Spinals and Epidurals Flashcards
What are (2) types of spinal needles?
- Pencil point
- Cutting
___ (pencil point/cutting) needles have a better feel and cause less trauma
Pencil point needles have a better feel and cause less trauma
___ (pencil point/cutting) needles should be placed longitudinally
Cutting needles should be placed longitudinally
Use of stylet with needle prevents introduction of ___ cells, thus preventing ___ spinal cord tumor
Use of stylet with needle prevents introduction of dermal cells, thus preventing dermal spinal cord tumor
Sizes of spinal needles–___-___ gauge, ___-___ mm
22-27 gauge, 90-145 mm
(4) absolute contraindications to spinal–1) patient ___; 2) lack of ___; 3) uncorrected ___; 4) ___ at the site of block
1) patient refusal
2) lack of cooperation
3) uncorrected coagulopathies
4) infection at the site of block
Patient refusal is a ___ (absolute/relative) contraindication to spinal anesthesia
Patient refusal is an absolute contraindication to spinal anesthesia
Sepsis at the site of injection is ___ (absolute/relative) contraindication to spinal anesthesia
Absolute
Hypovolemia is ___ (absolute/relative) contraindication to spinal anesthesia
Absolute
Coagulopathy is ___ (absolute/relative) contraindication to spinal anesthesia
Absolute
Indeterminate neurologic disease is ___ (absolute/relative) contraindication to spinal anesthesia
Absolute
Increased intracranial pressure is ___ (absolute/relative) contraindication to spinal anesthesia
Absolute
Infection distant from site of injection is ___ (absolute/relative) contraindication to spinal anesthesia
Relative
Unknown duration of surgery is ___ (absolute/relative) contraindication to spinal anesthesia
Relative
Factors affecting uptake/spread from subarachnoid space–___ of LA in CSF; ___ of nerve tissue exposed; ___ content of nerve tissue; ___ flow to nerve tissue
Concentration of LA in CSF; surface area of nerve tissue exposed; lipid content of nerve tissue; blood flow to nerve tissue
(3) factors affecting distribution of spinal
- Baricity
- Position
- Dose
Factors affecting level of spinal–___ity; ___ion; ___; ___ of injection; ___?; ___ of injection; ___ume; ___tion
baricity; position; dose; site of injection; age? speed of injection; volume; concentration
What is the specific gravity of CSF?
1.0069
If MAP is maintained during spinal anesthesia, there are no physiologic changes to the liver?–T/F?
True
CV effects of spinal anesthesia–___thectomy, dependent on block height
Sympathectomy
___tension and ___cardia are most common effects of sympathectomy that occurs with spinal
Hypotension and bradycardia
Occur d/t venodilation and arterial dilation
How should you treat sympathectomy from spinal?
Fluids and vasopressors
Spinal has little effects on those with normal lung physiology–T/F?
True
Major respiratory effects may occur with ___ spinal–feeling of ___ related to inability to feel chest move
Major respiratory effects may occur with high spinal–feeling of dyspnea related to inability to feel chest move
GI–sympathetic innervation from __-__
T6-L2
GI effects of spinal–___ (increased/decreased) secretions; sphincters ___ (contract/relax); bowel ___ (constricts/dilates); nausea/vomiting occurs in about __%, use ___ to treat after high spinal
GI effects of spinal–increased secretions; sphincters relax; bowel constricts; nausea/vomiting occurs in about 20%, use atropine to treat after high spinal
Review slide 17 suggested LA doses for spinals (suggestions that are not currently approved by FDA)
.
Prone position for spinal–use ___baric or ___baric solutions
Use isobaric or hyperbaric solutions
When going to place spinal, you should first identify the ___
iliac crests–L4-L5
(3) approaches to spinal
- Median
- Paramedian
- Taylor
Midline approach for spinal anesthesia–introducer should be placed slightly ___ (cephalad/caudal) __-__ degrees
Midline approach for spinal anesthesia–introducer should be placed slightly cephalad 10-15 degrees
When spinal needle is placed through introducer, resistance will be met at all levels, most likely at ___, then pop through ___
When spinal needle is placed through introducer, resistance will be met at all levels, most likely at ligamentum, then pop through dura
After you pop through the dura, remove stylet and check for ___ flow
After you pop through the dura, remove stylet and check for CSF flow
What should you do if there’s no CSF flow?
