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Anesthesia Concepts > Spinal And Epidural Anesthesia > Flashcards

Spinal And Epidural Anesthesia Flashcards

1
Q 
How many total vertebra
Numbers:
Cervical
Thoracic
Lumbar
Sacral
Coccygeal
A 
33
7
12
5
5
4
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2
Q

High vertebral curves

A

C5 and L3

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3
Q

Low vertebral curves

A

T5 and S2

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4
Q

Purpose of ligaments

Where supraspinous ligament runs from

A

Stabilizing vertebral body

C5 to sacrum

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5
Q

Where inter spinous ligament runs from

A

Entire length

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6
Q

Outside to in ligaments (5)

A 
Supraspinous 
Interspinous
Ligamentum flavum 
Posterior longitudinal ligament
Anterior longitudinal ligament
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7
Q

Ligamentum flavum

Extends from where to where

Shaped like what and composed of what

A

Foramen magnum to sacral hiatus

Wedge shaped, elastin

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8
Q

Ligamentum flavum

Thickest where

What color

Landmark for what

Tough and fibrous in who

A

Mid line 3-5 mm at L3

Yellow

Epidural placement

Young pregnant women

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9
Q

Spinal meninges are continuous with what

A

Cranial meninges

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10
Q

Dura mater

_____ meningeal tissue

Begins where and ends where in adults and where in infants

Abuts the what

A

Thickest

Foramen magnum, ends caudally at S2/Dural sac (PSIS) S3 in babies

Arachnoid mater/ subdural space

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11
Q

Arachnoid mater

Principal physiologic ____ for ____ moving between epidural space and ___ ____

Abuts the ___ ___ giving rise to the subarachnoid space

Ends at ____.

It is ____ and ____

A

Barrier for drugs
Spinal cord

Pia mater

S2

Delicate and nonvascular

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12
Q

Subarachnoid space

Contains _____

Continuous with cranial ____ and provides vehicle for ___ in the spinal _____ to reach the ____

Houses what (2)

A

CSF

CSF, drugs, CSF, brain

Spinal nerve roots and rootlets

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13
Q

Spinal cord

Runs from ___ ___ to ___ ____ ends at level ___-___

___ pairs of spinal nerves

Each with ___ root (motor) and ____root (sensory)

___ are composed of _____

A

Foramen magnum to conus medullaris, L1-L2

31

Anterior, posterior

Roots, rootlets

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14
Q

Dural sac terminates at what level

What is role of filum terminale

A

S2

Anchors everything down

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15
Q

Dorsal/posterior (____) roots — _____

Ventral/anterior (_____/____) roots — _____

A

Sensory, dermatomes

Motor/autonomic, Myotome

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16
Q

_____ is the skin area innervated by a spinal nerve and its segment

The portion of the spinal cord that gives rise to all the rootlets of a signal spinal nerve is called a _____

A

Dermatome

Segment

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17
Q

Cutaneous distribution of spinal nerves

C6 \_\_\_
C7 \_\_\_ and \_\_\_ \_\_\_
C8 \_\_\_\_ and \_\_\_ \_\_\_
T4 \_\_\_\_
T6 \_\_\_\_
T8 \_\_\_\_ \_\_\_\_
T10 \_\_\_\_\_\_
A 
Thumb 
2nd and 3rd finger
4th and 5th finger
Nippe
Xiphoid 
Last rib
Umbilicus
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18
Q

CSF
_____ cc in subarachnoid space

Volume replaced ___-___x per day

Produced ___ml/hr by ___ ____

Specific gravity ____-____

A

150

3-4

21, choroid plexus

1.004-1.008

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19
Q

Blood supply

Spinal cord supplied by ___ ___ spinal artery and __ ___ spinal arteries

___ branches come off of the ___ to supply these arteries

2 ____ arteries have better continuity of blood supply than the ___ spinal artery

