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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
Q

Describe the needle placement for a spinal block.

A

Median approach- needle is placed midline, perpendicular? to spinous processes, aimed slightly cephalad.

26
Q

Name the tissue layers traversed during an epidural block.

A

Skin, subcutaneous tissue, supraspinous ligament, interspinous ligament, ligamentum flavum.

27
Q

Name the tissue layers traversed during a subarachnoid block.

A

Skin, subcutaneous tissue, supraspinous ligament, interspinous ligament, ligamentum flavum, dura matter, arachnoid matter.

28
Q

What anatomic landmarks do you identify for a subarachnoid block?

A

Superior iliac crests and L4.

29
Q

What gauge needle and how much lidocaine do you use for your skin wheel during a SAB?

A

25G needle and 2 ml.

30
Q

What gauge introducer do you use and what layers do you go through for a SAB?

A

17G indtroducer through skin, subcutaneous tissue, supraspinous ligament, interspinous ligament and stopping in the ligamentum flavum.

31
Q

What gauge needle is passed through the introducer and what layers will it go through for a SAB?

A

A 25G needle will pass through ligamentum flavum, dura, and arachnoid space stopping when presence of CSF is determined..

32
Q

Describe the steps after determining presence of CSF in a SAB.

A
  • 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
Q

What is the approximate length from the skin to the ligamentum flavum?

A

4-6 cm.

34
Q

What are 3 epidural insertion sites?

A

Thoracic, caudal, lumbar.

35
Q

What is the widest point of the epidural space?

A

L2 (5cm).

36
Q

What is contained in the epidural space?

A

Fat and blood vessels. Medication deposited and catheter in potential space.

37
Q

What pre-procedure equipment do you need for an epidural block?

A

Monitors, fluid bolus, airway management and resuscitation equipment available, emergency drugs drawn and available, consider sedation prior to procedure.

38
Q

How thick is the ligamentum flavum?

A

5-6 mm at midline in lumbar region.

39
Q

Describe the loss of resistance technique.

A

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
Q

How far should the epidural catheter be advanced?

A

2-3 cm or 4-6cm in parturients.

41
Q

What specific gravity is considered hyperbaric compared to CSF and what can you mix anesthetic with make it hyperbaric?

A

Specific gravity> 1.11, mix with dextrose.

42
Q

What specific gravity is considered hypobaric comparted to CSF and what can you mix anesthetic with to make it hypobaric?

A

<1.005, sterile water.

43
Q

How do you make an isobaric anesthetic solution?

A

Mix the anesthetic with CSF.

44
Q

Name the factors that affect the spread of the local anesthetic in a subarachnoid block.

A
  • 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
Q

What factors influence the block height of a subarachnoid block?

A

Dose, site of injection, baracity, position of patient.

46
Q

What factors should you consider when deciding the dose for a SAB?

A
  • Surgical site
  • Length of procedure
  • Body size
  • Physiology
47
Q

When can a patient be discharged to the floor after a SAB? To home?

A

PACU to floor- after 4 dermatome regression <T10, stable and comfortable
Home- after ambulation without orthostatic changes and voids

48
Q

Approximately how many mls of local anesthetic block each segment for an epidural.

A

1.25-1.6 ml

49
Q

Where is the needle placed for a caudal block?

A

The epidural space via injection through the sacral hiatus.

50
Q

What are some uses of caudal anesthesia?

A

Pediatric post-op pain:

  • hypospadias
  • inguinal hernia repair
  • procedures of the perineal and sacral areas
51
Q

What are some limitations of caudal anesthesia?

A
  • variable anatomy in adults
  • high risk of injectin into a venous plexus
  • difficulty maintaining sterility should a catheter be used
52
Q

What are some complications of spinal/epidural and caudal anesthesia?

A
  • 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
Q

What populations/situations have an increased risk for post dural puncture headache?

A
  • Younger patients
  • Female patients
  • Caucasian
  • Larger needle size
  • Pregnancy
  • Dehydration
  • Cutting tipped needles
  • Multiple puncture attempts
54
Q

When can post dural puncture headache occur?

A

Within one day to one week of spinal or epidural anesthesia.

55
Q

What are some treatments for post dural puncture headache?

A
  • Epidural blood patch
  • Epidural saline injection
  • Bedrest
  • Hydration
  • Oral analgesics
  • Abdominal binder
  • Caffeine
56
Q

Describe an epidural blood patch.

A

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
Q

What is the primary cause of an epidural hematoma and how does it present?

A

Primary cause is coagulation defect and it presents with numbness or lower extremity weakness.

58
Q

How long should you hold LMWH before and after epidural?

A

10-12 hours pre-placement and 10-12 hours post-surgical procedure.

59
Q

What are some signs of local anesthetic toxicity?

A
  • 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
Q

How much higher than the sensory blockade can the sympathetic blockade be?

A

2-6 levels

61
Q

How much higher than the motor blockade can the sensory blockade be?

A

2 levels

62
Q

What are some advantages/disadvantages of spinal anesthesia over epidural anesthesia?

A
  • 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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