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APA3 levi 2019 S.Horvath > spinals and epidurals > Flashcards

spinals and epidurals Flashcards

1
Q

what is the advantage of a pencil point needle?

A

better feel, less trauma

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2
Q

the stylet prevents the introduction of dermal cells, but can lead to ____ ____ ____ ____

A

dermoid spinal cord tumor

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3
Q

what are the absolute contraindications to spinal?

A

patient refusal, lack of cooperation, uncorrected coagulopathies, infection at the site of block, increased ICP, indeterminate neurological disease

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4
Q

what three factors affect distribution?

A

barcity, position, dose

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5
Q

what factors affect uptake and spread from subarachnoid space?

A

concentration of LA in CSF, surface area of nerve tissue exposed, lipid content of nerve tissue, blood flow to nerve tissue

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6
Q

drugs in dextrose are hypo iso or hyperbaric?

A

hyper

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7
Q

T/F Physiologic changes with a spinal include venodilation and arterial dilation

A

true

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8
Q

sympathectomy is dependent on block ____

A

height

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9
Q

physiologic changes related to a spinal and the GI system come from sympathetic innervation at what levels?

A

T6-L2

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10
Q

GI effects of spinal = ____ secretions, sphincters ___ and bowel ____

A

increased secretions, sphincters relax, bowel constricts

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11
Q

the iliac crest which spinal level?

A

L4-L5

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12
Q

if you contact bone while doing a spinal what should you do

A

withdraw needle and stylet to skin and redirect. [moving introducer inside can cut and tough ligaments wont allow the needle to move well inside]

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13
Q

which approach is good for calcified intraspinous ligament or difficult positioning

A

paramedian

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14
Q

paramedian approach - angle the needle ___ and ____

A

medially and cephalad

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15
Q

what are some causes of neurologic injury

A

needle introduction to nerve or cord, spinal cord ischemia, bacterial contamination, hematoma

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16
Q

what causes caudal equina syndrome

A

microcatheters, 5% lido, repeated dosing

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17
Q

what are causes of arachnoiditis?

A

infection, myelograms from oil based dyes, blood, neuro irritant, surgical interventions, intrathecal steroids, trauma

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18
Q

what are the causes of meningitis?

A

bacterial or aseptic, use strict sterile technique

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19
Q

PDPH has up to a ___% incidence

A

25

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20
Q

PDPH is worse when head __, relief when ____

A

up, supine

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21
Q

PDPH may take up to ___ weeks to resolve

A

1-6

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22
Q

epidural blood patch is 1st effective in up to ___% OB and __% non-OB.

2nd effective up to ___%

A

90

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23
Q

what are risk factors for spinal hematoma?

A

anticoagulation, increased age, female, hx of GI bleed, length of therapy

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24
Q

epidurals - can use adult levels after age __

A

8

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25
Q

vasomotor tone is controlled by __-___

A

T5-L1

[decreased venous return, subsequent decreased CO]

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26
Q

where are cardiac sympathetic fibers?

A

T1-T4

[profound hypotension and bradycardia]

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27
Q

respiratory arrest with an epidural is usually due to?

A

sympathectomy and brain and brainstem ischemia

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28
Q

what is the key factor affecting spread for an epidural?

A

volume

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29
Q

lumbar gets more spread ____ than ____

A

cephalad than caudal

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30
Q

how to dose epidurals :
<5’2 use?
>5’2 use?

A

<5’2 use 1ml per level

>5’2 increase by 0.1ml for each 2 inches

31
Q

why do you decrease the dose for pregnancy and obesity?

A

epidural vein engorgement and increased adipose tissue

32
Q

the hanging drop technique is most commonly used for ____ epidurals

A

thoracic

33
Q

for a caudal block, the sacral ____ is ID’d by the sacral ___

A

hiatus, cornu

34
Q

for a caudal block, insert the needle at ___ degree angle, and a distinct pop or snap is felt when through _____

A

45

sacrococcygeal membrane

35
Q

what is the test dose for an epidural

A

3ml of 1.5% lido with 15mcg epi

36
Q

what should you do if you have a unilateral block?

A

pull catheter back, unaffected side down, redose, replace

37
Q

what should you do if you have an inadequate block?

A

raise head and redose with higher concentration. add fentanyl or give 50mcg

38
Q

what should you do if the epidural is questionable and you need to go to the OR

A

in OR remove catheter, do CSE with new catheter placement

39
Q

what should you do with a dissipating block? (requires more or doesn’t last)

A

check for intravascular placement, rebels with higher concentration and increase rate, add opiod.

