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Priniclpes Of Anesthesia > Spinals and epidurals (exam 4) > Flashcards

Spinals and epidurals (exam 4) Flashcards

1
Q

The lamina of S5 is ________ and bridged _____

A

incomplete and bridged only by ligaments

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2
Q

Sacral hiatus correlates with

A

s5

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3
Q

Conus medullaris spinal level (adult and infant)

A

Adult: L1-L2
Infant: L3

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4
Q

Dural sac spinal level adult and peds

A

adult: S2
Infant: S3

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5
Q

Cauda Equina area

A

Bundle of spinal nerves from clonus to dural sac

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6
Q

Two fixation points of filum terminale

A

conus medullaris and Coccyx

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7
Q

Supra spinous ligament role

A

Joins tips of spinous processes (posterior)

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8
Q

Interspinous ligament location

A

adjacent to spinous process

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9
Q

Ligamentaum flavum is thickest in the

A

Lumbar region

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10
Q

CSF circulates between

A

pia and arachnoid mater layers

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11
Q

Nerves responsible for touch (3)

A

-A beta
-A delta
-C dorsal root

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12
Q

Nerves responsible for temperature (2)

A

-A delta
-C dorsal root

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13
Q

Sensory, Visceral and Somatic/pain afferents are transmitted through the

A

posterior (dorsal) root

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14
Q

Autonomic and motor nerve efferents are transmitted through the

A

anterior (ventral) root

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15
Q

Vertebra prominence is at

A

C7

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16
Q

Spine of scapula is at

A

T3

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17
Q

Inferior angle of scapula is at

A

T7

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18
Q

Rib margin is at

A

10 cm from midline L1

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19
Q

Superior aspect of illiac crest is at

A

L4

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20
Q

Posterior Superior illiac spine is at

A

S2

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21
Q

Intercristal or Tuffier line is

A

S1 at the level of posterior illiac crest

apex L4?

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22
Q

cauda equina nerve bundle

A

roots L2-S5 pairs and coccygeal nerve

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23
Q

Dural sac is the

A

termination of the subarachnoid space

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24
Q

Best place for a block

A

lower = lowest incidence of injuring spinal cord by direct needle trauma

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25
Q

Midline approach - go thourgh:

A

supraspinous ligament –> interspinous ligament –> ligamentum flavum

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26
Q

Taylor’s approach is the technique for locating

A

the L5-S1 space

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26
Q

Midline approach: average depth from skin to epidural space is

A

3-5 cm (in adult)

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27
Q

Taylor’s approach aka

A

paramedian approach

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28
Q

Taylors Approach needle insertion direction:

A

Upward and medially

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29
Q

Caudal anesthesia location

A

up to a T10 sensory block

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30
Q

Caudal anesthesia is common in

A

pediatrics

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31
Q

Caudal anesthesia uses (5)

A
  1. circumcision
  2. hypospadias
  3. anal
  4. inguinal herniorrhapthy
  5. Low thoracic surgery
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32
Q

Caudal block landmarks:

A

Posterior iliac spine
Sacral hiatus

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33
Q

In caudal anesthesia, you should not

A

use air for LOR (loss of resistance)

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34
Q

When using chlorohexadine for an epidural

A

wait full 30 seconds to dry because chlorohex is nuerotoxic

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35
Q

Spinal needle with highest incidence of spinal HA

A

cutting needle

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36
Q

Average thread of an epidural catheter into epidural space

A

3-5

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37
Q

If you go too deep with an epidural, it may

A

enter an epidural vein or exit through intervertebral foramen

blood black = vein

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38
Q

Pros of cutting tip needle

A

Requires less force

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39
Q

Cons of cutting needle

A

Higher risk of PDPH

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40
Q

Pros of non-cutting tip needle

A

Less likely to injure cauda equina

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41
Q

1st digit (thumb) spinal nerve root correlation

A

C6

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42
Q

2-3 digits (pointer, middle) spinal nerve root correlation

A

C7

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43
Q

4-5 digits (ring, pinky) spinal nerve root correlation

A

C8

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44
Q

Xiphoid process spinal nerve root correlation

A

T6

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45
Q

Umbilicus spinal nerve root correlation

A

T10

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46
Q

Pubic symphysis nerve root correlation

A

T12

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47
Q

Anterior knee nerve root correlation

A

L4

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48
Q

Vaginal delivery sensory level block required at

A

T10

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49
Q

Lower extremity surgical block level

A

L1-L3

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50
Q

C section surgical block level

A

T4

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51
Q

THA (total hip arthroplasty) surgical block level

A

T10

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52
Q

TURP surgical block level

A

T10

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53
Q

Upper abdominal surgical block level

A

T4

54
Q

Cystectomy block level

A

T4

55
Q

Thoracic T2-T6 (upper thoracic) dosing

(local anesthetic)

