Spinal & Epidural Part 4 ( Tubog) Exam 1 Flashcards
The failure of a dura puncture site to properly “seal over” once breached by a needle can lead to a continuous leak of ______.
A) blood
B) cerebrospinal fluid
C) synovial fluid
D) interstitial fluid
B) cerebrospinal fluid (CSF), CSF
The CSF leak d/t dura puncture lowers the pressure in the brain area, causing the brain to ______ slightly and stretch the surrounding membranes, leading to a ______.
A) expand, migraine
B) contract, seizure
C) sag, headache
D) swell, stroke
C) sag, headache
Slide 91
The headache associated with Post Dural Puncture Headache (PDPH) is usually felt from the ______ to the back of the head and may be accompanied by other symptoms such as ______, sensitivity to light, double vision, and ringing in the ears.
A) temples, vertigo
B) crown, dizziness
C) forehead, nausea
D) neck, fever
C) forehead, nausea
Fronto-Occipital
Slide 91 Postdural Puncture Headache
Which of the following symptoms is commonly associated with postdural puncture headache (PDPH)?
A) Headache that feels worse when lying down
B) Headache that occurs immediately after puncture
C) Headache that feels worse when sitting or standing
D) Headache that is localized to one side of the head
C) Headache that feels worse when sitting or standing
Slide 91
The headache from PDPH usually occurs ______ days post puncture.
A) 1-2
B) 2-3
C) 3-4
D) 4-5
B) 2-3
Slide 91
Factors affecting the risk of PDPH include patient factors such as being younger, being female, and being ______.
A) elderly
B) male
C) pregnant
D) overweight
C) pregnant
Slide 91
Practitioner factors affecting the risk of PDPH include using a needle with a cutting tip such as ______ and using a large ______ needle.
A) Quincke, diameter
B) Whitacre, gauge
C) Tuohy, diameter
D) Sprotte, flexible
A) Quincke, diameter
Pencil point and smaller diameter helps prevent PDPH
Slide 91
One of the key preventative measures to reduce the risk of PDPH is to position the needle ______ to the spine’s long axis.
A) parallel
B) perpendicular
C) paramedian
D) oblique
B) perpendicular
Slide 91
True or False
Using air for Loss of Resistance with epidural placement is a practitioner factor for increased risk of Postdural Puncture Headache
True
Slide 91
Which of the following needle designs has the highest incidence of PDPH?
A) Quincke 22 gauge
B) Whitacre 27 gauge
C) Sprotte 24 gauge
D) Tuohy 16 gauge
A) Quincke 22 gauge
cutting needle
Slide 91
The main treatment for severe headaches after dural puncture is the ______, which involves injecting the patient’s own blood into the ______ space.
A) intrathecal blood patch, intrathecal
B) epidural blood patch, epidural
C) epidural blood patch, subarachnoid
D) subarachnoid blood patch, subdural
B) epidural blood patch, epidural
Slide 92
Select all the conservative treatments for postdural puncture headache (PDPH).
Select 3
A) Bed rest
B) NSAIDs
C) Physical Theraphy
D) Caffeine
E) Intravenous fluids
A) Bed rest
B) NSAIDs
D) Caffeine
Slide 92
Select all the interventional treatments for postdural puncture headache (PDPH). Select 2
A) External Ventricular Device (EVD)
B) Sphenopalatine ganglion block
C) Spinal fusion
D) Nerve ablation
E) Epidural blood patch
B) Sphenopalatine ganglion block - It is a simpler, low-risk treatment alternative for PDPH.
E) Epidural blood patch
Slide 92
The epidural blood patch is not routinely recommended within 24 hours of a dural puncture; ______ has shown to be the standard for better outcomes.
A) 32 hours
B) 36 hours
C) 48 hours
D) 72 hours
C) 48 hours has shown to be the standard for better outcomes.
Slide 92
How much of the patient’s own blood is typically injected into the epidural space during an epidural blood patch to treat postdural puncture headache (PDPH)?
A) 5-10 mL
B) 10-20 mL
C) 20-30 mL
D) 30-40 mL
B) 10-20 mL
What is the success rate of the epidural blood patch in treating postdural puncture headache (PDPH)?
A) About 70%
B) About 80%
C) About 90%
D) About 95%
C) About 90%
Slide 92
If two epidural blood patches do not work, what should be considered next?
A) Increasing the dose of caffeine
B) Switching to oral analgesics
C) Other causes of headache
D) Repeating the epidural blood patch
C) Other causes of headache
Cardiothoracic consult
Slide 92
The sphenopalatine ganglion block procedure involves soaking a cotton swab with which of the following solutions?
Select 2
A) 1-2% Lidocaine
B) 0.9% Saline solution
C) 0.5% bupivacaine
D) 3% Chloroprocaine
A) 1-2% Lidocaine
C) 0.5% bupivacaine
Slide 92
How long should the cotton swab be left in place during the sphenopalatine ganglion block procedure to reduce headache symptoms?
A) 1-2 minutes
B) 3-4 minutes
C) 5-10 minutes
D) 15-20 minutes
C) 5-10 minutes
This can quickely reduce headache symptoms
Slide 92
The higher incidence of paresthesia during needle placement is typically associated with ______ techniques, and the deficit usually follows the area where the paresthesia occurred.
A) lumbar puncture
B) combined spinal-epidural
C) intramuscular injection
D) peripheral nerve block
B) combined spinal-epidural (CSE)
Slide 93
When paresthesia is elicited during needle placement, ______ of the needle is indicated to prevent further injury.
A) advancement
B) retraction
C) redirection
D) withrawal
C) redirection
Slide 93
If a spinal block has not set up after 15-20 minutes and no anesthesia effect is observed, it may be necessary to ______ the block.
