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Principles Exam 1 > Spinal/Epidural Random things > Flashcards

Spinal/Epidural Random things Flashcards

1
Q

Desired Dermatomal Levels for Peri-anal/anal surgery (“saddle block”)

A

S2-S5

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2
Q

Desired Dermatomal Levels for Foot/Ankle Surgery

A

L2

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3
Q

Desired Dermatomal Levels for thigh/lower leg/knee

A

L1

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4
Q

Desired Dermatomal Levels for vaginal delivery/uterine/hip procedure/tourniquet/ TURP

A

T10 (level of the umbillicus)

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5
Q

Desired Dermatomal Levels for scrotum

A

S3

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6
Q

Desired Dermatomal Levels for Penis

A

S2

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7
Q

Desired Dermatomal Levels for Tsticular Procedure

A

T8

** Testicles are embryonically derived from the same level as the kidneys for pain transmission (T10-L1)

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8
Q

Desired Dermatomal Levels for Urology, gynecologic, and lower extremities

A

T6

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9
Q

Desired Dermatomal Levels for Cesarean section and upper abdominal

A

T4

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10
Q

Target: LA acts on the myelinated preganglionic fibers of spinal nerve roots

A

Spinal

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11
Q

Target for ____: LA diffuse through the dural cuff to reach nerve roots

A

Epidurals

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12
Q

With epidurals, the LA can leak through the ____ ____ into the para-vetebral area

A

intervertebral foramen

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13
Q

Baricity, pt position, dose, site of injections are _____ factors that affect the spread of LA in spinals

A

Controllable factors

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14
Q

Volume of CSF, increased intra-abdominal pressure (obesity, pregnancy), elderly are ____ factors

A

non-controllable factors that affect the spread of LA. in spinals

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15
Q

T or F: These things effect the spread of LA in spinals

-Barbotage (repeated aspiration and reinjection of CSF)

-speed of injection

-orientation of bevel

-addition of vasoconstictor
-gender

A

False: these do not affect the spread

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16
Q

Low or High CSF volume correlates to extensive spread of LA in intrathecal space

A

low CSF volume (think less dilution)

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17
Q

During pregnancy, CSF volume _____ dt increased intra-abdominal pressure

A

decreases

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18
Q

With age, neural nerves are ____ to LA and SCF volume ____

A

nerves are vulnerable to LA

CSF decreases

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19
Q

Factors that affect LA distribution and block height with epidurals:

These are _____ factors that have a significant effect on spread:

-Local anesthetic volume

-Level of injection

-LA dose

A

controllable

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20
Q

Factors that affect LA distribution and block height with epidurals:

These are _____ factors:

pregnancy and old age

A

non-controllable factors

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21
Q

Factors that affect LA distribution and block height with epidurals:

These are _____ factors that have a small effect on spread:

-LA concentration

-pt position

A

controllable factors

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22
Q

Factors that affect LA distribution and block height with epidurals:

These are _____ factors that have a small effect on spread:

-Height

A

Non-controllable Factors

Taller or shorter stature may slightly affect spread

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23
Q

Additives in the anesthetic might change ____ or ____ but not spread

A

onset or duration

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24
Q

(epidurals)
Injections of LA in the lumbar region mostly spread _____

A

cephalad

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25
Q

(epidurals)
Injections of LA in the mid-thoracic region spread is ____

A

balanced both cephalad and caudal

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26
Q

(epidurlas)
Injections of LA in the cervical region spreads

A

caudal

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27
Q

Nerve Fiber: myelination and function?

A alpha

A

heavily myelinated

function: skeletal muscle- motor proprioception

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28
Q

Nerve Fiber: myelination and function?

A beta

A

Myelination: heavy

Function: touch pressure

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29
Q

Nerve Fiber: myelination and function?

A gamma

A

Myelination: medium

Function: skeletal muscle- tone

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30
Q

Nerve Fiber: myelination and function?

A delta

A

Myelination: medium

Function: fast pain, temperature, touch

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31
Q

Nerve Fiber: myelination and function?

