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APA 3 - Wolfe > Spinals and Epidurals > Flashcards

Spinals and Epidurals Flashcards

1
Q

What are the types of needles

A

Pencil (better feel, less trauma)

Cutting (place longitudinal)

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2
Q

Name the 4 spinal needles

A

Quincke (medium cutting)
Pinkin (cutting)

Sprotte (pencil point)
Whitacre (pencil point)
Pencan (pencil point)

Greene (noncutting rounded bevel)

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3
Q

Name the 3 epidural needles

A

Crawford (0 degrees)
Hustead (15 degrees)
Touhy (30 degrees)

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4
Q

What does a stylet in the needle do?

A

Prevents introduction of dermal cells

can lead to dermoid spinal cord tumor

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5
Q

What are the needle sizes?

A

22-27 gauge

90-145mm

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6
Q

ABSOLUTE contraindications to a spinal

A 
PATIENT REFUSAL
Lack of Cooperation
Uncorrected coagulopathies
Infection at the site of block
Hypovolemia
Indeterminate neurologic disease
Increased ICP
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7
Q

Relative contraindications to a spinal

A

Infection distinct from site of injection

Unknown duration of surgery

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8
Q

Uptake and spread from subarachnoid space depends on

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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9
Q

Distribution of LA depends on

A

Baricity
Position
Dose

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10
Q

The level of spread depends on

A 
Baricity 
Position
Dose
Site of injection
Age?
Speed of injection
Volume
Concentration
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11
Q

Specific gravity of CSF

A

0.002-0.009

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12
Q

Define baricity

A

the density of a LA relative to CSF

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13
Q

Define Isobaric

A

Baricity similar to CSF
LA will remain in place
Saline added

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14
Q

Define hyperbaric

A

Baricity higher than CSF
LA will sink
Dextrose added to increase baricity

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15
Q

Define hypobaric

A

Baricity lower that CSF
LA will rise
Water added to reduce baricity

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16
Q

Systemic effects of Neuraxial anesthesia:

Liver and Kidneys

A

if MAP maintained, no changes

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17
Q

Systemic effects of Neuraxial anesthesia

Cadiovascular

A

Sympathectomy - vasodilation of arterial and venous capacitant vessels (venous predominantly). Reduction in venous return, CO and BP

Volume load with 15ml/kg

Bradycardia from block of cardiac accelerators (T1-T4) and Bezold-Jarish reflex)

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18
Q

Systemic effects of Neuraxial anesthesia

Respiratory

A

Little effect with normal lung physiology

Accessory muscle function reduced (imprint of inspiratory & expiratory and ability to cough)

Major effect with high spinal

Loss of proprioceptive input = dyspnea feeling (maintain reassurance, if they can talk, they can breath)

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19
Q

Systemic effects of Neuraxial anesthesia

GI

A

Sympathetic innervation from T6-L2

  • Increased secretions
  • Sphincters relax
  • Bowel constricts

Nausea and Vomiting about 20%
- Atropine to treat after high spinal

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20
Q

Systemic effects of Neuraxial anesthesia

CNS

A

Reduced sensory input from the reticular activating system (RAS) can lead to drowsiness

