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Principles I summer 2024 > spinal and epidural part 3 > Flashcards

spinal and epidural part 3 Flashcards

1
Q

parasympathetic innervation is primarily via the _______ nerve

A

vagus

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2
Q

parasympathetic afferent GI

A

transmits sensations of satiety dissension and nausea

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3
Q

parasympathetic efferent GI

A

tonic contractions, sphincter relaxation, peristalsis and secretions

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4
Q

sympathetic afferent GI

A

transmits visceral pain

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5
Q

sympathetic efferent GI

A

inhibit peristalsis and gastric secretion and cause sphincter contraction and vasoconstriction

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6
Q

sympathetic innervation of GI tract stems from

A

T5-L2

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7
Q

impact of neuraxial anesthesia on GI (3 discussed in lecture)

A

reduces sympathetic tone
increase parasympathetic activity
changes is unopposed vagal tone

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8
Q

what are the resulting changes in unopposed vagal tone with neuraxial anesthesia in GI

A

relaxes sphincters
increase peristalsis
small contracted gut with active peristalsis
increased GI blood flow
N/V
reduce post op ileus

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9
Q

systemic effects of neuraxial anesthesia on GU

A

no change in renal blood flow (if MAP maintained)
sympathetic blockade above T10 affects bladder control
need foley catheter

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10
Q

what is elevated from metabolic/endocrine with neuraxial anesthesia

A

cortisol
epinephrine
norepinephrine
vasopressin
RAAS

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11
Q

which LA is more common to have allergies

A

esters
PABA

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12
Q

is there cross sensitivity in ester

A

yeah

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13
Q

what does amide contain that can cause an allergic reaction

A

methyparaben

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14
Q

what is onset of action determined by

A

pKa

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15
Q

what is potency determined by

A

lipid solubility

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16
Q

what is duration of action determined by

A

protein binding
alpha 1 acid glycoprotein

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17
Q

LA inhibition of peripheral nerves occurs in what order

A

B fibers
C fibers
small diameter A fibers
large diameter A fibers

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18
Q

what are the 5 factors influencing vascular uptake and plasma concentration of LA

A

site of injection
tissue blood flow
physiochemical properties
metabolism
addition of vasoconstrictor

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19
Q

highest blood concentration to lowest blood concentration of LA

A

IV
tracheal
intercostal
caudal
paracervical
epidural
brachial
sciatic
subcutaneous

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20
Q

baracity refers to

A

density of a LA solution compared to CSF

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21
Q

isobaric

A

density equal of CSF
stays in place

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22
Q

hyperbaric

A

density greater than CSF (greater than 1)
sinks within CSF

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23
Q

hypobaric

A

density less than CSF (less than 1)
rises within the CSF

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24
Q

high points for hyperbaric

A

C3 L3

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25
Q

low points for hyperbaric

A

T6 and S2

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26
Q

lipophilic drugs have ______ reuptake and _______ affinity for epidural fat

A

slow reuptake
high affinity

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27
Q

bupivacaine 0.5-0.75% spinal dose for t10, T4, onset and duration

A

10-15mg T10
12-20mg T4
onset 4-8 min
duration 130-220min (add 20-50% with epi)

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28
Q

levobupivacaine 0.5% dose T10, T4 onset, duration

A

10-15mg
12-20 mg
4-8 min
140-230min

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29
Q

ropivicaine 0.5-1% dose T10, T4 , onset, duration

A

12-18mg
18-25mg
3-8min
80-210 min

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30
Q

2 chloroprocaine 3% dose t10, t4, onset, duration

A

30-40mg
40-60mg
2-4 min
40-90min

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31
Q

tetracaine 0.5-1% dose t10, t4, onset, duration

A

6-10mg
12-16mg
3-5min
90-120min (epi add 20-50%)

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32
Q

which drugs can you add epi to

A

bupivacaine
tetracaine

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33
Q

which drug has shortest onset for spinal

A

2-chloroprocaine

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34
Q

which drug has longest duration

A

levobupivacaine

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35
Q

which drug has highest dose

A

2 chloroprocaine

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36
Q

which drug has lowest dose

A

tetracaine

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37
Q

how do you dose epidural

A

1-2mL/segment
incremental dosing with 5mL

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38
Q

what is the concentration of 2-chloroprocaine used for surgical

A

3%

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39
Q

what is a popular drug for OB epidural

A

2-chloroprocaine

40
Q

what does alkalization do

A

speed up onset of block
increase rate of diffusion
increase pH of LA

41
Q

what is a top up dose

A

50-75% of the initial dose used to maintain the block without letting it wear off too much

42
Q

what is the timing of the top up dose

A

administer before the block decreases more than 2 dermatomes

43
Q

epidural space variation

A

thoracic is smaller than lumbar so use 1mL/segment

44
Q

place the epidural drugs from fastest to slowest onset/shortest to longest duration

A

2-cloroprocaine
lidocaine
ropivacaine
bupivacaine
levobupicaine

45
Q

what are the typical concentrations of the following drugs
2-cloroprocaine
lidocaine
ropivacaine
bupivacaine
levobupicaine

A

3%
2%
0.75%
0.5%
0.5%

46
Q

which drugs improve density, duration and analgesia

A

alpha 2 agonists
dexmedetomidine
clonidine

47
Q

which drugs extends duration only

A

vasopressors

48
Q

which drugs improves density and analgesia

A

opioids
sufent
fent
morphine

49
Q

which opioids are hydrophilic

A

morphine
hydromorphone
meperidine

50
Q

which opioids are lipophilic

A

fentanyl
sufentanil

51
Q

characteristics of hydrophilic drugs

A

spreads widely in CSF
stays longer in CSF
longer onset
longer duration
less systemic absorption
respiratory depression occurs late