A) adjust
B) delay
C) discontinue
D) repeat
D) repeat
Slide 93
In the case of a patchy block, repeating the block should be avoided due to the risk of ______, and alternative strategies such as ______ or general anesthesia should be considered.
A) infection, antibiotics
B) neurotoxicity, IV sedation
C) bleeding, anticoagulants
D) inflammation, corticosteroids
B) neurotoxicity, IV sedation
Slide 93
Select all the correct statements about the risk factors and management of paresthesia during needle and catheter placement.
Select 3
A) Higher incidence if paresthesia was encountered after placement.
C) Epidural catheter placement has a much lower risk.
D) Noncooperative or moving patients can increase risks.
E) Placement was not aligned with the midline
C) Epidural catheter placement has a much lower risk.
D) Noncooperative or moving patients can increase risks.
E) Placement was not aligned with the midline
Higher incidence if paresthesia was encountered during placement.
Slide 93
If a unilateral block is observed, the first management step is to:
A) Increase the dose of anesthetic
B) Adjust the patient’s position
C) Use a different type of anesthesia
D) Apply heat to the affected area
B) Adjust the patient’s position
If still ineffective consider IV sedation or general anesthesia
Slide 93
Select all the ways infections can happen after a spinal procedure.
A) Aseptic technique failure
B) Bacteria in blood
C) Contaminated instruments
D) Poor patient hygiene
A) Aseptic technique failure -allowing germs to enter the spine area during the procedure
B) Bacteria in blood -patient already has an infection, it can infect the spine during the procedure
Slide 94
Streptococcus viridans, a common bacterium involved in post-spinal bacterial meningitis, is found in the ______ and on ______.
A) nose, feet
B) mouth, hands
C) throat, skin
D) ears, hair
B) mouth, hands
Wearing a mask and washing hands are essential to prevent spread of this bacteria
Slide 94
Select all the skin preparation options mentioned for preparing the patient’s back before a spinal procedure.
A) Iodine
B) Alcohol
C) Chlorhexidine
D) Hydrogen peroxide
E) Dawn Dish Soap
A) Iodine
B) Alcohol
C) Chlorhexidine
Recommended combination is Alcohol and Chlorhexidine is VERY effective in preventing bacterial meningitis
Slide 94
Why must chlorhexidine be allowed to dry before a spinal procedure begins?
A) To avoid causing an allergic reaction
B) To ensure maximum antiseptic effect
C) To avoid arachnoiditis
D) To prevent skin irritation
C) To avoid arachnoiditis
Slide 94
Cauda equina syndrome affects the ______ nerves and coccygeal nerves.
A) T1-T12
B) L2-S4
C) C1-C7
D) S1-S5
B) L2-S4
Slide 95
The primary cause of cauda equina syndrome is ______ due to high levels of local anesthetic drugs affecting nerve function.
A) infection
B) inflammation
C) neurotoxicity
D) trauma
C) neurotoxicity
Serious neurological complications can be permanent!!
Slide 95
Factors that increase the risk of cauda equina syndrome include the use of high concentration local anesthetics such as ______ lidocaine in SAB and the use of ______.
A) 3%, microcatheters
B) 1%, macrocatheters
C) 5%, microcatheters
D) 10%, macrocatheters
C) 5%, microcatheters
Slide 95
Select the factor that increases the risk of cauda equina syndrome.
A) Using 3% lidocaine in SAB
B) Low concentration local anesthetics
C) Macrocatheters
D) Whitacre 25/26 needle
D) Whitacre 25/26 needle
Slide 95
Select all the signs and symptoms of cauda equina syndrome.
Select 3
A) Bowel and bladder dysfunction
B) Sensory deficits in the arms and legs
C) Back pain
D) Fever and chills
E) Sensory deficits in the legs or feet
A) Bowel and bladder dysfunction
C) Back pain
E) Sensory deficits in the legs or feet
Slide 95
Which of the following is NOT a sign or symptom of cauda equina syndrome?
A) Saddle anesthesia
B) Sexual dysfunction
C) Weakness or paralysis
D) Hypertension
D) Hypertension
True or False
Paraplegia is an early sign of Cauda Equina Syndrome
False
Paraplegia is a late sign of Cauda Equina Syndrome
slide 95
Which treatment is recommended if compression (disc, hematoma, etc.) is a factor in cauda equina syndrome?
A) Epidural blood patch
B) Laminectomy
C) Antibiotics
D) Corticosteroids
B) Laminectomy
Immediate laminectomy within <6hrs
Other treatment includes supportive care and treating symptoms
Slide 95
Transient neurologic symptoms can be caused by improper ______ during procedures, which can stretch nerves such as the sciatic nerve, causing temporary symptoms.
A) anesthesia
B) medication
C) positioning
D) hydration
C) positioning
Myofascial Strain and Spasims
Slide 96
Factors that increase the risk of transient neurologic symptoms include a higher incidence when using ______ lidocaine and certain surgical positions such as the ______ position.
A) 1%, prone
B) 2%, lithotomy
C) 5%, lithotomy
D) 10%, right lateral decubitus
C) Lidocaine 5% (19%), lithotomy (hip or knee flex)
Outpatient surgeries and knee arthroscopy are associated with higher risks.
Slide 96
Factors that do not increase the risk of transient neurologic symptoms include early ______ and the concentration and ______ of local anesthetics.
A) hydration, viscosity
B) ambulation, baricity
C) medication, volume
D) positioning, density
B) ambulation, baricity
Slide 96
Signs and symptoms of transient neurologic symptoms include severe radicular pain in the back and buttocks that spreads down both legs, with pain usually starting within ______-______ hours after surgery and lasting from 1 to ______ days.