A

1 anterior, 2 posterior

Radicular, aorta

Posterior, anterior

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20
Q

Neural blockade

Local anesthetic bathes the ___ ___ in that space

\_\_\_\_ block (spinal anesthesia)
Local anesthetic is injected into \_\_\_ to directly bathe the nerve root, leads to rapid onset 
Epidural anesthesia (outside of \_\_\_\_)
Local anesthesia is injected into \_\_\_ or \_\_\_ space and diffused through the \_\_\_\_ cuff before bathing the nerve root. Slower onset
A

Nerve roots

Subarachnoid, CSF

Meninges, epidural, caudal, Dural

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21
Q

Physiology of neural blockade

Goal: blockade of ___ impulse, a stimulus that causes ___ or ___

Blocks all ___ regardless of fiber type

4 types:

__ and ___ function are also blocked

A

Nocioceptive, pain, injury

Impulses

Autonomic, sensory, proprioception, motor

Autonomic and motor

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22
Q

Physiology of neural blockade

Different nerve types have different ___ to local anesthetic

___ nerves highly sensitive with rapid onset of blockade

___ nerve intermediate sensitivity

__ nerves more resistant to LA and have slower onset

A

Sensitivities

Autonomic

Sensory

Motor

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23
Q

Physiology of neural blockade

Spinal blockade

  • autonomic blockade ___-___ levels ___ sensory blockade
  • motor blockade ___ ___ sensory blockade

Epidural blockade

  • autonomic blockade __ level as sensory blockade
  • motor blockade ___-___ levels ___ sensory blockade
A

2-6, above
2 below

Same
2-4 below

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24
Q

Benefits of neuroaxial anesthesia

  • decreased incidence of ___, cardiac ___, and ____
  • decreased lower extremity vascular ___ ___ due to vasodilation and increased blood flow ___ blockade
  • decreased incidence of ____
A

DVT, morbidity, death

Graft occlusion, below

Pneumonia

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25
Q

Benefits of neuroaxial anesthesia

  • decreased ___ response
  • avoids ____ manipulation
  • decreased incidence of ____
  • intra and postop ___ relief
A

Stress

Airway

PONV

Pain

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26
Q

Disadvantages of neuroaxial anesthesia

  • ___
  • delayed ____ start
  • failure rate depends on _____
  • not a ____ anesthetic
A

Hypotension

Case

Experience

Benign

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27
Q

7 considerations for choosing a technique

A 
Anatomy
Age
Pregnancy
Patho/comorbidities 
Sensory level required vs adverse physiologic effects
Length of procedure
Post op analgesic needs
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28
Q

Indications for SAB/Epidural

Anesthesia

  • sole ___
  • combined ____-___ blockade
  • combined _____/____ used in major ____ procedures and lower ___ ____ cases
A

Anesthetic

Spinal-epidural

GA/regional

Abdominal, extremity vascular

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29
Q

Indications for SAB/epidural

Analgesia

____ and in ___ and ____

A

Postop and in labor and delivery

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30
Q

Contraindications

One absolute:

Semi absolute ____

____ at injection site

___ defects/____ therapy

A

Patient refusal

Increased ICP

Infection

Clotting, anticoagulant

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31
Q

Contraindications

Severe _____ or ____

CNS ___/____

Inability to remain ____ for block

_____

______

A

Hemorrhage or hypovolemia

Disease/meningitis

Still

Bacteremia

Septicemia

32
Q

Contraindications

____ lesions with fixed __ ___ (severe ___/___ and ___ cardiomyopathy)

Difficult _____

Full ____

______ neuropathies

A

Valvular, stroke volume, AS/MS, hypertrophic

Airway

Stomach

Peripheral

33
Q

Cardiovascular changes

Loss of ____ activity results in vasodilation ___ blockade, decreasing SVR ___-___%, decreased ___, therefore CO ___-___%

___ dilation greater than ___ dilation

A

Sympathetic, below,

15-20,

preload,

10-15

Venous, arterial

34
Q

Cardiovascular changes

If blocked is at or cephalad to __-__ level the cardiac accelerators are blocked resulting in ___