A

5-10 mL

56
Q

T6-L1 (lower thoracic) surgical dosing

(local anesthetic)

A

10-20 mL

57
Q

L2-L5 (lower extremity) surgical dosing

(local anesthetic)

A

20 mL

58
Q

General trend for local anesthetic dosing

A

lower in spine = higher dose

59
Q

sacral LA dosing

A

12-15 mL

60
Q

Do not exceed this dose for LA in peds

A

2.5 mg/kg

61
Q

Baracity is

A

analogous to specific gravity

62
Q

Baracity changes with

A

fever

63
Q

Hyperbaric

A

goes down canal (more dense sinks)

i.e. dextrose

64
Q

hypobaric

A

goes up canal (less dense floats)
i.e water

65
Q

Isobaric

A

doesn’t sink or float (stay in same spot)

i.e. saline

66
Q

How do neuroaxial opioids work

A

Inhibit afferent pain transmission in substantia gelatinosa by decreasing cAMP, Ca conductance and increasing K conductance.

(bring axon membrane to lower potential/hyperpolarize/more negative)

67
Q

Neuraxial opioids create no (3):

A
  1. Sympathectomy
  2. Skeletal muscle weakness
  3. Change in proprioception
68
Q

Which stays in the CSF for longer: Hydrophillic opioids or Lipophillic opiods

A

Hydrophillic opioids stay in for a longer periods of time

69
Q

Resp depression in Lipophillic opioids

A

early AND late

?

70
Q

Resp depression in lipophillic opioids

A

early only (less than 6 hrs)

71
Q

4 primary side effects of neuraxial opoids

A
  1. Pruritis*
  2. Resp depression
  3. Urinary retention
  4. N & V
72
Q

6 factors that increase the risk of resp. depression

A
  1. Increase dose of LA
  2. co administration of sedatives
  3. Lower lipid solubility
  4. advanced age
  5. opioid naive
  6. Increased intrathoracic pressure
73
Q

Spinal site of action

A

Subarachnoid space myelinated preganglionic fibers of roots

74
Q

epidural site of action

A

dural cuff to nerve roots

intervertebral foramen to paravertebral area

75
Q

Increased intra abdominal pressure (couging, labor) - does it significantly alter anesthetic spread?

A

No

76
Q

For spread of epidural, caudad=

A

cervical

77
Q

For spread of epidural, cephalad =

A

lumbar

78
Q

Factors that affect spread of spinals:

A
  1. Patient position
  2. Baricity of LA
  3. Dose
  4. LA volume (most important drug - related)
  5. Level of injection
79
Q

For a sensory block,

A

2 dermatomal levels above motor

80
Q

For an autonomic block, you should block

A

2-6 dermatomal levels above sensory

81
Q

For a sensory block, your blockade is always _____ above ____

A

2 dermatomal levels above motor

82
Q

Autonomic block is ____ above ___

A

2-6 dermatomal levels above sensory

83
Q

Nerve fibers blocked

A

B-preganglionic ANS fibers

84
Q

Factors that affect the spread of epidurals

A
  1. LA volume (most important drug related)
  2. level of injection (most important procedure related factor)
  3. dose
85
Q

Dermatome differential blockade

A

Autonomic –> sensory –> motor

Dermatome high to liow
autonomic is always higher than sensory, sensory is always higher than motor

86
Q

Spinal sensory block level

A

2 dermatomes above motor

87
Q

Spinal autonomic block level

A

2-6 dermatomes above sensory

88
Q

Epidural sensory and ANS block

A

2-4 dermatomes above motor

89
Q

When testing effectiveness of block, test in this order:

A
  1. Temp
  2. Pain (pin prick)
  3. light touch
90
Q

Motor monitoring/ Bromage scale

A

0 = no motor
1 = pt cannot raise extended leg but can move knees and fe
2 - cannot raise extended leg or move the knee but can move feet
3= complete motor block

91
Q

Density =

A

ratio of mass of substance relative to its volume

92
Q

Baricity is

A

density of LA solution relative to CSF

93
Q

If spinal is hypobaric, what should you do and why

A

Do not keep patient in sitting position because it goes to brain

94
Q

What maintains arterial and venous tone in autonomic blockade

A

Preganglionic B fibers

95
Q

What are blocked first by neuroaxial anesthesia

A

Preganglionic B fibers

96
Q

Autonomic blockade =

A

Decreased sympathetic tone:
1. vasodilation
2. decrease venous return
3. decrease CO
4.Increase venous capacitance (venous pooling)
5. Hypotension
6. Bradycardia

97
Q

Main mechanism of bradycardia and asystole in autonomic blockade

A

Bezold- Jarisch relfex

98
Q

Bradycardia mechanism (what is blocked?)

A

T1-T4 cardio accelerator fiber block

99
Q

Even with a high T4 thoracic level dermatome spread of local anesthetic, what does not change?

