Spinals Flashcards
1
Q
History
A
- First spinal
- Cocaine
- 1885-1890
- Large evolution since then
- A little technique
- A lot of needle design
2
Q
Preparation
A
- Assessment of patient
- Thorough History
- Medication History
- Surgical History
- Type of Surgery
- Informed Consent
- Lots of misconceptions, may require discussion
3
Q
Anesthetic Prep:
#1 Resuscitation Equipment
A
- # 1 Resuscitation equipment
- Monitors
- Equipment (Spinal or Epidural)
- Working IV
- Medication
- O2
- Sedation
4
Q
Equipment
A
- Trays
- Cleaning solution
- Betadine
- Chloroprep
- Syringes
- Needles
- Spinal
- Local
- Introducer
- Medications
- Fenestrated Drape
- Filter
- Catheter?
- Cleaning solution
5
Q
Needles
A
- Types
- Pencil Point
- Better feel, less trauma
- Cutting
- Place Longitudinal
- Stylet
- Prevents introduction of dermal cells
- Can lead to dermoid spinal cord tumor
- Prevents introduction of dermal cells
- Sizes
- 90-145 mm
- 22-27 guage
- Pencil Point
6
Q
Needles:
Pictures
A
7
Q
Contraindications
A
- Absolute
- PATIENT REFUSAL
- Lack of Cooperation
- Uncorrected coagulopathies
- Infection at the site of block
8
Q
Factors Affecting Spinals
A
Factors Affecting Spinals
- Uptake and Spread from Subarachnoid space
- Concentration of LA in CSF
- Surface area of nerve tissue exposed
- Lipid content of nerve tissue
- Blood flow to nerve tissue
- Distribution
- Baricity
- Position
- Dose
- Level
- Baricity
- Position
- Dose
- Site of injection
- Age?
- Speed of injection
- Volume
- Concentration
9
Q
Baricity
A
Baricity
10
Q
Physiologic Changes
A
Physiologic Changes
- Liver
- If MAP maintained no changes
- Cardiovascular
- Sympathectomy
- Dependent on block height
- Hypotension and Bradycardia most common
- Venodilation and Arterial dilation
- Treat with fluid bolus
- Preload or Co-load?
- Treat with vasopressors
- Ephedrine or Neosynephrine?
- Sympathectomy
- Respiratory
- Little effects with normal lung physiology
- Major effect with high spinal
- Feeling of dyspnea
- Related to inability to feel chest move
- Maintain with reassurance
- If they can talk they can breath
- Maintain with reassurance
- Related to inability to feel chest move
- GI
- Sympathetic innervation from T6-L2
- Increased secretions
- Sphincters relax
- Bowel constricts
- Nausea and Vomiting about 20%
- Atropine to treat after high spinal
- Sympathetic innervation from T6-L2
11
Q
Dosages
A
Dosages
LA doses for spinals (suggestions) Not currently approved by FDA
Preservative free Onset (min) Duration (min) Dose (mg)
2-Chloroprocaine 60 40 (20-40) (30-100)
Lidocaine 3-5 60-90 25-50(25-100)
Tetracaine 3-6 70-180 5 -20
Bupivicaine 5-8 90-150 5-20
12
Q
Positioning
A
Positioning
- Proper Table height
- Patient Comfort
- Sitting - Ease of identification
- Stool or footrest
- Neck flexed and lower back pushed out
- Lateral
- Back parallel to edge of bed
- Knees flexed to abdomen and neck flexed
- Prone
- Can be used if pt in this position for surgery
- Iso or Hypobaric solutions
- Can be used if pt in this position for surgery
13
Q
Technique
A
Technique
- ID iliac crests
- L4-5
- Clean Skin
- Drape
- ID level to block
- Local
- Use local needle as finder
- Approach
- Median
- Paramedian
- Taylor
14
Q
Midline Approach
A
Midline Approach
- Introducer placed
- Caution with thin pts
- Slightly cephelad 10-15 degrees
- Spinal needle placed through introducer
- Resistance at all layers
- Most likely at ligamentum
- Then “Pop” through dura
- Resistance at all layers
- Remove stylet and check for CSF flow
- Smaller gauge may take longer
- If no flow rotate needle
- May be up against something
- After Freeflow CSF
- Attach syringe
- Aspirate CSF
- Slow injection (0.5 mL/sec)
- Aspirate again?
- Attach syringe
15
Q
Complications during placement
A
Complications during placement
- Bone contacted
- Withdraw needle and stylet to skin and redirect
- Moving introducer inside can cut
- Tough ligaments won’t allow needle to move well inside
- Withdraw needle and stylet to skin and redirect
- Parasthesia
- Stop advancing
- Remove stylet and check for CSF
- Blood
- Not usually a problem unless excessive
- Reattempt
- Position
- May use table to alter block during first few minutes
16
Q
Paramedian
A
Paramedian
- Good for calcified intraspinous ligament or difficult positioning
- Needle inserted
- 1 cm lateral and 1 cm inferior to space
- Angle needle medially and cephelad
- Ligamentum Flavum
- 1st resistance
- If lamina contacted walk off bone
17
Q
Management
A
Management
- Assess VS regularly
- Supplement as needed
- Offer reassurance
- Pt to void prior to discharge
18
Q
Complications
A
Complications
- Neurologic Injury
- 0.03% occurance
- Needle introduction to nerve or cord
- Spinal cord ischemia
- Bacterial contamination
- Hematoma
- 0.03% occurance
- Cauda Equina Syndrome
- Microcatheters
- 5% lido, repeated dosing
- Arachnoiditis
- Infection
- Myelograms from oil based dyes
- Blood
- Neuro irritant
- Surgical interventions
- Intrathecal steriods
- Trauma
- Meningitis
- Bacterial or aseptic
- Use Strict sterile technique
- PDPH
- Up to 25% incidence
- Worse when head up, relief when supine
- Treatment
- Fluids
- Caffeine (500mg 1-2 doses)
- Bed rest
- Analgesics
- Sumatriptan
- May take up to 1-6 weeks to resolve
- Epidural Blood Patch
- Mainstay of invasive treatment
- 1st effective up to 64% OB and 95% non-OB
- 2nd effective up to 90%
- Mainstay of invasive treatment
- Spinal Hematoma
- Incidence 0.00063%
- Anticoagulation, increased age, female, hx of GI bleed, length of therapy
- Medical Emergency
- Neurologic symptoms
- Immediate neuro consult and MRI
- Incidence 0.00063%
- High Spinal
- Monitor and treat appropriately
- Airway and Pressor support
- Monitor and treat appropriately
- Cardiovascular collapse
- Bradycardia usually 1st
- Treat aggressively
- Bradycardia usually 1st