Results in profound ____

Treatment includes: 3

A

T1-T4, bradycardia

Hypotension

Vasopressors, volume load (15 ml/kg), vagolytics to treat bradycardia

35
Q

Pulmonary changes

Low levels of blocked- minimal effect of ___/___/___/___ space

As block ascends, _____ muscle paralysis occurs, a perception of ineffective breathing and decrease ability to ___ develops

No direct ___ effects except those related to positioning unless high block (___-___, ___ nerve)

With profound hypotension, may see ___ of central respiratory centers which causes respiratory ___

A

MV, TV, RR, Dead

Accessory, protect

Respiratory, C3-5, phrenic

Ischemia, arrest

36
Q

GI/Renal effects

Nausea vomiting effects ___%

_____ due to unopposed ___ activity

Flow to liver ___ dependent, maintenance of MAP-___untoward liver effects

Renal blood flow has ____ effect

_____ dysfunction, urinary ____. Avoid excessive ____ if no foley

A

20

Hyperperistalsis, parasympathetic

BP, no

Minimal

Bladder, retention, IVF

37
Q

Metabolic/endocrine effects

Blocks ___ response to surgery

____ release may be blocked from the ___ ___

____ secretion is delayed

____ due to altered ____ with vasodilation

A

Stress

Catecholamine, adrenal medulla

Cortisol

Shivering, thermoregulation

38
Q

Neuro effects

___ maintained unless MAP less than ___

Manifested by ___/___ and if sufficiently decreased, ___ and ___

Decreased signals to ____ ___ system leads to ___

A

CBF, 60

N/V, apnea and hypoxia

Reticular activating system, drowsiness

39
Q

Lateral decubitus

___ to the ___. ___ flexed to the ___

Sitting
Low ___
____ block
Improved ___ anatomy

A

Forehead to the knees, thighs flexed to abdomen

Lumbar, sacral, midline

40
Q

Pre-procedure set up

Monitors: 3

____

___ delivery

Fluids ____-___ ml

Equipment for ___ management and resuscitation available

Emergency ___ drawn

Consider___ prior to procedure, identify ____

A

Pulse ox, ekg, BP

Suction

Oxygen

500-1000

Airway

Meds

Sedation, landmarks

41
Q

Median approach

Most ___, needle placed ___, ___ to spinous processes, aiming slightly ____

A

Common, midline, perpendicular, cephalad

42
Q

Paramedian approach

Indicated in patients who can’t ___

Spinal needle placed ____ cm ____ and slightly ___ to the center of the selected interspace

A

Flex

1.5, laterally, caudal

43
Q

Midline approach

Layers transversed
\_\_\_\_
\_\_\_\_\_ \_\_\_\_
\_\_\_\_ \_\_\_\_
\_\_\_\_ \_\_\_\_ 
\_\_\_\_ \_\_\_\_
(\_\_\_\_ \_\_\_)
\_\_\_ \_\_\_ 
\_\_\_ \_\_\_
(\_\_\_\_ \_\_\_)
\_\_\_ \_\_\_
\_\_\_ \_\_\_ 
If reached last 2, too far
A 
Skin 
SQ tissue
Supraspinous ligament 
Interspinous ligament 
Ligamentum flavum 
Epidural space 
Dura mater 
Arachnoid mater
Subarachnoid space
Pia mater
Spinal cord
44
Q

Paramedian approach

Misses the ___ and ___ ligaments

Unable to use ___ ___ as guide

Useful in ___ epidurals or pts with narrow ___ openings

A

Supraspinous and inter spinous

Spinous process

Thoracic, vertebral

45
Q

Pencil point needle (___/___)

  • designed to spread fibers and reduce ___ ___ ___
  • yield a distinct ___ as pencil point penetrates the ___
  • offers increased ___ strength to minimize bending or breakage
A

Sprotte, Whitacre

Post Dural headache

Pop, dura

Tip

46
Q

Cutting needle (_____)

Dural ___ less likely to be noticed due to ___ tip

Increased risk of __ ___ ___

Introducer may not be ___

Bevel must be facing ___/___ in sitting position and ___/___ in lateral position to reduce headache risk

