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Foundations > Spinal And Epidural > Flashcards

Spinal And Epidural Flashcards

1
Q

Cocaine, Procaine, Tetracine and Chloroprocaine are all ______.

A

Esters

1 “i” in the name

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2
Q

Dibucaine, Lidocaine, Mepivacaine, Prilocaine … are all _____.

A

Amides

2 “i’s” in the name

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3
Q

Local anesthetics are (strong/weak) / (bases/acids).

A

Weak Bases

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4
Q

The chemical structure of LAs have a ______ ______ portion and an _____ ______ portion.

A

Aromatic lipophilic, Amine hydrophilic

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5
Q

Amino Esters have a ______ chain in the middle.

A

C-O-C

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6
Q

Amino Amides have a ______ chain in the middle.

A

NH

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7
Q

What is pKa?

A

The pH at which 50% of LA is charged and 50% is uncharged.

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8
Q

LA with a lower pKa value will have a _____ onset.

A

faster

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9
Q

Both _______ and ________ molecules are present in LA (pKa).

A

charged and uncharged

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10
Q

The _______ form is most _______ _______ and able to gain access to the axon.

A

Uncharged, lipid soluble

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11
Q

Insert SLide 7 HERE

A

Here too

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12
Q

MOA of LA:

A

BLock nerve conduction, impairs propagation of action potential in axons

< rate of rise of AP = threshold potential is not reached.

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13
Q

LA MOA interact directly with receptors on the ___ channel.

A

Na+

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14
Q

_____ determines speed of onset of neural blockade.

A

pKa

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15
Q

Agents with a > degree of protein binding will __ _______ effect.

A

> duration

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16
Q

LA _____ cross membranes.

A

Easily

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17
Q

Lipid solubility is related to _______.

A

Potency.

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18
Q

_____ / _______ fibers are more easily blocked than _____ / _______fibers.

A

Thin, thick

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19
Q

Myelinated fibers procude block only at:

A

Node of Ranvier

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20
Q

Sequence of clinical anesthesia of LAs:

A

ATP TP MVP

1st: autonomic block myelinated b fibers (and c?)
Skin temp and pain

2nd: Loss of touch and pressure sensation

3rd: Motor paralysis
Vibration
Proprioception

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21
Q

A fibers ___ B fibers ___ C fibers

A

> , >, >

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22
Q

How many types of A fibers?

A

4

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23
Q

B fibers are:

A

Preganglionic autonomic fibers

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24
Q

Metabolism is either _______ or _______.

A

ESTERS or AMIDES

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25
Q

Esters is readily cleaved by ______ ________. 1/2 life is:

A

plasma cholinesterase (1 min)

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26
Q

What is the degradation product of Ester metabolism?

A

P-aminobenzoic acid.

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27
Q

P-aminobenzoic acid has > rates of:

A

Patient allergic reactions

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28
Q

Amides is cleaved through __________ followed by __________.

A

N-dealkylation, hydrolysis.

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29
Q

1/2 life of AMIDES:

A

2-3 hours

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30
Q

Where does metabolism of amides primarily occur?

A

Liver. (Hepatic disease > reactions)

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31
Q

Baricity

A

Hypobaric (floats up)
Hyperbaric (sink down)
Isobaric (stay)

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32
Q

Different additives to LA will > ________.

A

Baricity

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33
Q

(4) Epinephrine added to LAs will:

A

Prolong duration of LA
> intensity of block
(< surgical bleeding?)
Assists in evaluation of test dose

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34
Q

When not to add epi to LAs?

And what other additive?

A
  • Peripheral (fingers, toes, penis)
  • Beir block
  • Hx uncontrolled HTN, CAD, arrhythmia, > thyroid, uterus-placental insufficiency.

-Phenylephrine

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35
Q

Adding Na Bicarb to LAs does what 2 things?

A

> pH, this > non-ionized base

> rate of Diffusion across nerve membrane (> onset speed).

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36
Q

Add how munch of Na Bicarb equivalents with lidocaine?

Add how munch of Na Bicarb equivalents with bupivicaine?

A

1 mEq added to each 10 ml of lido

0.1 mEq added to each 10 ml of bupivi

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37
Q

Does Na Bicarb in combos with LAs sting?

A

No. Helps to prevent sting.

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38
Q

Fentanyl (opioid) added to LAs will ___ ________ of block

A

> strength

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39
Q

Fentanyl added to LA will work on ____ receptors.