A) 1 to 6, 3
B) 6 to 36, 7
C) 12 to 24, 5
D) 24 to 48, 10
Correct Answer:
B) 6 to 36, 7
Slide 96
Factors that do not increase the risk of transient neurologic symptoms include early ______ and the concentration and ______ of local anesthetics.
A) hydration, viscosity
B) ambulation, baricity
C) medication, volume
D) ambulation, density
B) ambulation, baricity
Slide 96
Select all the signs and symptoms of transient neurologic symptoms.
Select 2
A) Severe radicular pain in thoracic and lumbar spine
B) Pain spreading down both one leg
C) Muscle spasms and pain
D) Pain that resolves within a week in 90% of cases
C) Muscle spasms and pain
D) Pain that resolves within a week in 90% of cases
slide 96
NSAIDs like ibuprofen and opioid painkilers can help along with _______________ to relieve muscle spasms and pain associated with transient neurologic symptoms.
A) Antibiotics
B) Antihistamines
C) Trigger point injections
D) Antipyretics
C) Trigger point injections
slide 96
If there’s resistance when trying to remove an epidural catheter, place the patient in the position they were in during insertion or ______ decubitus.
A) supine
B) prone
C) lateral
D) dorsal
C) lateral
Slide 97
If a catheter breaks, always ______ the patient if a piece of the catheter breaks off inside them.
A) monitor
B) treat
C) inform
D) sedate
C) inform
If no symptoms they can often live safely with the fragment
Slide 97
If neurological symptoms develop after a catheter breaks, ______ may be needed to remove the catheter piece.
A) physical therapy
B) medication
C) surgery
D) rest
C) surgery
Slide 97
What should you do if there is resistance when trying to remove an epidural catheter?
A) Apply maximum force to pull it out.
B) Leave the catheter in place and try again later.
C) Apply gentle, continuous pulling.
D) Cut the catheter and remove it in pieces.
C) Apply gentle, continuous pulling
slide 97
True or false
Tape can be used to try and remove an epidural catheter that is stuck
true
Tape Traction: Tape the catheter to the skin and gently pull.
slide 97
If blood is found in the needle during an epidural procedure, the needle could be too far ______, and the solution is to adjust the needle to aim more towards the ______.
A) medial, lateral
B) lateral, midline
C) anterior, posterior
D) posterior, midline
B) lateral, midline
Slide 98
When handling blood in the catheter, if blood is aspirated, slightly ______ the catheter and flush it with ______.
A) advance, saline
B) rotate, lidocaine
C) pull back, saline
D) twist, epinephrine
C) pull back, saline
Repeat until no more blood is drawn or if the catheter can’t be adjusted further safely
Slide 98
To prevent epidural vein cannulation, it is recommended to ______ fluid in the epidural space before placing the catheter.
A) aspirate
B) inject
C) drain
D) measure
B) inject
Slide 98
Risk factors for epidural vein cannulation include multiple attempts, pregnancy, catheter type, and ______ to the epidural vein during the block procedure.
A) infection
B) trauma
C) inflammation
D) compression
B) trauma
Stiffer catheters are harder to maneuver and more likely to puncture a vein
Slide 98
What are possible causes of a unilateral epidural block? (Select 2)
A) Catheter tip too close to a nerve.
B) Catheter inserted too far
C) Catheter is in the bloodstream.
D) Catheter is positioned correctly.
A) Catheter tip too close to a nerve.
B) Catheter inserted too far exiting the epidural space through intervertebral foramen.
Slide 99 - Spinals/Epidurals
What are possible solutions if the catheter is causing issues? (Select 3)
A) Pull the catheter slightly, about 1-2 cm.
B) Reposition the patient to lateral decubitus position.
C) Inject a concentrated local anesthetic.
D) Replace the catheter if adjustments don’t work.
A) Pull the catheter slightly, about 1-2 cm.
B) Reposition the patient to lateral decubitus position.
D) Replace the catheter if adjustments don’t work.
* slide 99 - inject DILUTE LA to even out block
If we try to adjust the catheter to fix a unilateral block, how many cm should we ensure remain in the epidural space?
A) 10cm
B) 5cm
C) 4cm
D) 3cm
D) 3 cm
Slide 99 - pull the cath back 1-2cm
What is the most common cause of Local Anesthetic Systemic toxicity?
A) Delayed injection
B) Inadequate dosage
C) Inadvertent injection
D) Improper storage of the anesthetic
C) Inadvertent injection
Slide 100
Which statements are true regarding local anesthetic systemic toxicity (LAST)? (Select 2)
A) The most common cause of toxicity is inadvertent injection.
B) The most frequent symptom of toxicity is dizziness.
C) With bupivacaine, cardiac arrest may come before a seizure.
D) LAST is more common in epidural than in peripheral nerve blocks.
A) The most common cause of toxicity is inadvertent injection.
C) With bupivacaine, cardiac arrest may come before a seizure.
slide 100
* most frequent symptom - seizure
* LAST more common w/ peripheral nerve blocks
Match the plasma concentration of lidocaine (mcg/mL) with the corresponding CNS or cardiopulmonary effects:
1) 1-5 mcg/mL
2) 5-10 mcg/mL
3) 10-15 mcg/mL
4) 15-25 mcg/mL
5) >25 mcg/mL
Effects:
A) seizures, LOC
B) Coma, Respiratory Arrest
C) Tinnitus, skeletal muscle twitching, circumoral numbness, restlessness, vertigo, blurred vision, hypotension, myocardial depression
D) CV collapse
E) Analgesia
1 - E
2 - C
3 - A
4 - B
5 - D
Slide 100
How does hypercarbia increase the risk of CNS toxicity w/ LAST?
