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Principles 2 > Spinal Anesthesia (pt 2) > Flashcards

Spinal Anesthesia (pt 2) Flashcards

1
Q

Detail some things to look for on Pre-op Assessment for Spinal Anesthesia

A

-Respiratory issues?
-Ability to lie flat
-Cardiac issues (Fixed cardiomyopathy, Aortic stenosis - anyone who can’t recover if their BP drops)
-Active infection
-Prior back surgery
-Neurological issues
-Coagulopathy
-Expected length of case
-Patient consent, understanding, and cooperation

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2
Q

Which type of needle ends in a pencil point and separates the dura instead of cutting it? (3 names)

A

Whitacre Needles (also Sprotte or Greene non-cutting needles)

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3
Q

What is the purpose of using a non-cutting needle?

A

-Less trauma to the dura and less CSF leakage
-Less post-dural puncture headaches
-Pencil point pushes through the fibers and allows them to come back together.

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4
Q

What is the line drawn at the most superior point of the iliac crests?

A

Tuffier’s Line

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5
Q

What vertebrae is approx. at Tuffier’s Line?

A

L4

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6
Q

Describe sitting positioning for SAB

A

-Back should be maximally flexed to maximize opening between interspaces
-“Mad Cat” or “Boiled Shrimp”

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7
Q

Describe lateral position for SAB

A

-“Fetal Position”
-“Cannonball into pool position”

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8
Q

Describe prone positioning for SAB

A

-Jack knife
-Hypobaric or isobaric LA used ( will flow to the non-dependent region - away from the head). Ex: Tetracaine with water
-Must aspirate CSF - it will not drip out
-Utilized for rectal procedures
-Can also use Caudal anesthesia in prone position

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9
Q

Describe the preparation prior to performing a NA block.

A

-Patient consented
-Standard monitoring and baseline VS +/- O2
-Drugs and airway equipment
-Emergency drugs for hypotension (have Neo and Ephedrine drawn up prior to starting)
-+/- Bolus of NS/LR (10-15 mL/kg, reduce dose for elderly)
-Sedation needed?
-Patient & nurse cooperation?
-Position patient appropriately

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10
Q

List the steps to performing a NA Block.

A

-Know block tray - open it
-Gown/gloves/mask
-Prepare meds and equipment
-Apply sterile drape and prep skin
-Mark interspace
-Do a skin wheal with LA (Superficially raised)
-Insert Introducer
-Insert spinal needle through introducer
-Continue until you feel a POP (Dura Mater)
-Remove stylet and observe flow of CSF
-Grab syringe with local, aspirate CSF (swirl), inject.
-Remove the introducer, needle, and syringe as one unit.
-Position patient how you want and cycle BP (q 2 minutes)

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11
Q

Why are Introducers used in SAB?

A

-For smaller intrathecal needles
-Provides stability
-Establishes direction
-Can act like a finder needle

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12
Q

What gauge needle does not need an Introducer?

A

-22g does not need an introducer (good for elderly with thicker ligaments)
-25-27 g is flimsy and needs support

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13
Q

Which way should the bevel of the Introducer be oriented when using a midline vs paramedian approach?

A

-Bevel to the side (Midline)
-Bevel facing up (Paramedian)

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14
Q

How do you introduce your spinal needle through the introducer?

A

With the notch facing cephalad at a 10-15 degree angle

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15
Q

What is the order of structures that you pass through when performing a SAB via the Midline approach?

A

-Skin
-Subcut tissue
-Supraspinous Ligament
-Interspinous Ligament
-Ligamentum Flavum
-Epidural space
-Dura Mater
-Arachnoid Mater

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16
Q

What is the order of structures that you pass through when performing a SAB via the Paramedian approach?

A

-Skin
-Subcut tissue
-Ligamentum Flavum
-Epidural space
-Dura Mater
-Arachnoid Mater

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17
Q

If you are using a _____ solution, you may not see a swirl.

A

Isobaric

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18
Q

When is the Paramedian Approach utilized?

A

-Patients unable to flex/arch back well
-Older patient believed to have calcified ligaments
-After multiple unsuccessful midline attempts

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19
Q

What is the technique for the Paramedian Approach?

A

-Find the spinous process and walk laterally 1-2 cm, and down 1 cm
-The angle of the needle should be pointed into midline at about a 45 degree angle cephalad, and 15 degree angle medial.
-First resistance felt is Ligamentum Flavum

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20
Q

What is the Taylor Approach to SAB?

A

-A modified paramedian approach
-Utilized with difficult anatomy (Kyphoscoliosis, Scoliosis)
-Uses the L5-S1 interspace
-Lower most prominent iliac spine to avoid the twisting or malposition of the vertebrae.