A

Quincke

Pop, sharper

Postdural puncture headache

Necessary

Left/right, up/down

47
Q

SAB

  1. An atomic landmark is identified, ___ ___ ___ palpated and ___ is identified
  2. A __ ___ is established and a prep solution applied with ___ basic sponges, applied in what fashion
  3. A drape is applied, using a ___ ___ wipe the ___ from the injection site
  4. A skin wheel is raised with ___ml of ___ ___ with a ___G needle
A

Superior iliac crest, L4

Sterile field, 3

Sterile gauze, iodine

2, 1% lidocaine, 25

48
Q

SAB

  1. A ___G introducer is passed through skin ___, angled cephalad, stopping in the ___ ___
  2. A ___G needle is inserted into introducer, stopping at ___ space where presence of ____ determined

Layers further than epidural:

A

17, wheal

Ligamentum flavum

25, arachnoid, CSF

Dura, arachnoid, subarachnoid space

49
Q

SAB

  1. CSF is ___ and ___ ___ are identified as a change in ___ and ____ as the local anesthetic and CSF mix
  2. The dose is slowly injected, ___ after installation
  3. All needles are removed and patient is ___
A

Aspirated, mixing lines, baricity, temperature

Aspirating

Positioned

50
Q

Midline approach

Palpated ___ ___ of upper vertebra to make sure midline

Increased resistance as pass through the ___ ___ then loss of resistance as pass through ___ to ___ ___

Remove ___ and confirm free flow of CSF (rotate ___ degrees ___times)

Aspirate CSF ___ and ___ med admin

A

Transverse processes

Ligamentum flavum, dura, subarachnoid space

Stylet, 90, 4

Before and after

51
Q

Paramedian approach

Identify ___ edge of ___ ___ process

Skin wheel ___ cm ___ and ___ cm ___ to that point

Needle aimed __-__ degrees __ and slightly ___

If lamina contacted needle and walked off in a __ and __ direction

After ___ obtained ___ technique as midline

A

Caudad, superior spinous

1, lateral, 1 caudad

10-15, medial, cephalad

Medial and cephalad

CSF, same

52
Q

Density

Specific gravity

A

The weight in grams of 1 cc of solution at a certain temp

The ratio of the density of a solution to the density of water at a constant temperature

53
Q

Baricity

What substances are referring to in SAB

CSF specific gravity

A

The density of a solution to the density of another substance

CSF and LA

1.004- 1.008 (heavier than water)

54
Q

Specific gravity of LA can be altered by adding ___, ___ or ___

_baric and ___baric produce reliable blocks

A

Dextrose, water, CSF

Isobaric and hyperbaric

55
Q

Hyperbaric solution

Specific gravity:

Mix the local anesthetic with ___ and allows LA to ___ into ___ areas

A

Greater than 1.11

Dextrose, settle, dependent

56
Q

Hypobaric solution

Specific gravity:

Mix LA with what

Will go where

A
57
Q

Isobaric solution

Specific gravity

How you mix it

A
58
Q

Factors affecting spread of LA

Top 3 affecting spinal and not epidural

3 others that affect both

A

Baricity of LA,
position of patient,
concentration and volume injected

Level of injection,
rate of injection (barbotage),
direction of needle and bevel

59
Q

Which solution used in hip surgery

A

Hypobaric

60
Q

4 decisions to consider when dosing SAB

A

Surgical site

Length of procedure

Body size (height and width)

Physiology

61
Q

Duration of spinal block

___ of local anesthetic ___ determines duration

Done by ___ absorption via ___ and ___ blood vessels

Metabolized in ___

___ can prolong length of block

A

Rate, elimination

Vascular, subarachnoid, epidural

Vasoconstrictors

62
Q

Epidural placement

___ ___ technique with __ needle, ___ facing opening

___ of ___ technique, __ or ___ filled glass syringe

A

Continuous catheter, touhy, laterally

Loss, resistance, air, saline

63
Q

Epidural insertion sites: 3

A

Thoracic, lumbar, caudal

64
Q

Epidural space

Widest point is ___, ___ mm

Contains ___ and __ ___

Closed space

Medication and catheter deposited into ___ space

A

L2, 5

Fat and blood vessels

Potential

65
Q

Epidural

Ligamentum flavum depth from skin is __ cm, 80% of pts between __-__ cm

___-__mm thick at midline in lumbar region

A

4

3.5-6

5-6

66
Q

Epidural placement

LOR technique

Steady ___ on ___ compress __ __ while advancing needle, when epidural space entered __ is gone and fluid is easily injected