A) Decreases cerebral perfusion
B) Decreases drug delivery to the brain
C) Increases cerebral perfusion
D) Reduces the free fraction of local anesthetic available to enter the brain
C) Increases cerebral perfusion (think vasodilation)
* SLIDE 101 - increases drug delivery to brain
How does hyperkalemia increase the risk of CNS toxicity w/ LAST?
A) Makes the neurons less excitable
B) Makes the neurons more excitable and more likely to depolarize
C) Makes the neurons require larger stimuli to depolarize
D) Protects the neurons from depolarization
B) Makes the neurons more excitable and more likely to depolarize
* slide 101
LAST - CNS toxicity
What condition lowers the seizure threshold and increases brain drug retention?
A) Hyperkalemia
B) Hypercarbia
C) Metabolic acidosis
D) Hypokalemia
C) Metabolic acidosis
* slide 101
* think ion trapping
Which factors increase the risk of a patient developing CNS toxicity w/ LAST? (Select 3)
A) Hypercarbia
B) Hypokalemia
C) Hyperkalemia
D) Metabolic acidosis
A) Hypercarbia, C) Hyperkalemia, D) Metabolic acidosis
Which factors decrease the risk of CNS toxicity? (Select 3)
A) Hypocarbia
B) CNS depressants (like benzodiazepines and barbiturates)
C) Hypercarbia
D) Hypokalemia
A) Hypocarbia (vasoconstriction)
B) CNS depressants (like benzodiazepines and barbiturates)
D) Hypokalemia
slide 101
Fill in the blank: Metabolic acidosis lowers the seizure threshold and increases brain drug retention, also known as ________.
ion trapping
slide 101
LAST
Which factors determine the extent of cardiotoxicity of a local anesthetic? (Select 3)
A) Affinity to the voltage-sodium channel in the active state
B) Affinity to the voltage-sodium channel in the inactive state
C) Rate of dissociation from the receptor during diastole
D) Affinity to the voltage-calcium channel
A) Affinity to the voltage-sodium channel in the active state
B) Affinity to the voltage-sodium channel in the inactive state
C) Rate of dissociation from the receptor during diastole
slide 101
List the LAs in order from most difficult cardiac resuscitation to least difficult
A) Lidocaine, Bupivacaine, Levobupivacaine, Ropivacaine
B) Levobupivacaine, Lidocaine, Bupivacaine, Ropivacaine
C) Bupivacaine, Levobupivacaine, Ropivacaine, Lidocaine
D) Ropivacaine, Lidocaine, Levobupivacaine, Bupivacaine
C) Bupivacaine, Levobupivacaine, Ropivacaine, Lidocaine
slide 101
Local anesthetics (LA) affect which of the following heart functions? (Select 5)
A) Heart’s automaticity
B) Conduction velocity
C) Myocardial contractility
D) Blood pressure
E) AP duration
F) Effective Refractory Period
A) Heart’s automaticity
B) Conduction velocity
C) Myocardial contractility
E) AP duration
F) Effective Refractory Period
decreases all
slide 101
LAST - CV toxicity
Local anesthetics (LA) depress myocardium by affecting ___________ regulation.
intracellular calcium
slide 101
Which 4 of these are the main treatments for LAST? (select 4)
A) Typical ACLS
B) Manage the Airway
C) Propofol Therapy
D) Limid Emulsion Therapy
E) Treat Seizures
F) Modified ACLS
G) Prevent Seizures
B) Manage the Airway
D) Limid Emulsion Therapy
E) Treat Seizures
F) Modified ACLS
slide 102
Which of the following steps are included in lipid emulsion therapy according to the 2020 ASRA Guidelines? (Select 3)
A) Start with a 100 mL bolus over 2-3 minutes for patients over 70 kg.
B) Follow the bolus with a 250 mL infusion over 15-20 minutes for patients over 70 kg.
C) Start with a 1.5 mL/kg bolus over 2-3 minutes for patients under 70 kg.
D) Continue the infusion until 30 minutes after stability is regained.
A) Start with a 100 mL bolus over 2-3 minutes for patients over 70 kg
B) Follow the bolus with a 250 mL infusion over 15-20 minutes for patients over 70 kg
C) Start with a 1.5 mL/kg bolus over 2-3 minutes for patients under 70 kg.
continue infusion for 15 min after stability is regained
slide 102
In the modified ACLS protocol for LAST, which of the following are true? (Select 2)
A) Use high doses of epinephrine.
B) Be cautious with epinephrine.
C) Use amiodarone for ventricular arrhythmias.
D) Administer a 100 mL bolus of lipid emulsion over 2-3 minutes for patients over 70 kg.
B) Be cautious with epinephrine (use < 1mcg/kg)
C) Use amiodarone for ventricular arrhythmias
slide 102
LAST Tx
Why should propofol be avoided during seizure management in LAST?
A) It is ineffective against seizures.
B) It can weaken the heart in large doses.
C) It interferes with oxygen delivery.
D) It replaces lipid therapy.
B) It can weaken the heart in large doses
- does not replace lipid therapy
slide 102
Which proposed mechanism of action for lipid emulsion therapy involves reducing the plasma concentration of local anesthetics (LA)?
A) Metabolic effect
B) Lipid sink
C) Inotropic effect
D) Membrane effect
B) Lipid sink
- sequesters the LA
slide 102
What should be prepared if a patient is unresponsive to modified ACLS and lipid therapy during a LAST event?
