Spinal & Epidural Part 4 ( Tubog) Exam 1 Flashcards
What are possible causes of a unilateral epidural block? (Select all that apply - 2)
A) Catheter tip too close to a nerve.
B) Catheter exiting the epidural space through intervertebral foramen.
C) Catheter is in the bloodstream.
D) Catheter is positioned correctly.
A) Catheter tip too close to a nerve.
B) Catheter exiting the epidural space through intervertebral foramen.
Slide 99 - Spinals/Epidurals
What are possible solutions if the catheter is causing issues? (Select all that apply)
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 all that apply)
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 all that apply)
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 all that apply)
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 all that apply)
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 all that apply)
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 all that apply - 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 all that apply)
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 all that apply - 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 all that apply - 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 all that apply)
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 all that apply - 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 all that apply)
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 all that apply)
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 all that apply - 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 all that apply - 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 all that apply)
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 all that apply)
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 all that apply - 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 all that apply - 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
What are the components commonly found in all spinal trays? (Select all that apply - 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
Which of the following are cutting spinal needles? (Select all that apply - 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 all that apply - 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 steps can be taken if there is resistance with injection during SAB? (Select all that apply)
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
Which items are included in an epidural kit for the administration of anesthesia? (Select all that apply - 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
Which of the following characteristics describe the Tuohy needle? (Select all that apply - 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 all that apply - 2)
A) Hustead
B) Tuohy
C) Crawford
D) Weiss
A) Hustead, D) Weiss
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
Which steps are involved in the Combined Spinal-Epidural (CSE) procedure? (Select all that apply - 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