Note needle __ when this happens

Advance __-__ cm, ___-__ is pregnant

A

Pressure, plunger, air bubble

Resistance

Depth

2-3
4-6

67
Q

Caudal block

Involved delivery into __ space via injection through ___ ___

Acces via ___ ligament and __ ___

__ or __g needle and syringe

A

Epidural, sacral hiatus

Sacrococcygeal ligament and sacral hiatus

22 or 23

68
Q

Landmarks in caudal anesthesia: 3

A

Sacral Cornu

Posterior illiac spines S2

Sacral hiatus

69
Q

Caudal anesthesia

Identify __ __ and __

Needle is introduced in a slightly ___ direction through __ at a __ degree angle

The needle advanced until a __ felt as going through __ membrane

Needle is then __ to a __ degree angle and advanced __-__ __ to make sure bevel is in caudal epidural space

A

Sacral hiatus and PSIS

Cranial, 60

Pop, sacrococcygeal

Drop, 20, 2-3 mm

70
Q

Caudal anesthesia

___ to confirm absence of ___ and __

Make sure no ___ injection with other hand

There should be very little ___ to injection

A

Aspirate, blood and CSF

SQ

Resistance

71
Q

Caudal anesthesia uses: 4

A

Peds post op pain control

Hypospadias

Inguinal hernia repair

Perineal and sacral area procedures

72
Q

Limitations to caudal anesthesia

Variable anatomy in ___, best in pts in what age group

High risk of injection into a ___ ___

Difficulty maintaining ___ should a catheter be used

A

Adults, less than 7 years old

Venous plexus

Sterility

73
Q

Spread of epidural

While injecting test dose will notice what if in vascular space or what in subarachnoid space

The quality and extent of epidural dependent on ___ and __ of LA

For induction use ___-___ ml per segment

A

Rise in heart rate from epi, can’t feel legs if in subarachnoid

Volume and concentration

1.25-1.6

74
Q

Post dural puncture headache

__-__% incidence

Due to decrease in ___ pressure with compensatory cerebral ___. Causes brain stem to ___ which stretches __ and pulls on ___

Fronts-occipital postural headache occurs within what range of anesthesia

Treatment: 7

A

1-4

Intracranial, vasodilation, sag, meninges, tentorium

One day to one week

Bed rest, hydration, NSAIDS, abdominal binder, epidural saline injection, caffeine, epidural blood patch

75
Q

PDPH

Increased incidence in

\_\_\_ \_\_ patients 
\_\_\_ needle size 
\_\_\_ population 
\_\_\_ for LOR 
\_\_\_ tip needles \_\_ to meninges 
\_\_\_ attempts
A 
Young female 
Larger
Pregnant 
Air 
Cutting, perpendicular 
Multiple
76
Q

Procedure for epidural blood patch

__-__ ml

Aseptic epidural injection of autologous blood into ___ level, at same level or more ___

__% effective

If more than __ attempts than other causes need to be ruled out

Side effects: 2

A

10-20

Epidural, caudad

Greater than 90

2

Backache and radicular pain (pain radiating to lower extremity)

77
Q

Epidural hematoma

Primary cause is what

Presents with __ or __ ___ weakness

Consult ___ right away if suspected, __-__ hours before permanent injury

Greater than __ hours makes odds of decompression less successful

Hold LMWH __-__ hours before placement and hold __-__ hours after. Heparin can be given __-__ post.

A

Coagulation defect

Numbness or lower extremity weakness

Neurosurgery, 6-8

8

10-12, 10-12

1-2

Anesthesia Concepts (12 decks)

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