52
Q

lipophilic drug characteristics

A

shorter duration
limited spread
quicker onset
more systemic absorption
respiratory depression earlier

53
Q

sufentanil intrathecal, epidural, epidural infusion dose

A

5-10mcg
25-50mcg
10-20mcg/hr

54
Q

fentanyl intrathecal, epidural, epidural infusion dose

A

10-20mcg
50-100mcg
25-100mcg/hr

55
Q

hydromorphone intrathecal, epidural, epidural infusion dose

A

no intrathecal dose
0.5-1mg
0.1-0.2mg/hr

56
Q

meperidine intrathecal, epidural, epidural infusion dose

A

10mg
25-50mg
10-60mg/hr

57
Q

morphine intrathecal, epidural, epidural infusion dose

A

0.25-0.3mg
2-5mg
0.1-1mg/hr

58
Q

pruritis occurs in what % of population

A

30-100%

59
Q

what is the treatment of pruritis

A

benadryl 25-50mg
naloxone 0.1mg
buprenex

60
Q

prophylaxis of pruritis

A

minimize dose of morphine <300mcg
ondansetron 4mg
nubain 2.5-5mg

61
Q

what are common side effects of A2 agonist

A

hypotension
bradycardia

62
Q

dose of dexmedetomidine

A

3mcg

63
Q

dose of clonidine

A

15-45mcg

64
Q

dose of epinephrine

A

0.2-0.3mg
epi wash

65
Q

phenylephrine dose

A

2-5mg

66
Q

symptoms of epidural hematoma

A

lower extremity weakness, numbness
lower back pain
bowel and bladder dysfunction

67
Q

high risk and intermediate risk procedures hold aspirin for

A

4-6 days

68
Q

precautions for aspirin for central neuraxial blocks

A

no additional precautions

69
Q

NSAIDS for high risk procedures

A

hold for 5 half lives

70
Q

Glycoprotein IIB/IIIA antagonists for regional anesthesia

A

tirofiban and eptifibatide 4-8 hours
abciximab 24-48 hours

71
Q

thienopyridine for regional anesthesia

A

clipidogren 5-7 days
prasugrel 7-10 days
ticlopidine 10 days

72
Q

unfractionated heparin regional anesthesia

A

low dose <5000U hold 4-6 hours
higher dose hold 12 hours
therapeutic dose >20000U hold 24 hours
greater than 4 days have plt count checked

73
Q

low molecular weight heparin regional anesthesia

A

delay at least 12 hours for prophylactic dose
delay 24 hours after therapeutic dose

74
Q

Vit K antagonists regional anesthesia

A

hold for 5 days and verify INR

75
Q

thrombolytic agents

A

absolute contraindication

76
Q

direct oral anticoags

A

discontinue 72 hours before
antifactor 10a check

77
Q

postural puncture headache is caused by

A

failure of a dura puncture site to properly seal over once breeched by a needle
leak of CSF causes reduction in CSF volume

78
Q

symptoms of PDPH

A

headache that worsens when sitting or standing; felt from forehead to back of head
nausea
sensitivity to light
double vision
ringing in ears

79
Q

what are patient factors contributing to PDPH

A

younger
female
pregnant

80
Q

what are practitioner factors contributing to PDPH

A

cutting tip needle
large diameter needle
air for LOR
positioning needle perpendicular to spines long axis

81
Q

treatment for PDPH

A

bed rest
NSAIDs
Caffeine
epidural blood patch
sphenopalatine ganglion block

82
Q

what is the common bacteria involved in infection with regional

A

streptococcus viridans

83
Q

what is the recommended skin prep for regional anesthesia

A

alcohol and chlorhexidine

84
Q

what nerves are affected in cauda equine syndrome

A

L2-S5 and coccygeal nerves

85
Q

what causes cauda equina syndrome

A

neurotoxicity due to high levels of LA drugs affecting nerve function

86
Q

factors that increase risk of cauda equina syndrome

A

using 5% lidocaine in SAB
micro catheters
whiticare 25/26 needle

87
Q

s/s of cauda equina syndrome

A

serious neurologic complication can be permanent
bowel and bladder dysfunction
sensory deficits (loss of feeling in the legs or feet)
back pain
saddle anesthesia
sexual dysfunction
weakness or paralysis
paraplegia (late sign)

88
Q

treatment of cauda equina syndrome

A

supportive care
laminectomy <6hours if compression

89
Q

transient neurologic symptoms causes

A

patient positioning
myofascial strain and spasms

90
Q

factors that increase risk of transient neurologic symptoms

A

higher incidence when using lidocaine 5%
surgical positions (lithotomy position)
outpatient surgeries (knee arthroscopy)

91
Q

factors that do not increase risk of transient neurologic symptoms

A

early ambulation
LA concentration ad baricity

92
Q

s/s of transient neurologic symptoms

A

pain: severe radicular pain the the back and buttocks that spreads down both legs
starts w/in 6-36 hours and last 1-7 days

93
Q

treatment of transient neurologic symptoms

A

NSAIDS and opioids
trigger point injections (muscle spasms and pain relief)

94
Q

how do you prevent retained catheter fragments in epidural

A

withdraw needle and catheter at the same time to prevent the pathetic from sheering

95
Q

risk factor for epidural vein cannulation

A

multiple attempts
pregnancy
stiffer catheters
trauma to epidural vein during block procedure

Principles I summer 2024 (7 decks)

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