A) Defibrillation
B) Immediate Surgery
C) Increased epinephrine dosage
D) Cardiopulmonary bypass
D) Cardiopulmonary bypass
slide 102
Which proposed mechanism of action for lipid emulsion therapy involves boosting myocardial fatty acid metabolism and increasing heart energy use?
A) Lipid sink
B) Metabolic effect
C) Inotropic effect
D) Membrane effect
B) Metabolic effect
slide 102
Which of the following are proposed mechanisms of action for lipid emulsion therapy in treating LAST? (Select 4)
A) Lipid sink
B) Metabolic effect
C) Inotropic effect
D) Receptor-blocker effect
E) Membrane effect
F) Protein-binding effect
A) Lipid sink
B) Metabolic effect
C) Inotropic effect
E) Membrane effect
slide 102
Which effects are attributed to the inotropic mechanism of lipid emulsion therapy? (Select 2)
A) Decreasing intracellular calcium concentration
B) Increasing calcium influx
C) Reducing LA plasma concentration
D) Increasing heart muscle calcium levels
B) Increasing calcium influx
D) Increasing heart muscle calcium levels
slide 102
According to the LAST checklist, which of the following is a preferred treatment for seizures?
A) Epinephrine
B) Benzodiazepine
C) Calcium channel blockers
D) Propofol
B) Benzodiazepine
slide 103
Which of the following steps are included in the management of a patient with LAST experiencing arrhythmia or hypotension? (Select 2)
A) Smaller than normal dose of epinephrine
B) Use of calcium channel blockers
C) Use of vasopressin
D) Avoid local anesthetics
A) Smaller than normal dose of epinephrine
D) Avoid local anesthetics
slide 103
Which steps should be taken once a LAST patient is stable? (Select 3)
A) Continue lipid emulsion for at least 15 minutes once hemodynamically stable
B) Observe for 2 hours after seizure
C) Observe for 4-6 hours after cardiovascular instability
D) Administer additional bolus of lipid emulsion
A) Continue lipid emulsion for at least 15 minutes once hemodynamically stable
B) Observe for 2 hours after seizure
C) Observe for 4-6 hours after cardiovascular instability
slide 103
If a patient with LAST remains unstable after the initial bolus of lipid emulsion, you should __________ and __________ the infusion.
repeat, double
slide 103
In the management of LAST, which medications should be avoided? (Select 4)
A) Local anesthetics
B) Amiodarone
C) Beta-blockers
D) Epinephrine
E) Calcium channel blockers
F) Vasopressin
G) Versed
A) Local anesthetics
C) Beta-blockers
E) Calcium channel blockers
F) Vasopressin
Slide 103
Which of the following is a major risk factor for developing an epidural/spinal hematoma?
A) Hypertension
B) Diabetes
C) Preexisting abnormalities in clotting hemostasis
D) Hyperlipidemia
C) Preexisting abnormalities in clotting hemostasis
slide 104
Which conditions or situations are associated with an increased risk of epidural/spinal hematoma? (Select 2)
A) Traumatic or difficult needle placement
B) High blood pressure
C) Previous spinal surgery
D) Indwelling catheters and long-term anticoagulation
A) Traumatic or difficult needle placement
D) Indwelling catheters and long-term anticoagulation
slide 104
Which of the following are important considerations for the diagnosis and intervention of an epidural/spinal hematoma? (Select 2)
A) Prompt diagnosis and intervention
B) Use of MRI for diagnosis
C) Delaying intervention until symptoms are severe
D) Ignoring pain as a symptom
A) Prompt diagnosis and intervention B) Use of MRI for diagnosis
slide 104
The symptom of ________ is a major indicator of an epidural/spinal hematoma and should not be confused with ________ or ________ caused by the use of local anesthetics.
- Pain
- numbness or weakness
slide 104
What is the critical time frame for performing a laminectomy to potentially reverse cord ischemia caused by an epidural/spinal hematoma?
A) Within 2 hours
B) Within 4 hours
C) Within 6 hours
D) Within 8 hours
D) Within 8 hours
slide 104
What is arachnoiditis?
A) Inflammation of the spinal cord
B) Inflammation of the brain tissue
C) Inflammation of the meninges
D) Inflammation of the muscles
C) Inflammation of the meninges
slide 105
Which factors are associated with the development of arachnoiditis? (Select 3)
A) Using non-preservative free solutions
B) Betadine contamination
C) Use of antibiotics
D) Nonapproved administration of drugs into the intrathecal or epidural space
A) Using non-preservative free solutions
B) Betadine contamination
D) Nonapproved administration of drugs into the intrathecal or epidural space
slide 105
Arachnoiditis can lead to: (Select 2)
A) Improved vascular supply
B) Reduction in sclerosis of arachnoid membranes
C) Extensive sclerosis of arachnoid membranes
D) Constriction of vascular supply
C) Extensive sclerosis of arachnoid membranes
D) Constriction of vascular supply
slide 105
Which patient groups are mentioned in lecture as being involved in ASA claims related to spinal cord injuries? (Select 2)
A) Anticoagulated patients
B) Pediatric patients
C) Chronic pain patients
D) Elderly patients
A) Anticoagulated patients
C) Chronic pain patients
slide 105
What factors contributed to the deaths from cardiac-related events after spinal anesthesia? (Select 2)
A) Positioning injuries
B) Undetected respiratory compromise
C) Sympathetic blockade
D) High doses of local anesthetics
B) Undetected respiratory compromise
C) Sympathetic blockade
slide 105
Which situations require readiness to convert to general anesthesia in neuraxial cases? (Select 5)
A) Failed block
B) Bradycardia
C) High spinal
D) Hypoxia
E) Severe CV collapse
F) LAST (Local Anesthetic Systemic Toxicity)
G) Anaphylaxis
A) Failed block
C) High spinal
E) Severe CV collapse
F) LAST
G) Anaphylaxis
slide 108
What are common reasons for failure in neuraxial anesthesia that may necessitate conversion to general anesthesia? (Select 3)
A) Wrong dose
B) Wrong location
C) Patient refusal
D) Wrong position
A) Wrong dose
B) Wrong location
D) Wrong position
slide 108
What are the components commonly found in all spinal trays? (Select 4)
A) Styleted needle
B) Opioids
C) Pad for under patient
D) Introducer
E) Alcohol
F) Local anesthetic
G) Sterile drapes
A) Styleted needle
D) Introducer
F) Local anesthetic
G) Sterile drapes
slide 111
Why is it important to feel the “pop” when using a spinal needle?
