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*Anesthesia Concepts 1 > Spinals and Epidurals > Flashcards

Spinals and Epidurals Flashcards

1
Q

How many vertebrae?

A 
33 total
7 cervical
12 thoracic
5 lumbar
5 sacral (fused)
4 coccygeal (fused)
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2
Q

Describe the vertebral curves in the supine position:
High
Low

A

High - C5, L3

Low - T5, S2

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3
Q

What do the ligaments do?

Name them from outer to inner layer.

A
  • stabilize vertebral body

- supraspinous, interspinous, ligamentum flavum, (longitudinal, ligamentum nuchae)

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4
Q

Where does the ligamentum flavum extend?
What is it made of?
Where is it the thickest?
What is another name for it?

A
  • extends from foramen magnum to sacra hiatus
  • tough wedge shaped and made of elastin
  • thickest in mid-line at L3 (3 mm-5mm in adult)
  • “yellow ligament”
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5
Q

Describe the cranial meninges and spaces from outer to inner layer.

A
  • dura mater - thickest, extends from foramen magnum to S2
  • subdural space
  • arachnoid mater - physiologic barrier for drugs between epidura space and spinal cord
  • subarachnoid space - contains CSF (spinal block) and nerve roots
  • pia mater - adherent to spinal cord
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6
Q

Where does the spinal cord extend and end?

How many spinal nerves?

A
  • extends from foramen magnum to conus medullaris (L1-L2)

- 31 pairs

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7
Q

Which part of nerve root is sensory/motor?

A

dorsal/ventral

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8
Q

What is a segment?

dermatome?

A

part of spinal cord that gives rise to rootlets of one spinal nerve = segment
dermatome is skin innerv by 1 spinal nerve and its segment

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9
Q

Describe cutaneous distribution of T4, T6, T8, T10

A
  • nipple
  • xiphoid
  • last rib
  • umbilicus
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10
Q

What dermatome location would be concerning for potential losso f sensation of breathing?

A

C7/C8 (last 3 fingers)

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11
Q

How much CSF in SA space?

A

150 ml

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12
Q

How often is CSF replaced?

A

3-4x/day

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13
Q

What is the rate of production for CSF? Where is it made?

A

21 ml/hr by choroid plexus

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14
Q

What is the specific gravity of CSF?

A

1.004-1.008

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15
Q

What provides blood supply to the spinal cord? (3)

A
  • anterior spinal artery
  • posterior spinal arteries
  • radicular artery
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16
Q

What occurs in a SAB (Spinal)?

A

local anesthetic injected in CSF

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17
Q

What occurs in epidural anesthesia?

A

local anesthetic injected into epidural or caudal space

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18
Q

What is the goal of a neural blockade?

A

sensory (block painful stimuli) and motor (block skeletal muscle tone) blockade

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19
Q

Describe a neural blockade site.

A

Site: nerve root but can occur at any and all points along neural pathway from drug site to interior cord

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20
Q

What does a centroneuraxial blockade block? What is the goal? What happens to autonomic and motor function?

A
  • all impulses regardless of fiber type (nociceptive, motor, proprioceptive, autonomic)
  • block NOCICEPTIVE (pain)
  • autonomic and motor function are blocked
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21
Q

What are advantages of neuroaxial anesthesia?

A
  • decreased metabolic stress response to surgery compared to GA
  • avoid airway instrumentation
  • decreased post-op nausea
  • less intra-op sedation
  • post-op pain relief
  • allows pt to remain awake for C-section
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22
Q

What are the disadvantages of neuroaxial anesthesia?

A
  • hypotension (ANS)
  • slower case start is difficult placement
  • failure rate depends one experience
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23
Q

What would you consider when choosing a regional technique?

A
  • anatomy
  • age
  • pregnancy
  • patho
  • sensory level of anesthesia required vs physiologic s/e of regional anes
  • consider length of procedure, post-op analgesia, co-existing dz
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24
Q

What are indications for SAB/Epidural?

A
  • anesthesia (can be alone, combined with GA)

- analgesia (postop, L&D)

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25
Q

What are absolute contraindications for SAB/epidural?

A
  • pt refusal
  • infection at injections ite
  • increased ICP
  • anticoag therapy
  • severe hemorrhage or hypovolemia
  • CNS disease or meningitis
  • inability to cooperate/remain still
  • bacteremia/septicemia
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26
Q

What are CV physiologic changes that can occur with a neuraxial block?

A
  • dependent on spread of blockade and ANS
  • venous dilation > arterial dilation
  • SVR decreases 15-25% age dependent
  • CO decreases 10-15%
  • HR decreases T1-T4 (cardioaccelerators), unopposed vagal, decreased stimulation of RA barroreceptors
  • MAP decreases
27
Q

What are pulm physiologic changes that can occur with a neuraxial block?

A
  • low blockade levels have minimal pulm effect
  • as blockade ascends, accessory muscle paralysis occurs causing weakened breathing and coughin
  • no DIRECT resp effects except r/t positioning unless it is a high blockade (C3-C5 = phrenic)
  • w/ profound hypotension may have ischemia of central resp centers causing resp arrest
28
Q

What are GI/renal physiologic changes that can occur with a neuraxial block?

A
  • n/v
  • hyperperistalsis (unopposed PSNS)
  • flow to liver is BP dependent
  • maintenance of MAP (no untoward liver effects)
  • renal blood flow is autoregulated
  • bladder dysfunction - urinary retention, avoid excessive IVF if no catheter
29
Q

What are metabolic/endocrine physiologic changes that can occur with a neuraxial block?

A
  • blocks stress response to surgery
  • catecholamine release blocked from adrenal medulla
  • cortisol secretion delayed
  • shivering = altered thermoregulation with vasodilation
30
Q

What are the pt positions for neuraxial blocks?