If there’s no CSF flow, rotate needle (it may be up against something)
After free flow of CSF, attach ___, aspirate ___, ___ (slow/fast) injection of __ml/sec
After free flow of CSF, attach syringe, aspirate CSF, slow injection of 0.5 ml/sec
Complications during placement of spinal needle–___ contacted, ___thesia, ___, ___ of patient
Complications during placement of spinal needle–bone contacted, paresthesia, blood, position of patient
If bone is contacted during spinal needle placement, you should ___ needle and stylet to skin and re___
If bone is contacted during spinal needle placement, you should withdraw needle and stylet to skin and redirect
If patient experiences paresthesia during spinal needle placement, ___ (continue/stop) advancing; remove stylet and check for ___
If patient experiences paresthesia during spinal needle placement, stop advancing; remove stylet and check for CSF
If blood is encountered during spinal placement, it is usually not a problem (unless excessive); you should reattempt–T/F?
True
Paramedian approach is good for ___ intraspinous ligament or difficult ___
Paramedian approach is good for calcified intraspinous ligament or difficult positioning
For paramedian approach, needle is inserted 1 cm ___ and 1 cm ___ to space; angle needle ___ (laterally/medially) and ___ (caudal/cephalad)
For paramedian approach, needle is inserted 1 cm lateral and 1 cm inferior to space; angle needle medially and cephalad
For paramedian approach, what is the 1st resistance?
Ligamentum flavum
Complications with spinal anesthesia–___ injury; ___ syndrome; ___ditis; ___itis; post dural ___; spinal ___; ___ spinal; ___ collapse
Complications with spinal anesthesia–neurologic injury; cauda equina syndrome; arachnoiditis; meningitis; post dural puncture headache (PDPH); spinal hematoma; high spinal; CV collapse
Neurologic injury from spinal may result from needle introduction to ___ or ___; can result in spinal cord ___; bacterial ___; ___oma
Neurologic injury from spinal may result from needle introduction to nerve or cord; can result in spinal cord ischemia; bacterial contamination; hematoma
Cauda Equina Syndrome results from micro___; 5% ___ and repeated dosing
Cauda Equina Syndrome results from micocatheters; 5% lidocaine and repeated dosing
Treatment of arachnoiditis includes ___ interventions and intrathecal ___
Treatment of arachnoiditis includes surgical interventions and intrathecal steroids
How can you prevent meningitis? Use strict ___ technique
Can prevent meningitis by using strict sterile technique
PDPH has up to ___% incidence
PDPH has up to 25% incidence
PDPH is worse when head is ___, relief when ___
PDPH is worse when head is up, relief when supine
What (5) things can be used to treat PDPH?
- Fluids
- Caffeine (500 mg 1-2 doses)
- Bed rest
- Analgesics
- Sumatriptan
May take up to __-__ weeks for PDPH to resolve
May take up to 1-6 weeks for PDPH to resolve
What is the mainstay of invasive treatment for PDPH?
Epidural blood patch
What patient factors contribute to spinal hematoma?–anti___; ___ (increased/decreased) age; ___ (male/female); history of ___ bleed; length of therapy
Patient factors that contribute to spinal hematoma–anticoagulation; increased age; female; history of GI bleed; length of therapy
Spinal hematoma is a medical ___
Spinal hematoma is a medical emergency!
Need immediate neuro consult/MRI
If patient experiences high spinal, you should monitor and treat appropriately with ___ and ___ support
If patient experiences high spinal, you should monitor and treat appropriately with airway and pressor support
CV collapse from spinal–what is usually first sign?
Bradycardia–treat aggressively
Absolute contraindications for epidural–patient ___, uncorrected ___volemia, ___ ICP, ___ at site
Absolute contraindications for epidural–patient refusal, uncorrected hypovolemia, increased ICP, infection at site
Relative contraindications for epidural–___pathy, fixed ___ defect, anatomic ___, unstable ___ disease
Relative contraindications for epidural–coagulopathy, fixed cardiac defect, anatomic abnormalities, unstable neurologic disease
Epidurals are usually done at what levels?
L2-L4
You can use adult levels after age ___
8
Physiological effects of epidurals are similar to spinal–T/F?
True
Effects below T4–vasomotor tone is controlled by __-__; effects = ___ (increased/decreased) venous return, and subsequent ___ (increased/decreased) CO
Effects below T4–vasomotor tone is controlled by T5-L1; effects = decreased venous return and subsequent decreased CO
Effects above T4–__-__ = cardiac sympathetic fibers; effects = profound ___tension and ___cardia
Effects above T4–T1-T4 = cardiac sympathetic fibers; effects = profound hypotension and bradycardia
Respiratory effects of epidurals are minimal in midthoracic region–T/F?
True
Respiratory arrest from epidural is likely d/t ___tomy and brainstem ___
Respiratory arrest from epidural is likely d/t sympathectomy and brainstem ischemia
Lower concentration for epidural = ___ (sensory/motor) block
Lower concentration for epidural = sensory block
Higher concentration for epidural = ___ (sensory/motor) block
Higher concentration for epidural = motor blocker
What is a key factor affecting coverage for epidurals?