A) To confirm entry into the muscle
B) To confirm entry into the subarachnoid space
C) To confirm entry into the epidural space
D) To confirm entry into the skin
B) To confirm entry into the subarachnoid space
slide 111
What should be done immediately after feeling the “pop” with a spinal needle?
A) Pull the stylet to see CSF draining out
B) Inject the local anesthetic
C) Insert the introducer
D) Apply a sterile drape
A) Pull the stylet to see CSF draining out
slide 111
What type of needles are included in the spinal kit for skin anesthesia?
A) 25 gauge or smaller
B) 20 gauge or smaller
C) 18 gauge or smaller
D) 22 gauge or smaller
D) 22 gauge or smaller
- 18g spinal/introducer needle
slide 111
Which solution is used to clean the skin before a spinal procedure?
A) Alcohol
B) Saline
C) Chlorhexidine or Betadine
D) Sterile water
C) Chlorhexidine or Betadine
slide 111
Which steps are involved in the preparation of a spinal procedure? (Select 3)
A) Apply sterile drapes
B) Ensure the bevel of the needle is down
C) Insert the introducer to prevent needle bending
D) Use a filter needle to draw up SAB medication
A) Apply sterile drapes
C) Insert the introducer to prevent needle bending
D) Use a filter needle to draw up SAB medication
slide 111
What is the concentration of Lidocaine used for skin injection in a spinal?
A) 2%
B) 1.5%
C) 0.5%
D) 1%
D) 1%
slide 111
What is the volume (dose) for a SAB?
A) 1mL
B) 3mL
C) 2mL
D) 0.5mL
C) 2mL
slide 111
Which of the following are cutting spinal needles? (Select 2)
A) Quincke
B) Sprotte
C) Whitacre
D) Pitkin
A) Quincke
D) Pitkin
slide 113
Which of the following are non-cutting spinal needles? (Select 5)
A) Greene
B) Quincke
C) Whitacre
D) Gertie Marx
E) Pitkin
F) Sprotte
G) Pencan
A) Greene
C) Whitacre
D) Gertie Marx
F) Sprotte
G) Pencan
slide 113
What is a common complication associated with cutting spinal needles?
A) Infection
B) Bleeding
C) Post-dural puncture headache (PDPH)
D) Nerve damage
C) Post-dural puncture headache (PDPH)
slide 113
Which of the following are advantages of using pencil-point needles in SAB? (Select 3)
A) Dragging fewer contaminants into subnormal tissue
B) Higher risk of PDPH
C) Sensation of a “click” or “pop” during insertion
D) Lower risk of PDPH
A) Dragging fewer contaminants into subnormal tissue
C) Sensation of a “click” or “pop” during insertion,
D) Lower risk of PDPH
slide 114
Pencil-point needles have which of the following characteristics? (Select 2)
A) Less than 1% risk of PDPH
B) Higher failure rate than cutting needles
C) A failure rate of about 5%
D) Higher contamination rate
A) Less than 1% risk of PDPH,
C) A failure rate of about 5%
slide 114
What is the purpose of lying the patient flat in the first 5 min after a spinal?
A) prevents caudal spread
B) prevents high spinal
C) allows for better pain control
D) ensures more dermatomes will be blocked
B) prevents high spinal
slide 115
If the patient tells you their hand is getting numb, what should you be concerned for?
A) the spinal is not working
B) they are having an allergic reaction
C) a high spinal will soon follow
D) the local anesthetic volume injected was not the correct amount
C) a high spinal will soon follow
slide 115
How often do we need to get vital signs during a SAB per AANA standards?
A) every 30-60 seconds
B) every 5-10 min
C) every 1-2 min
D) every 3-5 min
D) every 3-5 min
slide 115
What action should be taken if the patient experiences paresthesia during SAB?
A) Continue with the procedure
B) Increase the dose of local anesthetic
C) Stop and reposition the patient
D) Apply pressure to the injection site
C) Stop and reposition the patient
slide 116
What should be done if blood instead of CSF is observed during SAB?
A) Continue the procedure
B) Withdraw the needle and start again if it is a lot of blood
C) Increase the dose of local anesthetic
D) Rotate the needle
B) Withdraw the needle and start again if it is a lot of blood
slide 116
What steps can be taken if there is resistance with injection during SAB? (Select 2)
A) Rotate the needle
B) Increase the dose of local anesthetic
C) Withdraw the needle completely
D) Push the needle in a little more
A) Rotate the needle
D) Push the needle in a little more
slide 116
What are common problems encountered during a SAB? (select 5)
A) Pain on injection
B) Lack of free flow CSF when spinning 360 degrees
C) Swirl present with aspiration
D) Resistance with Injection
E) No swirl
F) Hypotension
G) No block/partial block
H) Blood instead of CSF
B) Lack of free flow CSF when spinning 360 degrees
D) Resistance with injection
E) No Swirl
G) No block/partial block
H) Blood instead of CSF
slide 116
Which items are included in an epidural kit for the administration of anesthesia? (Select 4)
A) Tuohy needle
B) 3 ml, 5 ml, and 20 ml syringes
C) Line filter
D) Introducer Needle
E) Loss of resistance syringe
A) Tuohy needle
B) 3 ml, 5 ml, and 20 ml syringes
C) Line filter
E) Loss of resistance syringe
slide 120
What is the purpose of the loss of resistance syringe in an epidural kit?