A

Mu (in spinal cord, dorsal horn)

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40
Q

Fentanyl added to LAs are ________ together.

A

Synergistic

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41
Q

How to minimize LA systemic toxicity:

A
  • Aspiration prior to injection
  • Use of epi for test dose
  • Use of small incremental volumes. (5ccs q 5 mins)
  • Use of proper technique
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42
Q

Allergic reactions with LAs are common or rare.

A

Rare

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43
Q

Amides Allergic reaction:

A

Methyl-paraben (preservative)

And PABA

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44
Q

Ester allergic reactions with LAs:

A

Sulfonamides or Thiazides diuretics.

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45
Q

Progression of CNS toxicity:

A

Lightheadedness-Tinnitus-Visual-numbness of tongue and lip

Then progress to
Muscle twitching-LOC-seizure-coma

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46
Q

What LA is more toxic?

A

Bupivacaine > Lidocaine > Mepiv > Prilo > Pro

Reversed would be greatest convulsive threshold

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47
Q

What is a strong indicator of convulsive threshold?

A

PaCO2

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48
Q

Tx of LA CNS toxicity:

A 
O2
Seizure activity
-Midazolam 1-2 mg
-Thiopental 50-200mg
-Propofol
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49
Q

LA Cardiovascular Toxicity:

A

< contractility
< conduction
Loss of peripheral vasomotor tone
CV collapse (bupivicaine or etidocaine)

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50
Q

What LA has the greatest CV collapse dose threshold?

A

Lido>Etidocaine>Bupivacaine

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51
Q

Tx CV toxicity:

A 
O2
Vasopressin and inotropes
ACLS
To v-tach with cardioversion
Long resuscitation times (40 mins).
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52
Q

Research suggests that post op morbidity and mortality is ___ when neuraxial blockage is used.

A

<

Neuraxial is beneficial

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53
Q

7 Reduced Incidences of with LAs:

A
  • Thrombosis
  • PE
  • Cardiac complications
  • Vascular graft occlusion
  • Resp depression and Pnx
  • Blood loss and transfusion
  • Earlier return of GI function
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54
Q

Other names for Spinal Blocks:

A

Subarachanoid blocks

Intrathecal block

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55
Q

Indications for spinal:

A

Surgery of lower abd
Surgery of lower extremities
Surgery on perineum

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56
Q

Things in a good pre op exam:

A
  • Note Baseline neuromuscular deficits
  • Bacteremia - abscess
  • Current meds (can’t do with anticoags)
  • Cardiac disease
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57
Q

Aortic stenosis with LAs

A

Fixed CO

< Cardiac coronary BF (no pressure for BF)

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58
Q

Aortic stenosis os a relative or absolute contraindication for a spinal?

A

Relative

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59
Q

Slide 42 Here

Research for current

A

42

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60
Q

Must diagnose and surgically decompress a Spinal hematoma with in _____ for best outcome.

A

8 hours

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61
Q

Symptoms of spinal or epidural hematoma:

A
  • New onset weakness to lower limbs
  • New onset back pain
  • New onset bowel or bladder dysfunction
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62
Q

Risk of spinal neurological injury

A

1 - 4.2 : 10,000

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63
Q

Risk of epidural neurological injury:

A

0 - 7.6 : 10,000

64
Q

Minimum Cutaneous levels for spinal:

Lower extremities
Hip
Vagina/ uterus
Bladder / prostate 
Testis / ovaries
Lower abd
Nipple
Xifoid
Bellybutton
Pinky
A 
Lower extremities. T12
Hip. T10
Vagina/ uterus T10
Bladder / prostate  T10
Testis / ovaries T8
Lower abd T6
Nipple. T4
Xifoid T6T7
Bellybutton T10
Pinky C8-T1
65
Q

Where are the cardiac accelerators?

A

T1-T4 Bradycardia results with blockage

66
Q

Where would a block affect a patients breathing?

A

C3C4C5

67
Q

How many cervical vertebra?

A

7

68
Q

How many cervical nerve roots?

A

8

69
Q

How many thoracic vertebral?

A

12

70
Q

How many Lumbar vertebra?

A

5

71
Q

How many sacral vertebra?

A

5

72
Q

How many coccygeal vertebra?