VOLUME!
For epidurals in adults, you need __-__ ml for each level to be blocked
For epidurals in adults, you need 1-2 ml for each level to be blocked
Lumbar level gets more spread ___ (cephalad/caudal) than ___ (cephalad/caudal)
Lumbar level gets more spread cephalad than caudal
Thoracic level has even spread up and down–T/F?
True
How does age affect epidural dosing? Increased age = ___ (increased/decreased) dose
Increased age = decreased dose
How does height affect epidural dosing? If < 5’2”, use ___ ml per level; if > 5’2”, increase dose by ___ ml for every 2 inches
If < 5’2”, use 1 ml per level
If > 5’2”, increase dose by 0.1 ml for every 2 inches
How do pregnancy and obesity affect epidural dosing? ___ (increased/decreased) dose d/t epidural vein ___ and increased ___ tissue
Decreased dose d/t epidural vein engorgement and increased adipose tissue
What are (3) approaches for epidural?
Same as spinal
- Median
- Paramedian–start 1.5-2 cm laterally
- Taylor
What is (1) different technique for epidural?
-Caudal
How can you identify the epidural space?
Loss of resistance technique
Hanging drop technique is used mostly for ___ epidurals
Hanging drop technique is used mostly for thoracic epidurals
What is another way you can identify the epidural space?
Ultrasound
For caudal block, sacral ___ is identified by sacral ___
For caudal block, sacral hiatus is identified by sacral Cornu
Caudal block–needle is inserted at ___ degree angle; distinct pop or snap when you go through the ___ membrane; when you pass through membrane, lower angle to ___ degrees; advance for adults no more than ___ cm, for children no more than ___ cm; aspirate for blood or CSF, insert catheter or inject
Caudal block–needle is inserted at 45 degree angle; distinct pop or snap when you go through the sacrococcygeal membrane; when you pass through membrane, lower angle to 160 degrees; advance for adults no more than 1.5 cm, for children no more than 0.5 cm; aspirate for blood or CSF, insert catheter or inject
When placing epidural catheter, you should withdraw catheter through needle–T/F?
FALSE–NEVER WITHDRAW EPIDURAL CATHETER THROUGH NEEDLE
When dosing epidural catheter, always ___ prior to injection
When dosing epidural catheter, always aspirate prior to injection
Lumbar dosing–__-__ ml per segment; give in __ ml increments q __-__ min
Lumbar dosing–1-2 ml per segment; give in 5 ml increments q 3-5 minutes
Thoracic dosing–__ ml per segment; __-__ ml q __ min
Thoracic dosing–0.7 ml per segment; 3-6 ml q 30 min
Caudal dosing–__ ml per segment
Caudal dosing–3 ml per segment
Continuous infusion–__-__ ml/hr
Continuous infusion–4-15 ml/hr
Complications from epidurals include–__tension; ___lateral block; ___ block
Complications from epidurals include–hypotension; unilateral block; inadequate block
If patient has inadequate block with epidural, ___ (raise/lower) head and redose with ___ (lower/higher) concentration; can also add ___
If patient has inadequate block with epidural, raise head and redose with higher concentration; can also add fentanyl
If patient’s epidural is questionable quality and you need to go to the OR…in OR, ___ catheter; do ___ with new catheter placement
If patient’s epidural is questionable quality and you need to go to the OR…in OR, remove catheter; do CSE with no catheter placement
If patient’s block is dissipating–requires more or doesn’t last…check for ___ placement; rebolus with ___ (lower/higher) concentration and ___ (increase/decrease) rate; add ___
If patient’s block is dissipating–requires more or doesn’t last…check for intravascular placement; rebolus with higher concentration and increase rate; add opioid
Minor back pain has 20-30% incidence with epidural placement–T/F?
True
Back pain from epidural is usually self limiting; can use NSAIDs, Tylenol, heat to treat–T/F?
True
PDPH from epidural is most common in ___; usually expected after ___
PDPH from epidural is most common in younger female; usually expected after wet tap
Accidental subdural injection with epidural has a delayed response of __-__ minutes; get ready for ___
Accidental subdural injection with epidural has a delayed response of 5-10 minutes; get ready for high spinal
Subarachnoid injection of epidural dose will result in ___ (fast/slow) high spinal
Subarachnoid injection of epidural dose will result in fast high spinal
Meningitis symptoms–non-positional ___ache; ___; ___gy; ___ion; and classic ___ rigidity; emergent ___ therapy; ___ CT, ___ puncture, neuro consult to diagnose
Meningitis symptoms–non-positional headache; fever; lethargy; confusion; and classic nuchal rigidity; emergent antibiotic therapy; head CT, lumbar puncture, neuro consult to diagnose