A) To identify the epidural space
B) To inject the anesthetic
C) To clean the injection site
D) To draw up the medication
A) To identify the epidural space
slide 120
Which local anesthetic solution is used for the skin in an epidural kit?
A) 2% lidocaine (5 ml)
B) 1% bupivacaine (5 ml)
C) 1% lidocaine (5 ml)
D) 2% bupivacaine (5 ml)
C) 1% lidocaine (5 ml)
slide 120
What is the test dose used in an epidural kit?
A) 1% lidocaine
B) 0.5% bupivacaine
C) 2% lidocaine with 1:100,000 epinephrine
D) 1.5% lidocaine with 1:200,000 epinephrine
D) 1.5% lidocaine with 1:200,000 epinephrine (3 cc)
slide 120
Which of the following characteristics describe the Tuohy needle? (Select 3)
A) Most curvature (30 degrees)
B) Blunt tip
C) 15-degree curve
D) Less likely to puncture subarachnoid space
A) Most curvature (30 degrees)
B) Blunt tip
D) Less likely to puncture subarachnoid space
slide 121
Which epidural needles have a 15-degree curve? (Select 2)
A) Hustead
B) Tuohy
C) Crawford
D) Weiss
A) Hustead, D) Weiss
Crawford has 0 degree curvature
slide 121
Which epidural needle is preferred when catheter placement is difficult or the angle is steep, such as in thoracic epidural procedures, and has 0 degrees curvature?
A) Tuohy
B) Hustead
C) Crawford
D) Weiss
C) Crawford
slide 121
Epidural catheters are typically how many gauges smaller than the needle used for insertion?
A) 1 gauge
B) 2 gauges
C) 3 gauges
D) 4 gauges
B) 2 gauges
slide 123
What is the optimal length that should be in the epidural space when placing an epidural catheter?
A) 1-2 cm
B) 6-8 cm
C) 3-5 cm
D) 9-10 cm
C) 3-5 cm
slide 123
Which of the following are advantages of multi-orifice epidural catheters? (Select 3)
A) Better distribution of local anesthesia
B) Lower incidence of inadequate anesthesia
C) Lower risk of intravascular placement
D) Most commonly used currently
A) Better distribution of local anesthesia
B) Lower incidence of inadequate anesthesia
D) Most commonly used currently
slide 123
Which features are associated with coil reinforced epidural catheters? (Select 3)
A) Stronger
B) Less likely to shear when removed or placed
C) Higher risk of SAB placement
D) Softer tip
A) Stronger
B) Less likely to shear when removed or placed
D) Softer tip
slide 123
Which characteristics describe plastic catheters used in epidural procedures? (Select 4)
A) Easier to thread
B) Inadvertent SAB puncture is a possibility
C) Stiffer
D) Difficult placement
E) Less expensive
A) Easier to thread
B) Inadvertent SAB puncture is a possibility
C) Stiffer
E) Less expensive
slide 124
What steps are involved in measuring the distance from the skin to the epidural space? (Select 3)
A) Measure the total length of the needle
B) Measure the visible needle length
C) Subtract the visible needle length from the total length of the needle
D) Add the visible needle length to the total length of the needle
A) Measure the total length of the needle
B) Measure the visible needle length
C) Subtract the visible needle length from the total length of the needle
slide 125
If the total needle length is 9 cm and 4 cm is visible, the distance from the skin to the epidural space is __________ cm.
5
slide 125
How do you determine the distance from the skin to the epidural space after reaching the epidural space with the needle?
A) Subtract the visible needle length from the total length of the needle
B) Add the visible needle length to the total length of the needle
C) Multiply the visible needle length by two
D) Divide the total length of the needle by the visible needle length
A) Subtract the visible needle length from the total length of the needle
slide 125
What are the concerns regarding epidurals and tattoos? (Select 2)
A) Increased risk of neurological problems
B) Risk of carrying tattoo ink into the spine
C) Potential for inflammation (chemical arachnoiditis)
D) Decreased effectiveness of anesthesia
B) Risk of carrying tattoo ink into the spine
C) Potential for inflammation (chemical arachnoiditis)
slide 127
What is a recommended approach to avoid placing the needle through tattooed skin?
A) Midline approach
B) Subcutaneous approach
C) Intramuscular approach
D) Paramedian approach
D) Paramedian approach
slide 127
Epidural Procedure
What is the recommended direction for pointing the epidural needle tip during insertion?
A) Cephalad (upwards)
B) Downwards
C) Lateral
D) Medial
A) Cephalad (upwards)
slide 128
Epidural Procedure
What method is used to determine the correct placement of the epidural needle?
