristics
INTRA-ABDOMINAL PRESSURE

A

pregnancy, acites, abd masses= the pressure compressed epidural space and decreases CSF volume = increased spread of LA and increased Block

72
Q

Other factors affecting baricity:
pt characteristics
ANATOMIC CONFIGURATION OF THE SPINE

A

kyphosis and scoliosis have decreased CSF volume and give increased block
have issues finding landmarks and where to inject

73
Q

Other factors affecting baricity:

Technique of injection

A

site of injection
direction of injection (needle bevel)
turbulance (rate of injection, barbotage)
- no clinical signs with spread in CSF

74
Q

Other factors affecting baricity:

Characteristics of CSF

A

Barisity
volume
circulation - no significant difference
pressure (cough, strain, valsava)

75
Q

Other factors affecting baricity:
Characteristics of CSF
VOLUME

A

decreased CSF = higher spread of LA and block

76
Q

Other factors affecting baricity:
Characteristics of CSF
PRESSURE

A

moving, conflicting opinions. when you cough or strain - you have increased pressure = decreased CSF volume = block goes higher
DO NOT ALLOW PT TO MOVE THEMSELVES

77
Q

Other factors affecting baricity:

characteristics of injectate

A

baricity of inject ate (hyper, hypo, iso)
amount of anesthetic (mass of injectate)
concentration of injectate
volume injected
vasoconstrictors

78
Q

Other factors affecting baricity:
characteristics of injectate
AMOUNT OF ANESTHETIC

A

mg- directly afffects density and duration of block. 15mg bupiv = denser block and longer than 10mg bupiv

79
Q

Other factors affecting baricity:
characteristics of injectate
CONCENTRATION OF ANESTHETIC

A

increased conc, not really showing difference in spread

80
Q

Other factors affecting baricity:
characteristics of injectate
VOLUME INJECTED

A

under 2cc is injected BUT if you needed to give mix solution (hypobaric) and give epi wash or narc then volume is increased - which may increase spread
2cc= possible effect

81
Q

Other factors affecting baricity:
characteristics of injectate
vasoconstrictor

A

not affecting spread but will affect duration depending on drug

Basics (9 decks)

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