A
  1. TV
  2. RR
  3. ABG
100
Q

With a T4 high thoracic dermatomal spread, what does change?

A

Small decrease in vital capacity
^blockade of accessory muscles of respiration

101
Q

With a T4 high thoracic dermatomal spread, dyspnea is

A

normal and very troublesome

102
Q

In a spinal/epidural, apnea is cause by

A

Bran stem hypoperfusion, NOT phrenic paralysis, NOT hi concentration of LA in CSF

(in peripheral blocks, it is phrenic paralysis)

103
Q

What innervates the parasympathetic GI system

A

vagus nerve

104
Q

What transmits sensations of satiety, distension, nausea

A

parasypathetic AFFERENT

105
Q

What signals tonic contractions, sphincter relaxation, peristalis and secretion

A

parasympathetic EFFERENT

106
Q

Sympathetic innervation of GI tract stems from (nerve root)

A

T5-L2

107
Q

sympathetic AFFERENT transmits

A

viceral pain

108
Q

sympathetic EFFERENT:

A
  1. inhibits peristalsis and gastric secretion
  2. causes sphincter contraction and vasoconstriction
109
Q

Nueroendocrine effects of spinal/epidural:

A

Decreases circulation levels of:
1. catecholamines
2. renin angiotensin
3. glucose
4. thyroid stress hormone
5. growth hormone (only negative)

110
Q

Epidural/spinal abscess prevention

A
  1. hand washhing
  2. strict sterile technique (mask, gloves, hat
  3. chlorohexidine and alcohol
111
Q

Key treatment for epidural/spinal hematoma

A

Prompt diagnosis and intervention

112
Q

Major symptom of epidural/spinal hematoma

A

Pain

113
Q

Complications of neuraxial anesthesia

A

Horner’s syndrome

114
Q

Use of vasoconstrictors is a risk for

A

neurotoxicity

in anterior spinal artery syndrome

115
Q

How to avoid spinal induced hypotension

A
  1. vasopressors
  2. 5-HT3 antagonists (zofran)
  3. Bezold-jarisch relfex prevent
  4. co-loading 15 mL/kg crystalloids
  5. pelvic tilting
  6. anticholinergics
116
Q

Sudden cardiac arrest in neruaxial anesthesia is due to

A

unopposed tone to cardioaccelerator fibers T1-T4

117
Q

Sudden cardiac arrest in in neuraxial is common in

A

young adults with high parasympathetic tone

118
Q

Sudden cardiac arrest with neuraxial anesthesia is associated with

A

large blood loss and orthopedic cement placement

119
Q

Post dural puncture HA treatment

A
  1. Caffeine
  2. bedrest
  3. Nsaids/gaba
  4. Sphenopalatine ganglion block
  5. Epidural blood patch
120
Q

If a block fails and there is no anesthesia

A

Repeat injectionI

121
Q

If a block is patchy

A

do not repeat, switch technique

122
Q

If a block is unilateral

A

position patient side down

123
Q

Why is a full stomach contraindicated for spinals?

A

If failed, may need to switch to GA

124
Q

Absolute contraindications of spinal

A
  1. Coagulopathy
  2. Sepsis
  3. PT refusal/cooperation/competence/age/lack of informed consent
  4. Dermal site infection
  5. Hypovolemia
  6. Preexisting spinal cord disorder
  7. Vavlular heart disease
  8. Increased ICP
  9. Operation >duration LA
  10. IHSS (idopathic subaortic stenosis)
  11. Severe CHF
125
Q

Epidural complications

A
  1. post dural puncture HA
  2. post spinal bacterial meningitis
  3. spinal induced hypotension
  4. cauda equina syndrome
  5. transient neurologic symptoms
126
Q

Contraindications of epidural

A
  1. spina bifida
    2.meningomyelocele of sacrum
  2. meningitis
  3. pilonidal cyst
  4. hydrocephalus
  5. intracranial tumor degenerative neuropathy
127
Q

Transient neurologic symptom causes

A
  1. stretching sciatic nerve
  2. myofascial strain
  3. muscle spasms
  4. lidocaine
  5. lithotomy position
  6. ambulatory surgery
  7. knee arthorscopy
128
Q

Transient neurologic s/sx

A

Severe back and butt pain, 6-36 hrs, 1-7 days

129
Q

transient neurologic symptom treatment

A
  1. NSAIDs
  2. opioid analgesic
  3. trigger point injections
130
Q

Cauda equina syndrome neurotoxicity is form

A

high concentrations of lidocaine

131
Q

Cauda equina syndrome is more common when

A

microcatheters are used - focused on small area of cord, not enough spread

132
Q

Low molecular weight heparin should be d/c’d

A

12 hours for prophylactic dosing
24 hours for therapeutic dosing

133
Q

Theinopynidue derivative should be d/cs

A

7 days

Priniclpes Of Anesthesia (19 decks)

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