B

A

Myelination: light

Function: preganglionic ANS fiber

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32
Q

Nerve Fiber: myelination and function?

C (sympathetic)

A

Myelination: no

Function: post-ganglionic ANS fibers

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33
Q

Nerve Fiber: myelination and function?

C (dorsal root)

A

Myelination: no

Function: slow pain, temperature, touch

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34
Q

Order of blockade: first to last

A

1st: B fibers

2nd: C fibers

3rd: A delta and A gamma

4th: A beta and A alpha

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35
Q

Monitoring sensory block:

order of progression?

A

temp, then pain, then touch/pressure

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36
Q

Monitoring Motor block:

Modified Bromage Scale

What level is this?

-Complete motor block. The patient cannot move the legs, knees, or feet

A

3

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37
Q

Monitoring Motor block:

Modified Bromage Scale

What level is this?

No motor block

A

0

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38
Q

Monitoring Motor block:

Modified Bromage Scale

What level is this?

-The patient cannot raise an extended leg or move the knee but can move the feet

A

2: moderate motor block

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39
Q

Monitoring Motor block:

Modified Bromage Scale

What level is this?

The pt cannot raise an extended leg but can still move the knees and feet

A

1: slight motor block

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40
Q

The Modified Bromage Scale specifically evaluates the function of ______ nerves, which are the lower spine and sacral nerve areas, and does not assess movement above these regions.

A

lumbosacral

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41
Q

Neuraxial Anesthesia can drop SVR by __ % in healthy people or ___% in elderly or cardiac pt’s

A

healthy: 15%

elderly or CV pt’s: 25%

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42
Q

Neuraxal anesthesia –> decrease HR triggering two reflexes.

What are they?

A

Bezold-Jarisch Reflex

Reverse Bainbridge Reflex

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43
Q

This reflex responds to ventricular under-filling, potentially leading to a significant bradycardia and asystole

**This reflex is mediated by 5-HT3 receptors in the vagus nerve and ventricular myocardium

A

Bezold-Jarisch Reflex

** give ondansetron before procedure

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44
Q

This reflex is triggered by reduced stretching of heart’s right atrium to allow for more filling

A

Reverse bainbridge reflex

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45
Q

cardiac accelerators are?

A

T1-T4

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46
Q

Nerve that feed the diaphragm?

A

Phrenic nerve C3-C5

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47
Q

Sudden cardiac arrest after neuraxial anesthesia is more common in spinals and can occure _ - _ min after onset of spinal

A

20-60 mins after onset of spinal

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48
Q

prevention of spinal-anesthesia induced Hypotension

Co-loading: administering intravenous fluids (around 15 ml/Kg) before or after spinal

A

after

** avoid excess fluids –> it can overlaod the circulatory system, especially pt’s with heart conditions

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49
Q

Pulmonary effects of Neuraxial anesthesia:

usually minimal impact

How is tidal volume, RR, inspiratory reserve volume, ABG, and ERV effected?

A

All are unchanged besides ERV

** this is due to a small decrease in vital capacity dt loss of abdominal muscle contribution in forced expiration

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50
Q

High concentrations of local anesthetics in the spinal fluid rarely cause nerve paralysis that stops breathing.

Typically apnea is due to reduced blood flow to the _____ affecting the brain’s breathing center

A

brainstem

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51
Q

What two populations should you take special considerations in before giving neuraxial anesthesia

A

COPD and Pickwickian syndrome

It is very common to feel short of breath after receiving neuraxial anesthesia dt the loss of sensory feedback from the chest area, with these patients they have lose ability to take big breaths and strong cough

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52
Q

GI

Parasympathetic ____: tonic contractions, sphincter relaxation, peristalsis, and secretion.