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21
Q

What are the Pros of a SAB?

A

-Fast acting
-Dense block (motor and sensory)
-Small volume/dose (minimizes toxicity)
-Less time and simpler to perform
-Less N&V, decreased stress response, decreased opioid use
-Affects reticular activating system (due to decreased sensory input from the body), so patient can become somnolent

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22
Q

What are the Cons of a SAB?

A

-Hypotension (significant)
-Can’t prolong the block
-Lack of control with the level of the block

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23
Q

What is the Subdural Space?

A

A potential space between the Dura and Arachnoid Mater
-Needle is inserted partially in the dura, with the lumen not in CSF (won’t be able to aspirate CSF)
-Blocks in this space are variable. Can be unilateral, full motor, and/or partial sensory
-Depends on the amount of drug in the space
-Delayed onset
-High block (smaller space) and drug is sent upwards, farther away from the point of injection

24
Q

When does a Dry Tap occur?

A

If you go through the Dura and are in the PLL.

25
Q

T/F: It is ok to inject when a patient complains of pain.

A

False; Never inject when patient is in pain, can cause nerve damage

26
Q

What is Coring?

A

When you take a part of the skin, including the pigments from the tattoo, into the epidural or subarachnoid space.
-Modern day tattoo has inert metal salts.
-Phenolphthalein base (low allergy potential)

27
Q

How do you prevent problems with tattoos over insertion site?

A

Can change interspace, work around tattoo.
-Also, an introducer can help this problem (Spinal needle doesn’t touch skin)

28
Q

What should you do if you are unsure if the fluid coming out of the needle is CSF or LA from skin wheal?

A

Can always dipstick it and see if there is glucose/protein present
-Always rule this out before assuming that the Subarachnoid space is more superficial than you thought!

29
Q

What are the common complications of NA anesthesia?

A

-Backache
-Nerve injuries (bad positioning)
-Irritation from LA or puncture site
-Hematoma
-Inability to cough
-Decreased uterine flow (careful with OB)
-Double Crush Syndrome
-CV effects (blocks SNS)

30
Q

Backaches are more common with which type of NA anesthesia?

A

Epidural (30%) compared to SAB (11%)

31
Q

What should you do if you suspect hematoma?

A

-Get CT Scan
-Consult neuro
-Can result in permanent injury

32
Q

What causes the feeling of inability to cough with NA?

A

Anxiety regarding loss of feeling of intercostal muscles

33
Q

What is Double Crush Syndrome?

A

Patients with preexisting neurologic disease are susceptible to further injury if exposed to a secondary insult.
-Occurs with diabetics or those with demyelinating diseases like Guillain-Barre
-In already injured areas or paresthesias, intrathecal anesthesia may worsen them
-Damage to myelin can occur with LA, Epi, or Needle
-Identify and chart any existing neuropathies

34
Q

What are the cardiovascular effects associated with NA Anesthesia?

A

Sympathetic blocking effects.
-Remember: SNS runs from T2-L2 (small preganglionic fibers- B fibers)
-Causes both arterial and venous dilation (Venous > Arterial). Leads to venous pooling
-Bainbridge Reflex
-Cardiac accelerator fibers get blocked T1-T5, then the PNS becomes dominant (Marked hypotension and bradycardia***)
-Careful in patients with cardiac diseases the rely on preload

35
Q

How do you prevent marked hypotension and bradycardia associated with NA anesthesia?

A

-Manage patient position for first 5-10 minutes of setup
-Don’t move patient after injecting block to avoid it spreading
-Spinal is harder to control than Epidural

36
Q

What is the Bezold-Jarisch Reflex (BJR)?

A

-Activated with NA by effects on Chemoreceptors and Mechanoreceptors in the Left Ventricle
-Reflex is triggered by decrease in venous return and decreasing LV filling pressures
-Profound bradycardia, hypotension, and CV collapse

37
Q

What is the link between Serotonin and the Bezold-Jarisch Reflex?

A

Some studies are showing that the BJR is activated by Serotonin.
-Serotonin (5HT3) Inhibitors like Ondansetron may be effective in preventing the BJR or lessening the effects***

38
Q

What are positioning modalities to treat hypotension/bradycardia associated with NA Anesthesia?

A

-After the SAB has set up (5-10 minutes), you can try a slight head down or lift legs up for auto transfusion (these must be done after block is “fixed”***)
-If you put the head down too early, the block will move higher

39
Q

When do you treat a patient for hypotension?

A

If not within 20% of normal BP (within 30% for HTN people)

40
Q

What is important to know regarding fluid replacement with NA?