40
Q

what happens if you inject epidural into the SA space?

A

fast high spinal

41
Q

what happens if you give an epidural dose subdural?

A

delayed response 10-15min. get ready for high spinal

42
Q

what are the s/s for meningitis

A

non-positional headache, fever, lethargy, confusion, and classic nuchal rigidity

43
Q

what’s the tx for meningitis?

A

emergent abx therapy, head CT, LP, neuro consult

44
Q

what condition is thought to be from adherence of tissue pulling?

A

arachnoiditis

45
Q

how far in advance do aspirin and NSAID’s have to be d/c’d

A

they dont

46
Q

how far in advance does plavix need to be d/c’d?

A

7 days

47
Q

how far in advance does warfarin have to be d/c’d?

A

4-5 days

apex says 5

48
Q

you want the INR to be

A

1.5

49
Q

for IV heparin: delay until __h after block, remove catheter ___-___h after last dose

A

1, 2-4

50
Q

LMWH (ardeparin, dalteparin, enoxaparin, tinzaparin, danaparoid) PRE-OP guidelines?

A

block 10-12h after last dose; high dose delay 24h.

51
Q

LMWH post-op guidelines

A

once daily dose: 6-8h post op, remove catheter 10-12hr after last dose and wait 2h until next dose

52
Q

herbal drugs = d/c ___ days before surgery

A

5-7

53
Q

order the 5 ligaments form skin to sc

A

surpaspinous, interspinous, ligamentum falvum, posterior longitudinal, anterior longitudinal

54
Q

T/F With both the midline and paramedian approach, the needle should NEVER pass thru the anterior or posterior longitudinal ligaments

A

TRUE

55
Q

T/F Inadvertent injection of LA into the subdural space will cause a high spinal if using epidural dosing or a failed spinal if using spinal dosing.

A

TRUE

56
Q

(APEX) LA in the epidural space must first diffuse thru the ___ before they can block the nerve roots

A

dural cuff

57
Q

(APEX) in the subarachnoid space, the primary site of LA action is on the _____

A

myelinated pre-ganglionic fibers of the spinal nerve roots.

58
Q

(APEX) what are the factors that significantly affect spread for a spinal

A

baricity, patient position before/after, dose, site of injection, volume of CSF, density of CSF

59
Q

(APEX) T/F The factors that do not significantly affect spread of a spinal include barbotage, increased intrabdominal pressure, speed of injection, orientation of bevel, addition of vasoconstrictor, weight, gender.

A

TRUE

60
Q

(APEX) T/F Apnea after a spinal is usually the result of phrenic nerve paralysis or high concentrations of LA in the CSF?

A

FALSE. It is usually the result of cerebral hypo perfusion.

61
Q

(APEX) Spinal affect on GI system: inhibition of sympathetic outflow causes sphincters to ___ and ____ peristalsis

A

relax, peristalsis

62
Q

T/F in the setting of a spinal, as long as SBO is maintained, hepatic and renal blood flow and function are unchanged.

A

TRUE.

63
Q

(APEX) whats the deal with MS and neuraxials?

A

epidural anesthesia is safe but intrathecal technique may exacerbate symptoms

64
Q

a ____ solution will sink, a ____ solution will rise

A

hyperbaric sinks, hypobaric rises

65
Q

dextrose ___ baricity, water ___ baricity

A

increase, reduce

66
Q

(APEX) procaine 10% in water is an exception.. is it hyper, hypo, or isobaric?

A

hyperbaric

67
Q

which 2 needs are cutting tips

A

quincke and pitkin

68
Q

which 4 needles are non-cutting

A

pencil points = sprotte, whitacre, pencan.

rounded bevel tips = greene

69
Q

T/F the pencil point tips require less force.

A

false they actually require more force.

70
Q

which needle type is more easily deflected/

A

cutting tip (quincke, pitkin)

71
Q

(APEX) what two things about the tuohy needle minimize the risk of dural puncture?

A

30 degree curvature and blunt tip

72
Q

T/F you should never withdraw the epidural catheter thru the needle

A

TRUE. this can shear the catheter leaving fragments inside the patient.

73
Q

(APEX) what factors increase the risk of caudal equina syndrome

A

5% lido and spinal micro catheters

APA3 levi 2019 S.Horvath (16 decks)

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