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Anesthesia Exam 1 > Spinal and Epidural > Flashcards

Spinal and Epidural Flashcards

1
Q

At what spinal level is the top of the iliac crest?

A

T4-T5 (tuffers line)

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2
Q

What are the five ligaments of the vertebrae?

A
  • Supraspinous
  • Interspinous
  • Ligamentum flavum
  • Longitudinal
  • Ligamentum nuchae
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3
Q

What is the ligament you reach just before the epidural space?

A

Ligamentum flavum.

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4
Q

What is the termination of the spinal cord called?

A

Conus medullaris

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5
Q

What dermatome is at the level of the nipple?

A

T4

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6
Q

The T4 dermatome is at the level of the ____.

A

Nipple.

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7
Q

What dermatome is at the level of the xiphoid?

A

T6

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8
Q

The T6 dermatome is at the level of the ____.

A

Xiphoid.

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9
Q

What dermatome is at the level of the last rib?

A

T8.

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10
Q

The T8 dermatome is at the level of the ____.

A

Last rib.

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11
Q

What dermatome is at the level of the umbilicus?

A

T10.

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12
Q

The T10 dermatome is at the level of the _____.

A

Umbilicus.

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13
Q

What is the specific gravity of CSF?

A

1.004-1.008

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14
Q

What are some advantages of neuroaxial anesthesia? (spinals and epidurals)

A
  • Decreased metabolic stress response to surgery and anesthesia compared to GA.
  • Avoids airway instrumentation
  • Decreased incidence of post-op nausea
  • Less intra-operative sedation
  • Post-op pain relief
  • Allows patient to remain awake during C-section
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15
Q

What are some considerations of whether or not you would do a Spinal or Epidural?

A
  • Length of procedure.
  • Post-op analgesia needs.
  • Co-existing diseases
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16
Q

What are absolute contraindications for spinal/epidural anesthesia?

A
  • Patient refusal
  • infection at injection site
  • increased ICP
  • Clotting defects/anticoagulant therapy (could be relative)
  • severe hemorrhage or hypovolemia
  • CNS disease or meningitis (may not be able to tell if worsening weakness is from block or not)
  • Hysteria/inability to remain still for block placement
  • Bacteremia
  • Septicemia
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17
Q

What are some cardiovascular changes as a result of the neuroaxial blockade?

A
  • Venous dilation and arterial dilation
  • Decrease in SVR of 15-25%
  • CO decrease 10-15%
  • Decrease in heart rate
  • Decreased MAP
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18
Q

What are some pulmonary changes as a result of the neuroaxial blockade?

A
  • Accessory muscle paralysis and perception of ineffective breathing
  • With profound hypotenstion may see ischemia of the central respiratory enters causing respiratory arrest
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19
Q

What are some GI/Renal effects of the neuroaxial blockade?

A
  • Nausea and vomiting (20% of pts)
  • Hyperperistalsis due to unopposed parasympathetic activity
  • Flow to liver is BP dependent
  • Maintainance of MAP
  • Bladder dysfunction:urinary retention
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20
Q

What are some metabolic/endocrine changes as a result of the neuroaxial blockade?

A
  • Blocks the effect of the stress response to surgery
  • Catecholamine release may be blocked from the adrenal medulla
  • Cortisol secretion is delayed
  • Shivering-altered thermoregulation with vasodilation
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21
Q

What are the two positions that a patient can be in for a neuroaxial block?

A

Lateral decubitus or sitting.

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22
Q

What should you have in your pre-procedure set up for a SAB or epidural?

A
  • monitors (ecg, blood pressure, pulse oximeter, end tidal CO2, temperature)
  • fluid blous
  • airway and resuscitation equipment available
  • consider sedation prior to procedure
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23
Q

Where is the hole in a pencil point needle?

A

On the side.

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24
Q

What are the two needles that can be used for SAB?

A

pencil point and cutting(Quincke)