A

EFFERENT

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53
Q

GI

Parasympathetic _____: transmits sensations of satiety, distension, and nausea

A

AFFERENT

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54
Q

Sympathetic innervation of GI tract stems from ___ - ___

A

T5-L2

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55
Q

Sympathetic ____: transmit visceral pain

Sympathetic ____: inhibit peristalsis and gastric secretion and cause sphincter contraction and vasoconstriction

A

AFFERENT

EFFERENT

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56
Q

Neuraxial anesthesia effects on Genitourinary

no change in renal blood flow with maintained MAP; however a block above ___ affects bladder control

A

T10

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57
Q

An addition of neuraxial opioids leads to a ___ in detrusor contraction –> increase in bladder capacitance

A

decrease

*** these changes lead to urinary rention/incontinence and need for foley catheter with neuraxial anesthesia

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58
Q

Neuraxial blockade can ____ suppress (major invasive surgery) or ___ block (lower extremity) neuroendocrine response.

*** Maximal benefits occurs if the neuraxial blockade occurs before the surgical stimulus

A

partially suppress major invasive surgery

totally block lower extremities

59
Q

LA Pharmacology:

Aromatic ring is lipophilic or hydrophilic

A

Aromatic ring: lipophilic

Tertiary amine is hydrophilic and accepts protons

60
Q

LA pharm:

Intermediate chain determines 3 things

A

allergic potential, metabolism, drug class

61
Q

Esters: in the intermediate link connect to an ___

Amides: in the intermediate link coonect to ___

A

esters: oxygen (C O O)

amides: NH (NH C O)

62
Q

Benzocaine
Cocaine
Chloroprocaine
Procaine
Tetracaine

A

Esters

63
Q

Bupivacaine
Dibucaine
Lidocaine
Mepivacaine
Ropivacaine

A

Amides

64
Q

There are cross sensitivities in amino- ____ dt producing para-aminobenzoic acid (PABA)

A

esters

65
Q

Amide allergic reaction is rare and has _______ preservative

A

methylparaben

66
Q

T or F: There is cross-sensitivity btw esters and amides

A

False

67
Q

pKA determines

A

onset of action

68
Q

Lipid solubility determines

A

Potency

69
Q

The duration of action is determined by

A

Potein binding (alpha-1 acid glycoprotein)

70
Q

Site of Injection

Tissue blood flow

Physiochemical Properties

Metabolism

Addition of vasoconstrictor

A

factors influencing vascular uptake and plasma concentration of LA

71
Q

Baricity chart

A
72
Q

SAB Dosing

Bupivacaine 0.5-0.75%

Dose (T10)

Dose (T4)

Onset

duration

Duration + epi

A

Dose (T10): 10-15 mg

Dose (T4): 12-20 mg

Onset : 4-8 mins

duration: 130-220

Duration + epi: + 20- 50%

73
Q

SAB Dosing: Levobupivacaine 0.5%

Dose (T10):

Dose (T4):

Onset:

duration:

Duration + epi: NA

A

Dose (T10): 10-15 mg

Dose (T4): 12-20 mg

Onset: 4-8 mins

duration: 140-230 mins

Duration + epi: NA

74
Q

SAB Dosing: Ropivacaine 0.5-1%

Dose (T10)

Dose (T4)

Onset

duration

Duration + epi

A

SAB Dosing: Ropivacaine 0.5-1%

Dose (T10): 12-18 mg

Dose (T4): 18-25 mg

Onset: 3-8 mins

duration: 80-120 mins

Duration + epi

75
Q

SAB Dosing: 2- Chloroprocaine 3%

Dose (T10):

Dose (T4):

Onset :

duration:

Duration + epi: NA

A

SAB Dosing: 2- Chloroprocaine 3%

Dose (T10): 30-40 mg

Dose (T4): 40-60 mg

Onset : 2-4 mins

duration: 40-90 mins

Duration + epi: NA

76
Q

SAB Dosing: Tetracaine: 0.5-1.0%

Dose (T10)

Dose (T4)

Onset

duration

Duration + epi

A

Tetracaine: 0.5-1.0%

Dose (T10): 6-10 mg

Dose (T4): 12-16 mg

Onset : 3-5 mins

duration: 90-120 mins

Duration + epi: +20-50%

77
Q

Incremental dosing with __ mL avoids:

Accidental “high spinal”

Hypotension from rapid autonomic blockade (cardiac arrest)

Local anesthetic toxicity

A

5 mL

78
Q

If epi is added to epidurals, it can act as a ___ marker

A

intravenous

79
Q

Epidural onset

A

10-25 minutes onset

80
Q

2-Chloroprocaine comes in 2% and 3% (surgical anesthesia); rapid onset and metabolism; redose q ___ mins

A

45 mins

81
Q

Alkalinization of LA in epidurals increases the pH of LS, increasing the concentration of nonionized free base, rate of diffusion, and onset.

How much bicarb do you add?

A

1 meq/10 mL of LA

82
Q

_____ of the LA is crucial for determining how high the anesthetic block reaches in epidurals.

A

Volume

83
Q

Initial Dose: Typically, ______ per segment of the spine to be anesthetized.

A

1 - 2 mL

84
Q

Top-Up Dose: Should be _____ of the initial dose, used to maintain the block without letting it wear off too much.

A

50% - 75%

85
Q

Timing for Top-Up Dose: Administer before the block decreases more than _____ dermatomes.

A

2 dermatomes.

86
Q

With epidurals comparing lumbar vs thoracic, which one would have the greatest spread?

A

thoracic will have a greater spread bc it is smaller

87
Q

The concentration of LA in a epidural affects how ___ or ___ the block is

A

dense or strong the block is

88
Q

Neuraxial Adjucts:

Adjucts can provide postoperative analgesia, extends duration, and improves the density of the block

-Opioids do what?

-Alpha-2 agonist do what?

-Vasopressors do what?

A

Opioids (Sufentanil, Fentanyl, and Morphine): NO extension of duration (Analgesia/Density: YES)

Alpha-2 agonists (Dexmedetomidine IV or IT*, Clonidine): Improves density, duration, and analgesia

Vasopressors:
Extends duration only; No effect on density or analgesia

89
Q

Neuraxial opioids target the ______ ______ of the dorsal horn (Lamina 2)

A

substantia gelatinosa

90
Q

Neurotransmission is reduced by decreased ____ –> decreased Ca++ conductance and ____ K+ conductance

A

cAMP and increases K+ conductance

91
Q

Morphine, hyrdromorphone and meperidine (demerol) are hydrophilic or hydrophobic

A

hydrophilic –> so duration in longer in CSF and spreads widely affecting larger area for pain relief (more rostral spread)

92
Q

Neuraxial (hydrophilic ) opioid adjunct

onset longer: takes __ - ___ mins to start working

duration: last longer (___-___) hrts

A

onset: 30-60 mins

duration: 6-24 hrs

93
Q

Neuraxial (hydrophilic ) opioid adjunct

systemic absorption is ____

A

Less, it stays longer in CSF

94
Q

Fentanyl and Sufentanil hydrophiic or lipophilic

A

lipophilic

95
Q

high risk and intrmediate risk procedures

Hold aspririn for __-___ days

low risk procedures generally do not need to hold

A

4-6 days

*** no distinction in guidelines btw 81 mg and 325 mg dose

96
Q

Consideration for NSAID

High risk procedures: hold for __ half lives

Intermediate risk procedures: consider holding for cervical ESI (epidural sterioid injections) and _____ _____ block

low risk procedures:

Central neuraxial blocks:

A

high: 5 half lives

Intermediate: stellate ganglion block

low: do not need to routinely hold

central: no additional precautions

97
Q

This drug class inhibits platetl aggregation via surface receptors

ex. Tirofiban (Aggrastat); Eptifibatide (Intergrilin), Abciximab (ReoPro)

A

Glycoprotein IIb/IIIA antagonists

98
Q

Glycoprotein IIb/IIIA antagonists

-Tirofiban and eptifibatide hold for __-__ hrs

-Abciximab hold for __-___ hrs

A

-Tirofiban and eptifibatide hold for 4-8 hrs

-Abciximab hold for 24-48 hrs

99
Q

thienopyridine derivatives inhibits plt aggregation by blocking ____ transferase

ex. Clopidogrel (Plavix), Prasugrel (Effient), Ticlopidine (Ticlid)

A

ADP

100
Q

Regional anesthesia consideration for thienopyridine derivatives

Clopidogrel: Hold for - days.
Prasugrel: Hold for - days.
Ticlopidine: Hold for __ days.