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21
Q

Which LA is NOT approved for spinal

A

2-Chloroprocaine

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22
Q

Which LA are approved for spinals

A

Lidocaine
Tetracaine
Bupivacaine

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23
Q

What is the spinal inset/duration/dose for Lidocaine

A

Onset: 3-5 min
Duration: 60-90 min
Dose: 25-50 mg

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24
Q

What is the spinal onset/duration/dose for Tetracaine

A

Onset: 3-6 min
Duration: 70-180 min
Dose: 5-20mg

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25
What is the spinal onset/duration/dose for Bupivacaine
Onset: 5-8 min Duration: 90-150 min Dose: 5-20 mg
26
When you ID the iliac crest for spinal placement, what level are you at?
L4-L5
27
When doing a midline approach, Needle angle degree... Resistance at all layer, but mostly at.. Remove stylet and check for flow, if no what.. After free flowing CSF, attach syringe and..
Slightly cephalad 10-15 degrees Ligamentum flavus (will feel a pop when thru) Rotate needle (may be up against something) Aspirate, inject slow (0.5 ml/sec)
28
Complications during spinal placement: | Bone contacted
Withdraw needle and stylet to skin and redirect
29
Complications during spinal placement: | Paresthesia
Stop advancing | Remove stylet and check for CSF
30
Complications during spinal placement: | Blood
Not usually a problem unless excessive | Reattempt
31
Complications during spinal placement: | Position
May use table to alter block during first few minutes
32
When placing a spinal needle via midline approach, what structures do you meet (in order)
``` Skin Subcutaneous Supraspinous Ligament Intraspinous Ligament Ligamentum Flavum (epidural space) Dura mater (subdural space) Arachnoid mater (subarachnoid space- spinal placement) ```
33
What is the paramedic approach good for?
Good for calcified intraspinous ligament or difficult positioning
34
The needle will pass through 1 ligament during the paramedium approach, which one
Ligamentum Flavum
35
How is the needle inserted for paramedium approach?
1 cm lateral and 1 cm inferior to space Angle needle medially and cephelad If lamina contacted, walk off bone
36
If a patient receives a spinal, what must they do before being discharged?
Must void prior to discharge
37
Complications from spinal | Neurologic Injury
0. 03% occurance (1:240,000) - Needle introduction to nerve or cord - Spinal cord ischemia - Bacterial contamination - Hematoma
38
Complications from spinal | Cauda Equina Syndrome
Microcatheters | 5% lido, repeated dosing
39
Complications from spinal | Arachnoiditis
``` Infection Myelograms from oil based dyes Blood Neuro irritant Surgical interventions Intrathecal steriods Trauma ```
40
Complications from spinal | Meningitis
Bacterial or aseptic | Use Strict sterile technique
41
Complications from spinal Postdural puncture headache - up to __% incidence - what makes it worse/better
25% Worse when head up, relief when supine
42
Non-invasive treatment for PDPH
``` Fluids Caffeine (500mg 1-2 doses) Bed rest Analgesics Sumatriptan ``` May take up to 1-6 weeks to resolve
43
Invasive treatment for PDPH
Epidural Blood Patch Mainstay of invasive treatment 1st effective up to 64% OB and 95% non-OB 2nd effective up to 90%
44
Complications from spinal Spinal Hematoma Why is this important to diagnose? What increased the risk?
This is a MEDICAL EMERGENCY - Neurologic symptoms - Immediate neuro consult and MRI Incidence 0.00063% Anticoagulation, increased age, female, hx of GI bleed, length of therapy
45
Complications from spinal | High Spinal
Monitor and treat appropriately | Airway and Pressor support
46
Complications from spinal CV collapse What is the 1st S/S?
Bradycardia usually 1st | Treat aggressively
47
Absolute contraindications to epidurals
patient refusal uncorrected hypovolemia increased ICP infection at site
48
Relative contraindications to epidurals
coagulopathy fixed cardiac defect anatomic abnormalities unstable neurologic disease
49
Controversial contraindications to epidurals
inability to communicate, tattoos, complicated surgery with major blood loss
50
Where is the epidural placed?
Usually at L2-L4
51
When can you use adult levels for epidural placement?
after age 8
52
Physiologic effects spinal to spinal Above T4 Below T4
Above T4 T1-T4 cardiac sympathetic fibers Profound hypotension and bradycardia Below T4 Vasomotor tone controlled by T5-L1 Decreased venous return, and subsequent decreased CO