A
  • lateral decubitus = forehead to knees, thighs flexed up to abd
  • sitting = low lumbar/sacral block, improved midline anatomy
31
Q

What would you do for a pre-procedure prep prior to SAB/epidural?

A
  • monitors
  • IVF bolus
  • airway and resuscitation equipment
  • ER drugs drawn and available
  • consider preprocedure sedation
32
Q

Describe the 2 types of SAB needles.

A
  1. pencil point aka Sprotte
    -spreads dural fibers and reduced puncture headache
    -“pops” as penetrates dura
    -greater tip strength to minimize bending/breaking
    -side-hole eneables directional flow of anesthetic and reduces possible straddling dura
    -tracks straight as it advances thru
  2. cutting needle aka quincke
    -sharper tip, no “pop”
    -increased risk of postdural puncture headache due to trauma to dura
    introducer may not be necessary
33
Q

Discuss the SAB approach/technique.

A

Median - needle or introducer placed midline, perpendicular to spinous processes, aim slightly cephalad

34
Q

Describe the tissue layers when using a midline approach.

A
  • skin
  • SQ
  • supraspinous lig
  • intraspinous lig
  • ligamentum flavum
  • epid space
  • dura mater
  • subdural space
  • arachnoid mater
  • subarachnoid space

(-pia mater, -spinal cord)

35
Q

What are the anatomical landmarks for SAB?

A
  • identify L2-L3, L3-L4, L4-L5

- palpate sup iliac crests and L4

36
Q

List the 3 epidural insertion sites

A
  1. thoracic
  2. caudal
  3. lumbar
37
Q

Where is the epidural space the widest? What is in the epidural space?

A
  • L2 = 5mm

- potential space filled with fat, blood vessels

38
Q

Landmark for epidural?

A

???

39
Q

What are the tissue layers for a lumbar epidural.

A
  • skin
  • SQ
  • supraspinous
  • interspinous
  • ligamentum flavum
  • epidural space
40
Q

What is density?

A

weight in g of 1 ml of solution at specific temp

41
Q

What is specific gravity?

A

ratio of density of solution compared to density of water at constant temp

42
Q

What is baracity?

A

density of solution compared to density of other solution

43
Q

What is hyperbaric solution?

A

LA mixed with dectrose; heavier than CSF, flow down

44
Q

What is hypobaric solution?

A

LA mixed with sterile water; lighter than CSF, flow up

45
Q

What is isobaric solution?

A

LA mixed with CSF; equal to CSF

46
Q

What affects the spread of LA in SAB?

A

-baricity of LA solution
-position of pt
-concentration and volume of LA
-level of injection
(-barbotage/rate of injection, needle/bevel direction)

47
Q

What factors influence block height?

A
  • dose
  • site of injection
  • baracity
  • position of pt
48
Q

What should be considered when dosing SAB?

A
  • surgical site
  • length of procedure
  • body size (ht/wt)
  • physiology
49
Q

When can pt be d/c’d to floor or home?

A
  • PACU to floor after 4 dermatome regression, <T10, stable, comfortable
  • home after ambulating w/o orthostatic changes, + void
50
Q

What should be done before administering an epidural block?

A
  • aspirate and give test dose prior to injection/use incremental dosing
  • LA = large volume in a dilute solution for wide segmental spread?
51
Q

What is the dosing for epidural?

A

LA = 1.25-1.6 ml per segment

52
Q

What are complications of SAB/epidural?

A
  • hypotension
  • bradycardia
  • sudden cardiac arrest
  • n/v
  • IV injection
  • intrathecal injection
  • catheter shearing
  • post-dural puncture h/a
  • high blockade
  • inadequate blockade
  • neuro complications
  • backache
  • infection (septic meningitis)
  • urinary retention
  • epidural hematoma
53
Q

Who is at highest risk for post dural puncture h/a? And what causes increased risk for PDP h/a?

A
  • younger, white female pts
  • larger neede size
  • pregnancy
  • dehydration
  • using cutting tipped needles
  • multiple puncture attempts
54
Q

What causes post dural puncture h/a? What is the incidence rate? When does it occur?

A
  • d/t decrease ICP with compensatory cerebral vasodilation

- occurs w/in 1 day to 1 week of block

55
Q

How do you treat a post dural puncture h/a?

A
  • bedrest
  • hydration
  • oral analgesics
  • ABD binder
  • epidural saline injection
  • caffeine
  • epidural blood patch
56
Q

What is an epidural blood patch?

A

-forms a clot of leaking meningeal hole

57
Q

How do you perform epidural blood patch?

What are s/e?

A
  • asceptic autologous blood draw of 10-20 ml
  • asceptic epi injection of auto blood into epi evel (at same level or more caudad)
  • backache, radicular pain
58
Q

What is the efficacy of epidural blood patch for PDP h/a?

A

> 90% effective

59
Q

What causes an epidural hematoma?

A

coagulation defect

60
Q

What are symptoms of epidural hematoma?

A

numbness or LE weakness

61
Q

What do you do if hematoma is suspected?

A
  • consult NS immediately, 6-8 hrs before perm injury

- >8 hrs = decrompression may be less successful

62
Q

When should LMWH be held with an epidural placement?

A

-hold LMWH 10-12 hours pre-placement and post surgical procedure

63
Q

What are s/s of LA toxicity?

A
  • neuroligic: circum-oral numbness, tinnitus, vision changes, dizziness, slurred speech, restlessness, muscle twitching
  • seizure followed by CNS depression, apnea, hypotension
  • transient radicular irritation
  • cauda equina syndrome

*Anesthesia Concepts 1 (4 decks)

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