A

Clopidogrel: Hold for 5-7 days.
Prasugrel: Hold for 7-10 days.
Ticlopidine: Hold for 10 days.

101
Q

Unfractionated heparin potentiates _____ (enzyme inhibitor), inhibiting thrombin (factor 2) and factors 9, 10, 11, 12.

A

antithrombin

102
Q

Regional Anesthesia Consideration for unfractionated Heparin

Low-dose (<5,000 U): Hold __ - ___hours.

Higher-dose (≤20,000 U daily): Hold __ hours.

Therapeutic dose (>20,000 U daily or in pregnant patients): Hold __ hours.

UFH >4 days should have a platelet count before central neuraxial block

A

Low-dose (<5,000 U): Hold 4-6 hours.

Higher-dose (≤20,000 U daily): Hold 12 hours.

Therapeutic dose (>20,000 U daily or in pregnant patients): Hold 24 hours.

UFH >4 days should have a platelet count before central neuraxial block

103
Q

LMWH inhibits ___

ex. Enoxaparin (Lovenox), Dalteparin (Fragmin), Tinzaparin (INNOHEP)

A

Xa

104
Q

LMWH Regional anesthesia Consideration:

-Ensure coagulation status appears normal.

-No other blood thinners should be in use.

-Check platelet count if on LMWH for more than __ days.

A

4 days

105
Q

LMWH Regional anesthesia Consideration:

Delay at least ___ hours after a prophylactic dose.

Delay at least __ hours after a therapeutic dose.

*Consider checking anti-factor 10a activity in elderly or if renal insufficiency.

A

12 hrs (prophylactic dose)

24 hrs (therapeutic dose )

106
Q

Vitamin K dependent clotting facotrs (4)

A

2, 7, 9, 10

107
Q

Warfarin is a vitamin K antagonist

You hould hod for __ days and verify what lab

A

5 day; INR < 1.5

108
Q

Thrombolytic agents activate what?

ex. TPA; streptokinase, alteplase, urokinase

A

plasminogen

109
Q

This class of drug is an absolute contraindication to neuraxial anesthesia

A

thrombolytic agents

110
Q

Direct oral anticouagulants inhibit ___

ex. Apixaban (Eliquis), Betrixaban (Bevyxxa), Edoxaban (Lixiana), Rivaroxaban (Xarelto), Dabigatran (Pradaxa)

How long should you dc drug before block?

A

10a; 72 hrs if less than 72 hours check anti-factor 10a

111
Q

Being young, female, and pregnant are all factors that increase risk of what?

A

PDPH: post-dural puncure headache

112
Q

what needle used is mostly responsible for PDPH?

A

Quincke

113
Q

Bed rest
NSAIDs
Caffeine
Epidural Blood Patch
Sphenopalatine Ganglion Block (SGB)

These are all tx for _____

A

PDPH

114
Q

What two LA & concentrations are used for spenopalatine ganglion block

A

Lindocaine 1-2%

Bupivacaine 0.5*

leave it in for 5-10 mins

115
Q

If a spinal has not set up after __-__ mins, it may be necessary to redo the block

A

15-20 mins

116
Q

Streptococcus viridans

A

common bacteria involved in post-spinal bacterial meningitis

found in the mouth and hands –> wash hands and wear a mask

117
Q

This skin prep is neurotoxic and can cause arachnoiditis if not completely dry before starting a spinal

A

chlorhexidine

118
Q

Cauda Equina Syndrome:

-Nerves affected __-___ + coccygeal nerves

A

L1-S5

119
Q

Cauda Equina Syndrome:

factors that increase risk (3 things)

A

high Concentration Local Anesthetics: Using 5% lidocaine in SAB

Microcatheters: These catheters deliver the drug on a small area, increasing risk of nerve damage by exposing the area with a high concentration of LA.