53
If pt has respiratory arrest after epidural, what was it most likely from?
likely due to sympathectomy and brain and brainstem ischemia
54
What is the key factor effecting epidural coverage
Volume** Adults: 1-2 mL for each level to be blocked Lumbar gets more spread cephalad than caudal Thoracic even spread up and down
55
How does concentration effect coverage for epidural?
Lower – sensory | Higher – may get motor
56
Is position a factor for epidural spread?
NO
57
How does age effect coverage for epidural?
Inreased age = decreased dose
58
How does height effect coverage for epidural?
<5’2” use 1mL per level | >5’2” increase by 0.1mL for each 2 inches
59
How does pregnancy and obesity effect coverage?
Decreased dose | Epidural vein engorgement and increased adipose tissue
60
What is average onset time for epidural
10-20 min
61
What are the approaches for epidural placement
Median Paramedian start 1.5-2cm laterally Taylor
62
What are the 2 techniques for IDing epidural space
Loss of resistance (LOR) | Hanging drop
63
Explain LOR technique
Place needle & stylet through supraspinous ligament and into intraspinous ligament Remove stylet and attach syringe with air or fluid Always secure needle against patient 2 ways to proceed 1: Alternate very slow advancement and tapping pressure to plunger of syringe until LOR 2: Advance needle with continuous pressure on plunger until LOR
64
Explain hanging drop technique
Needle placed as before Small amount of fluid placed in needle hub Needle advanced until Epidural space encountered Drop will suck into needle Used mostly for Thoracic
65
For a caudal block, how is the sacral hiatus ID'd?
ID’d by Sacral Cornu
66
What angle is the needle inserted at for a caudal?
Needle inserted at 45 degree angle
67
During a caudal, there is a distinct “snap” or “pop” when through which membrane?
sacrococcygeal membrane
68
Once through the sacrococcygeal membrane, what are the next steps
Lower angle to 160 degrees Advance : Adults no more than 1.5 cm Children no more than 0.5 cm Aspirate for blood or CSF Insert catheter or inject
69
After IDing the epidural space with the needle, what are the next steps?
- Note depth on needle - Place catheter through needle - Mark for end of needle and resistance - Advance catheter 5-7 cm more - Remove needle over catheter - Withdrawal catheter until 3-5 cm remain in epidural space - Attach end to catheter - Aspirate for blood or CSF - Dressing – clear occlusive - Test Dose (3 mL of 1.5% Lido with 15mcg epi)
70
What should you NEVER do when placing an epidural catheter?
NEVER WITHDRAW CATHETER THROUGH NEEDLE***
71
What should you always do before dosing an epidural?
ALWAYS ASPIRATE PRIOR TO INJECTION
72
``` What is the dosing for Lumbar Thoracic Caudal Continuous infusion ```
Lumbar: 1-2 mL per segment Give in 5 mL increments q 3-5 min Thoracic: 0.7 mL per segment 3-6 mL q 30 min Caudal: 3 mL per segment Continuous infusion: 4-15 mL/hr (Individualize)
73
With an epidural, what should be done if you have a unilateral block?
Pull catheter back Unaffected side down Redose Replace
74
With an epidural, what should be done if you have an inadequate block?
Raise head & redose with higher concentration | Add fentanyl or give 50 mcg
75
With an epidural, what should be done if there is questionable quality and pt needs to go to OR?
In OR remove catheter | Do CSE with new catheter placement
76
With an epidural, what should be done if you have a dissipating block?
Requires more or doesn’t last Check for intravascular placement Rebolus with higher concentration & increase rate Add opiod
77
What is the incidence of back pain with epidurals? What is the treatment?
20-30% incidence Usually self limiting NSAIDS, Tylenol, Heat
78
PDPH is more common in what group and after what accidentally happens?
Most common in younger female Usually expected after wet tap
79
If inadvertent subdural injection, when will you see it?
Delayed response 10-15 minutes Get ready for High spinal (hallmark - high but patchy block)
80
If inadvertent subarachnoid injection, when will you see it?
Fast high spinal
81
What are they symptoms and treatment for men
Non-positional headache, fever, lethargy, confusion and classic nuchal rigidity Emergent antibiotic therapy Head CT, lumbar puncture, neuro consult
82
Arachnoiditis | Also thought to be from adherence of ____
tissue pulling

APA 3 - Wolfe (11 decks)

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