A

-10-15 mL/kg of Crystalloid
-Colloids (controversial)
-Careful in elderly

41
Q

What pharmacologic therapy can be instituted to treat hypotension and bradycardia?

A

-Ephedrine (Alpha 1 vasoconstriction + Beta 1 increased in HR and Contractility). Start with 10 mg
-Phenylephrine (Alpha 1 - must dilute in syringe. Give 40 - 80 mcg at a time)
-5HT3 inhibitors (Ondansetron) - 4 mg
-Atropine/Epinephrine

42
Q

What level is a Total Spinal?

A

-Classified as above mid cervical
-Paralysis of the Phrenic nerve with subsequent apnea
-Secure airway and hemodynamic support until level recedes
-Usually if you get a good BP back, breathing resumes.

43
Q

What is the most common cause of apnea with a Total Spinal?

A

Most commonly, apnea is due to brainstem ischemia, not phrenic nerve paralysis. If you get the BP back up, usually breathing resumes.

44
Q

What are the causes of a Total Spinal?

A

-High spinal
-Accidental epidural injection into the Subarachnoid Space with a large volume of LA

45
Q

What are the Respiratory effects of NA Anesthesia?

A

-Clinical significant alterations are usually minimal
-Tidal volume largely preserved with a small decrease VC probably due to blockade of the accessory muscles decreasing ERV
-Reassure patient that they are breathing (can’t feel it)
-Main effect is on exhalation

46
Q

What about NA Anesthesia and COPD patients?

A

COPD patients may not be the best candidates for this or may need LMA in addition to spinal.
-Depend on accessory muscles (intercostal and abdominal) to actively inspire and exhale
-Impaired coughing and clearing of secretions
-Risk vs benefits

47
Q

What are other causes (besides anesthesia) of neurological issues in the periop environment?

A

-Birth
-Trauma
-Retractors
-Positioning
-Exacerbation of a preexisting disease

Get neuro consult immediately
-Can be transient or permanent

48
Q

Describe Transient Neurological Symptoms (TNS) or Transient Radicular Irritation (TRI)

A

-Pain in the legs/buttocks
-Paresthesias usually resolve in 72 hours to 6 months
-Causes: Traumatic puncture of cord, intraneural injection
-Avoid by staying away from high concentrations of Lido and/or not using Lido at all.

49
Q

What is Cauda Equina Syndrome?

A

-Variable presentation: immediate or gradual
-Prolonged recovery from anesthesia blockade
-Motor & Sensory blockade in sacral region and lower extremities, perineal anesthesia with incontinence
-Associated with microcatheters specifically designed for continuous spinal anesthesia (postulated that this results in less dilution of LA and less spread)

50
Q

What LA is no longer used for SAB due to risk of Cauda Equina Syndrome?

A

Hyperbaric Lidocaine - 5%/7.5% dextrose

51
Q

What can you do to prevent epidural hematoma/Subarachnoid hemorrhage?

A

-Careful history with labs
-No NA if plt count < 100k or if Pt/PTT are over 2x normal
-Neuro consult, CT scan, may need surgery

52
Q

Why do you need to remove the US gel before performing NA Anesthesia?

A

US gel is associated with a distinct neuro-inflammatory reaction
-Epidural Abscess, septic meningitis, and aseptic meningitis (chemical)

53
Q

What are the GI effects r/t NA Anesthesia?

A

-Vagal tone dominance, PNS dominance
-Active peristalsis
-N/V (usually r/t hypotension - resolves with Ephedrine)
-N/V could also be due to gut ischemia or cerebral ischemia (Vomiting center)

54
Q

What are the other organ system effects of NA Anesthesia?

A

-Cerebral blood flow is maintained via auto-regulation as long as MAP > 55
-Renal blood flow is maintained via auto-regulation as long as MAP > 55
-Urinary retention
-Endo: Partially or completely suppresses the stress response, reduces catecholamines, and blunts hyperglycemia

55
Q

Management of Failed Spinal Anesthesia

A

-If after 15 min no typical signs of onset occur, spinal failure is likely
-Can repeat injection (With caution)
-Reposition
-IV analgesia/sedation/GA

Review slide 101

56
Q

When can patients be discharged home?

A

When they can void, and get up/walk around without drastic changes in BP

57
Q

In what order does a NA Block reverse?

A

-Motor movement comes back first (wiggles toes, lift legs)
-Sensation (may start to feel pain)
-Autonomic effects are the last thing to come back (this is why you have to be able to get up without drastic shifts in BP before going home)

Principles 2 (45 decks)

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