A) Fluoroscopy
B) Ultrasound
C) Loss of resistance (LOR)
D) Palpation
C) Loss of resistance (LOR)
slide 128
Epidural Procedure
Which methods can be used for determining loss of resistance (LOR) during epidural needle insertion? (Select 3)
A) Air
B) Saline
C) Contrast dye
D) Both air and saline
A) Air
B) Saline
D) Both air and saline
slide 128
Epidural Procedure
What are the important numbers to record during the epidural catheter procedure? (Select 3)
A) Catheter marking at the skin
B) Catheter depth/length in the epidural space
C) Depth from epidural to SA space
D) Depth to epidural space
A) Catheter marking at the skin
B) Catheter depth/length in the epidural space
D) Depth to epidural space
slide 128
Which symptoms should be monitored to identify accidental IV placement during an epidural procedure? (Select 4)
A) Ringing in ears (tinnitus)
B) Metallic taste in mouth
C) BP increase by 15-20%
D) Numbness around the mouth
E) Jump in heart rate by 20% or more
A) Ringing in ears (tinnitus)
B) Metallic taste in mouth
D) Numbness around the mouth
E) Jump in heart rate by 20% or more
slide 130
What special considerations should be taken into account when giving a test dose during an epidural procedure? (Select 2)
A) Use a higher concentration of lidocaine
B) For pregnant women, give the test dose after a contraction ends
C) Monitor for a big increase in blood pressure (>20 mm Hg) in patients on heart medications
D) Administer the test dose slowly
B) For pregnant women, give the test dose after a contraction ends
C) Monitor for a big increase in blood pressure (>20 mm Hg) in patients on heart medications
BP increase >20mmHg = needle in blood vessel - pts on heart meds
slide 130
What indicates an accidental spinal injection during an epidural procedure?
A) Ringing in ears
B) Metallic taste in mouth
C) Dense motor block within 5 minutes of a test dose
D) Increase in heart rate
C) Dense motor block within 5 minutes of a test dose
slide 130
What is the purpose of the test dose in epidural procedures?
A) To provide long-lasting anesthesia
B) To identify unintentional IV or SAB placement
C) To reduce inflammation
D) To monitor patient heart rate
B) To identify unintentional IV or SAB placement
slide 130
What are the two ways to maintain an epidural?
A) Bolus dose and continuous dose
B) Continuous dose and injection
C) Infusion and injection
D) Bolus dose and infusion
D) Bolus dose and infusion
slide 131
What is the recommended initial dose per segment of the spine to be anesthetized for an epidural?
A) 1-2 mL
B) 0.5-1 mL
C) 2-3 mL
D) 3-4 mL
A) 1-2 mL
slide 131
What are the best practices for maintaining an epidural? (Select 4)
A) Perform accurate dermatome assessments
B) Aspirate for blood or CSF
C) Inject slowly in 5 mL increments
D) Use a higher concentration of anesthetic
E) Administer the initial dose all at once
F) Monitor closely for 30 minutes
G) Perform the procedure in a supine position
H) Check the patient’s heart rate continuously
A) Perform accurate dermatome assessments
B) Aspirate for blood or CSF
C) Inject slowly in 5 mL increments
F) Monitor closely for 30 minutes
slide 131
When should the “top-up” dose be given to maintain adequate anesthesia?
A) After three-segment regression
B) After one-segment regression
C) Before two-segment regression
D) Before one-segment regression
C) Before two-segment regression
slide 131
Which anesthetics have a recommended top-up time of 120 minutes after the initial dose? (Select 2)
A) Lidocaine
B) 2-Chloroprocaine
C) Bupivacaine
D) Mepivacaine
E) Ropivacaine
C) Bupivacaine, E) Ropivacaine
slide 132
Which anesthetic has the shortest recommended top-up time after the initial dose?
A) 2-Chloroprocaine
B) Lidocaine
C) Mepivacaine
D) Bupivacaine
B) 2-Chloroprocaine 45 min
slide 132
What is the recommended top-up time for lidocaine after the initial dose in an epidural?
A) 30 minutes
B) 45 minutes
C) 60 minutes
D) 120 minutes
C) 60 minutes
Mepivacaine is also 60 min
slide 132
What is a CSF “wet tap” during an epidural procedure?
A) Puncturing a vein with the epidural needle
B) Accidentally injecting air into the epidural space
C) Penetrating the dura with the Tuohy needle and entering the subarachnoid space
D) Failing to insert the catheter into the epidural space
C) Penetrating the dura with the Tuohy needle and entering the subarachnoid space
slide 133
Which issues can be encountered during an epidural procedure? (Select 4)
A) Aspirate blood
B) High blood pressure
C) CSF “wet tap”
D) Difficulty locating the epidural space
E) Inability to thread the catheter
F) Positive test dose
G) Paresthesia
H) Patient anxiety
A) Aspirate blood
C) CSF “wet tap”
E) Inability to thread the catheter
G) Paresthesia
slide 133
If you can’t thread the catheter during an epidural, it might be due to the presence of the __________.
PLICA
slide 133
Which steps are involved in the Combined Spinal-Epidural (CSE) procedure? (Select 3)
A) Locating the epidural space
B) Introducing a spinal needle through the Tuohy needle
C) Removing the Tuohy needle before injecting the anesthetic
D) Observing CSF flow after removing the stylet
A) Locating the epidural space
B) Introducing a spinal needle through the Tuohy needle
D) Observing CSF flow after removing the stylet
slide 136
What are potential complications or considerations during a CSE procedure? (Select 2)
A) The catheter could enter the dural puncture site
B) Risk of shearing the spinal needle
C) Difficulty in locating the epidural space
D) The spinal anesthetic may set up in the sacral area without spreading cephalad
A) The catheter could enter the dural puncture site
D) The spinal anesthetic may set up in the sacral area without spreading cephalad
slide 136
Why must the spinal anesthetic/analgesic be injected quickly into the subarachnoid space during a CSE procedure?
A) To reduce pain
B) To avoid contamination
C) To prevent the spinal from setting up in the sacral area without spreading cephalad
D) To ensure proper needle placement
C) To prevent the spinal from setting up in the sacral area without spreading cephalad
slide 136