A

4

73
Q

Needle approach in ______ T12 - L5

A

Flat

74
Q

Needle approach is _______ thoracic T1-T12

A

Angled

75
Q

3 major ligaments involved with the spine:

SLIDE 51

A
  • Supraspinous ligament (Posterior) (links all together on top)
  • Interspinous ligament (in between)
  • Ligamentum flavum (anterior portion) (closest to LA epidural space)
76
Q

What intralaminar ligament is the most dense/thickest?

A

Ligamentum flavum

77
Q

Where does the spinal cord end at birth and 2yrs and adult?

A

L3
L1
L1

78
Q

What is the name of the end of the spinal cord?

A

Conus medularis

79
Q

Name of the nerves that hang at end of spinal cord?

A

Cauda equina

80
Q

Spinal needles are placed below ___ to not hit the spinal cord.

A

L2

Needle passes through cauda equina

81
Q

3 meninges that surround the spinal cord:

A
  • Dura mater (outside) (tough fibrous)
  • Arachnoid (between dura and pia)
  • Pia mater (NO needle STOP before)
82
Q

What meninge holds the CSF?

A

Arachnoid

83
Q

What is between ligamentum flavum and Dura?

A

Epidural space

84
Q

Difference between spinal and epidural?

A

Can give epidural slower and controlled, spinal is one does in and out.

85
Q

What is the total volume of CSF

A

140 mls

86
Q

CSF fills the ________ space

A

Subarachnoid space

87
Q

Volume of CSF in spinal canal is?

A

30-80 mls (rest is in the brain/ventricles)

88
Q

How much CSF is made every day?

A

500mls

20.8mls/hr

89
Q

CSF is replaced how many times a day?

A

3

90
Q

specific gravity of CSF:

A

1.004-1.009

91
Q

What produces CSF?

A

Corae plexus

Arachnoid villi or grandulations absorb CSF

92
Q

Factor that affect level of spinal block:

A

Drug Dose / Drug Volume

Turbulence of CSF

  • Rapid injection
  • Barbotage
  • Coughing
  • > pt movement

> intra abd Pressure (pregnancy, obese, ascities, abd tumors)

Spinal curvatures

Baricity of LA

93
Q

Spinals are placed between _______and __________.

A

Pia and arachnoid

94
Q

What do you do with does with > abd situations?

A

< dose

95
Q

What is the most common LA solution?

A

Hyperbaric

96
Q

What is added in hyperbaric solutions?

A

Glucose (dextrose)

97
Q

What is often added to hypobaric LA solutions?

A

Water

98
Q

Does positioning matter with isobaric solutions?

A

No

99
Q

> dose of a __________ solution will > _________ of LA not ________ of LA.

A

Isobaric, duration, spread

100
Q

______ is a cutting type needle.

A

Quickie

Turn bevel sideways

101
Q

Other name for Pencil point needle?

A

Whitacre

Sport

102
Q

What type of needle is used for epidurals?

A

Touhy (curved up)

103
Q

Benefits of pencil point needle:

A

< HA

Drag < contaminates in to subarachnoid space.

Better fill (feel pop more)

104
Q

What are the identifying marks in sitting position?

A 
Below L1-L2
Iliac crests (L4) (tuviers line)
105
Q

What is often the solution used of LA in sitting position?

A

Hyperbaric

106
Q

What solution is often used in prone position?

A

Hypobaric

Rectum, perineum, anus procedures

107
Q

Midline approach

Needle advanced through skin at same plane as ________ ________ with slight _________ angulation.

A

Spinous process, cephalad

108
Q

When is Paramedian approach useful?

A

Pts who cant maximally flex or intraspinous ligaments are ossified.

109
Q

Paramedian approach needle is placed …

A

1-1.5cm lateral to midline

110
Q

Contamination of spinal kit and antiseptic solution can cause….

A

Neurotoxicity

111
Q

Infiltrate skin with __ ________ with a ___ gauge needle

A

1% lidocaine, 25 gauge

112
Q

A sudden “pop” is felt as the needle is advances past the ______ ligament.

A

Ligamentum flavum (pull stylet out, wait for free flow CSF drain)

113
Q

What to do if paresthesia (pain) occurs?

A

Stop, wait for it to go away (take stylet out to see if your in the right spot)

Do not continue to push with paresthesia

114
Q

Aspiration of CSF confirms…

A

Free flow.

115
Q

Re-aspiration of CSF at end of injection confirms…

A

Needle tip is still in subarachnoid space.

116
Q

How long does the fixation of a LA take?