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25
Describe the needle placement for a spinal block.
Median approach- needle is placed midline, perpendicular? to spinous processes, aimed slightly cephalad.
26
Name the tissue layers traversed during an epidural block.
Skin, subcutaneous tissue, supraspinous ligament, interspinous ligament, ligamentum flavum.
27
Name the tissue layers traversed during a subarachnoid block.
Skin, subcutaneous tissue, supraspinous ligament, interspinous ligament, ligamentum flavum, dura matter, arachnoid matter.
28
What anatomic landmarks do you identify for a subarachnoid block?
Superior iliac crests and L4.
29
What gauge needle and how much lidocaine do you use for your skin wheel during a SAB?
25G needle and 2 ml.
30
What gauge introducer do you use and what layers do you go through for a SAB?
17G indtroducer through skin, subcutaneous tissue, supraspinous ligament, interspinous ligament and stopping in the ligamentum flavum.
31
What gauge needle is passed through the introducer and what layers will it go through for a SAB?
A 25G needle will pass through ligamentum flavum, dura, and arachnoid space stopping when presence of CSF is determined..
32
Describe the steps after determining presence of CSF in a SAB.
- Remove stylet and confirm free flow of CSF x4 while rotating 90 degrees - Aspirate CSF before and after medication injection - remove needle and position the patient
33
What is the approximate length from the skin to the ligamentum flavum?
4-6 cm.
34
What are 3 epidural insertion sites?
Thoracic, caudal, lumbar.
35
What is the widest point of the epidural space?
L2 (5cm).
36
What is contained in the epidural space?
Fat and blood vessels. Medication deposited and catheter in potential space.
37
What pre-procedure equipment do you need for an epidural block?
Monitors, fluid bolus, airway management and resuscitation equipment available, emergency drugs drawn and available, consider sedation prior to procedure.
38
How thick is the ligamentum flavum?
5-6 mm at midline in lumbar region.
39
Describe the loss of resistance technique.
Steady pressure on plunger while advancing the needle, when the epidural space is entered the resistance is gone and air will leave the plunger.
40
How far should the epidural catheter be advanced?
2-3 cm or 4-6cm in parturients.
41
What specific gravity is considered hyperbaric compared to CSF and what can you mix anesthetic with make it hyperbaric?
Specific gravity> 1.11, mix with dextrose.
42
What specific gravity is considered hypobaric comparted to CSF and what can you mix anesthetic with to make it hypobaric?
<1.005, sterile water.
43
How do you make an isobaric anesthetic solution?
Mix the anesthetic with CSF.
44
Name the factors that affect the spread of the local anesthetic in a subarachnoid block.
- baracity of the local anesthetic solution - position of the patient - concentration of the volume injected - level of injection - barbotage/rate of injection - direction of needle and bevel
45
What factors influence the block height of a subarachnoid block?
Dose, site of injection, baracity, position of patient.
46
What factors should you consider when deciding the dose for a SAB?
- Surgical site - Length of procedure - Body size - Physiology
47
When can a patient be discharged to the floor after a SAB? To home?
PACU to floor- after 4 dermatome regression
48
Approximately how many mls of local anesthetic block each segment for an epidural.
1.25-1.6 ml
49
Where is the needle placed for a caudal block?
The epidural space via injection through the sacral hiatus.
50
What are some uses of caudal anesthesia?
Pediatric post-op pain: - hypospadias - inguinal hernia repair - procedures of the perineal and sacral areas
51
What are some limitations of caudal anesthesia?
- variable anatomy in adults - high risk of injectin into a venous plexus - difficulty maintaining sterility should a catheter be used
52
What are some complications of spinal/epidural and caudal anesthesia?
- Post-dural puncture headache* - Neurological complications - Epidural hematoma - High blockade - Inadequate blockade - Backache - Infection - Urinary retention - Hypotension - Bradycardia - Sudden cardiac arrest - Nausea and vomiting - Unintentional intravascular injections - Unintentional intrathecal injection - Catheter shearing
53
What populations/situations have an increased risk for post dural puncture headache?
- Younger patients - Female patients - Caucasian - Larger needle size - Pregnancy - Dehydration - Cutting tipped needles - Multiple puncture attempts
54
When can post dural puncture headache occur?
Within one day to one week of spinal or epidural anesthesia.
55
What are some treatments for post dural puncture headache?
- Epidural blood patch - Epidural saline injection - Bedrest - Hydration - Oral analgesics - Abdominal binder - Caffeine
56
Describe an epidural blood patch.
An aseptic autologous blood draw is performed of 10-20ml. An aseptic epidural injection of the blood is performed at the same level or more caudad to the original site. This is 90% effective in relieving post-puncture headache.
57
What is the primary cause of an epidural hematoma and how does it present?
Primary cause is coagulation defect and it presents with numbness or lower extremity weakness.
58
How long should you hold LMWH before and after epidural?
10-12 hours pre-placement and 10-12 hours post-surgical procedure.
59
What are some signs of local anesthetic toxicity?
- Neurologic - Circum-oral numbness - Tinnitus, vision changes, dizziness - Slurred speech - Restlessness - Muscle twitching - Seizure followed by CNS depression, apnea, hypotension - Transient radicular irritation - Cauda equina syndrome
60
How much higher than the sensory blockade can the sympathetic blockade be?
2-6 levels
61
How much higher than the motor blockade can the sensory blockade be?
2 levels
62
What are some advantages/disadvantages of spinal anesthesia over epidural anesthesia?
- Epidural is slower - Larger risk of local anesthetic toxicity with epidural because of larger doses used - Epidural anesthesia is less reliable, can be patchy or one-sded - Sympathectomy from spinal anesthesia is rapid, leading to sudden and more drastic drops in BP

Anesthesia Exam 1 (5 decks)

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