Whiticare 25/26 needle have been associated with this syndrome

120
Q

These are all signs of what condition:

Serious neurologic complication that 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

Can lead to paraplegia (late sign)

A

Cauda equina syndrome

  • if a compressed disc is cause of issue –> immediate laminectomy < 6hrs
121
Q

This condition leads to pain within 6-36 hrs after surgery and lasts from 1-7 days. It is severe radiuclar pain in the back and buttocks that spreads down both legs

A

Transiet Neurological symptoms

122
Q

Tx for this condition include: NSAIDs (ibuprofen), opioids, and trigger point injections

A

Transiet Neurological symptoms

123
Q

All of these are risk factors for epidural ____ ____

Multiple Attempts

Pregnancy

Catheter Type: Stiffer catheters are harder to maneuver and more likely to puncture a vein.

Trauma to epidural vein during block procedure

A

epidural vein cannulation

124
Q

Local anesthetic systemic toxicity (LAST) is most commonly caused by inadvertent injection

LAST is more common in what procedure

A

peripheral nerve blocks > epidurals

125
Q

Most frequent symptom of LAST is ___; but with bupivacaine ____ ____ may come first before seizures

A

seizures; but with bupivacaine cardiac arrest may come first

126
Q

PLASMA CONCENTRATION (MCG/ML)

-Analgesia:

A

1-5

127
Q

PLASMA CONCENTRATION (MCG/ML)

-Tinnitus; skeletal muscle twitching, numbness of lips and tongue; restlessness; vertigo; blurred vision; hypotension; myocardial depression

A

5-10

128
Q

PLASMA CONCENTRATION (MCG/ML)

-sizures; loss of contiousness

A

10-15

129
Q

PLASMA CONCENTRATION (MCG/ML)

coma and respiratory arrest

A

15-25

130
Q

PLASMA CONCENTRATION (MCG/ML)

cardiovascular collapse

A

> 25

131
Q

With LAST these 3 things increase risk of CNS toxicity

A

hypercarbia, hyperkalemia (more excitable neurons); metabolic acidosis (lowers seizure threshold)

132
Q

Difficulty of cardiac resusitation from greatest to least (LAST)

A

bupivacaine > levobupivacaine > ropivacaine > lidocaine

133
Q

TX LAST:

> 70 kg

<70 kgs

A

> 70 kg : 100 mg bolus over 2-3 mins –> 250 mg infusion over 15-20 mins

<70 kgs: Start with a 1.5 mL/kg bolus for 2-3 minutes of 20% lipid emulsion, followed by a 0.25 mL/kg/min infusion. Repeat or double if unstable.

max dose is 12 mg/kg

134
Q

These drugs should be avoided in what tx?

beta blockers

LA, vasopressin

CCB

A

LAST

135
Q

Once pt is stable after receiving lipid emulsion, how long do you keep infusion going?

A

At least an edition 15 mins

136
Q

Quicke and Pitkin are consider what types of spinal needles

A

cutting

137
Q

PT (prothrombin time) normal lab value

A

12-14 secs

138
Q

INR (international normalized ratio) lab value

A

0.8-1.1

139
Q

aPTT: activated parial thomboplastin time

A

25-32 secs

140
Q

PLT count

A

150,000-300,000

141
Q

extrinsic pathway: factors and labs

A

III and VII

coumadin (warfarin): PT &I NR

142
Q

intrinsic pathway: factors and labs

A

12,11,9, 8

labs: PTT & ACT

143
Q

Common pathway for extrinsic and intrinsic clotting cascade

A

10, 5, 2, 1, 13

144
Q
A

Principles Exam 1 (2 decks)

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