A

20 mins

117
Q

Closely monitor VS for how long after LA is injected?

A

At least 1 min until pt is deemed stable.

118
Q

___ fibers are more easily blocked than _______ sensory and motor fibers.

A

C, larger

119
Q

The level of the autonomic blockade should be …

A

The highest point of the spinal bc it is the easiest blocked.

120
Q

_________ level, then _______ levels about 2 spinal levels below that, then _______ block 2 spinal level below that.

A

Sympathetic, sensory, motor

Top to bottom

121
Q

Autonomic block __ Sensory block __ Motor.

A

> , >

122
Q

CV is _________ to the degree of sympathetic block achieved.

A

Hypotension.
Dilation
< SVR
> risk w/ hypovolemic pts

123
Q

Lower block ___ hypotension

Higher block ___ hypotension.

A

<

>

124
Q

HR change with LA in most pts.

A

No significant change

125
Q

Bradycardia does occurs with LAs __ % of the time

A

10-15%

126
Q

> risk of bradycardia with LAs occurs with…

A

> sensory levels

Cardio block @ T1-T4

127
Q

Tx of CV response

A 
Fluid load 500-1000cc
O2 mask
Vasopressin
Atropine
Epinephrine
CPR
128
Q

CV effects _____ be anticipated with steps takes to minimize _____ and _____.

A

Should, hypotension and bradycardia.

129
Q

Significant

A

HTN

130
Q

Careful with pts who have chronic lung disease with LA, they don’t have ________ ________ if blocked. Difficult ______ing.

A

Accessory muscles, coughing.(use suction) (limited reserve)

131
Q

4 most important factors affecting level of LA.

A

Baricity
Position
Dose
Site of injection

Even more than:
Pregnancy
Volume
Age
Spine shape
132
Q

Young ________ _________ are > rush of dural puncture HA.

A

Pregnant females

133
Q

Common side effects of spinal anesthesia:

A

Nausea
Urinary retention
Hypoventilation
Backache

134
Q

The epidural space is _____ ____at midline.

A

5-6mm wide

135
Q

There is a more narrow margin of error at the ____________ region epidural space.

A

Mid-thoracic (it Is only 5-6mm wide)

136
Q

Depth of epidural space is __________.

A

3-9 cm

137
Q

Epidural onset is ________ and intensity is ________.

A

Slower, less

138
Q

A segmental type block is…

A

At pt cash still get up and walk around.

Selective blockade.

139
Q

Epidural position:

A

Lateral or sitting

140
Q

Epidural can be titrated to deliver ________ or _________.

A

Analgesia or anesthesia (dose amount)

141
Q

Epidural take _____ volumes of LA to achieve anesthesia and they take _______.

A

Large, longer

142
Q

Needle should alway enter the epidural space in the ______ regardless of approach.

A

Midline (space is wider there)

143
Q

Use wither the __________ technique or the __________ technique to locate the epidural space.

A

Loss of resistance, hanging drop.

144
Q

What kind of needle for epidural?

A

Long 25 gauge needle

145
Q

Thoracic epidural requires ____ dose of LA

A

Less

146
Q

Insert needle in a more _________ direction in thoracic epidural placement.

A

Cephalad

147
Q

Epidural test dose include what dose and med?

A

1:200,000 epi.

If in epidural vein, HR > 20-30%

148
Q

1: 200,000 —> 1,000,000/200,000 = 5 mcg/mL
1: 10,000 —> 1,000,000/10,000 = 100 mcg/ml

A

Conversion SLIDE 104

149
Q

Factors effects level of epidural blockade:

A 
Volume of LA
Age
Pregnancy
Speed of injection
Position
Spread of epidural blockade
150
Q

__ ml of NA bicarb for each __ mls of LA

A

1 ml, 10mls

151
Q

Sympathetic nervous system blockade has a ______ onset with a _______ incidence of abrupt hypotension.

A

Slower, decreased.

152
Q

Post dural puncture headache occurs _______.

A

1-2%

Backache 35-40%

153
Q

Variations of epidurals:

A 
Single shot
Continuous
Combined spinal/epidural
Combined epidural/general
Caudal anesthesia (< dose peds)
154
Q

Touey

A

Is bent up so you can move cath up.

Slide 113

155
Q

Spinal sympathetic block can result in __ preload, __ CO, __ BP

A

Decreased, decreased, decreased

Foundations (5 decks)

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