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Anesthesia Principles II > Spinals part 2 > Flashcards

Spinals part 2 Flashcards

1
Q

in what order are nerve fibers sensitive to LA? (most sensitive to least sensitive)

in what order are they blocked? (first to last)

A

large myelinated > smaller myelinated > smaller unmyelinated

B fibers
C and A-Delta fibers
larger A-gamma, A beta, and A-alpha fiberes

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2
Q

what do B fibers do?

A

preganglionic sympathetic efferents

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3
Q

what do C and A-delta fibers do?

A

pain, temp, touch afferents

post ganglionic sympathetics

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4
Q

factors that affect differential blocks?

A

size/myelination of the fibers
nodes of ranvier
location depth
Na and K channels on each nerve

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5
Q

in waht order are the nervous systems blocked?

A

sympathetic, sensory, motor

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6
Q

sings of a sympathetic block? and how to sympathetic, sensory, and motor block levels compare?

A

BP changes may be the first sign, and is usually 2 segments higher than the sensory block, which is usually 2 levels higher than a motor block

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7
Q

most accurate way to check for sensory block?

A

sharp or broken tongue depressor

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8
Q

is loss of sensation to cold or sharp pain first?

A

sesation to cold is first and occurs at higher levels

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9
Q

what fibers are blocked first in motor blockade?

A

A beta and A gamma, A alpha is a profound block

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10
Q

2 most important factors that affect height of nerve block for SAB?

A

baricity and patient position

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11
Q

how do you get a saddle block? what is it good for?

A

sitting position for SAB, leave sitting for 3-5min with a hyperbaric solution. Great for lower perineal procedures

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12
Q

how does LA distribute in position is sitting to supine with hyperbaric solution?

A

it moves more cephalad to the dependent region of the lumbar curve

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13
Q

spine high points in cervical and lumbar lordosis?

A

C3 and L3

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14
Q

spine low points in thoracic and sacral kyphosis?

A

T6 and S2 low points

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15
Q

other factors affecting height of spinal block?

A

age - older ligamentum flavum gets tougher and intrathecal space gets compressed, so higher spread of LA

height, more distance to travel and can increase dose

weight, decrease in intrathecal and epidural space if obese or pregnant

spinal fluid rate of circulation (coughing and straining)

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16
Q

hypobaric LAs?

A

tetracaine 0.33% with water
lidocaine 0.5% with water

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17
Q

isobaric LAs?

A

tetracaine 0.5% with 50% CSF
lidocaine 2% with water
bupivicane 0.5% with water

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18
Q

hyperbaric LAs?

A

tetracaine 0.5% with 5% dextrose
lidocaine 5% with 7.5% dextrose
bupivicane 0.5% with 8% dextrose
bupivicaine 0.75% with 8% dextrose

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19
Q

primary goal of neuraxial anesthesia?

A

block afferent fibers located in dorsal roots

motor and sympathetic fibers are close and they get blocked as they pass through ventral root

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20
Q

why must you use preservative free LA in SAB?

A

parabns high allergy potential
sulfites neurotoxic
EDTA muscle pain and can cause tetany

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21
Q

should you use multi dose or single dose vial for SAB?

A

single dose

22
Q

mech of action of LA?

A

limits sodium cahnnels and stops propogation of a nerve impulse

23
Q

which LA has strongest attachment to NA channels?

A

bupivicaine

24
Q

how do LAs find their way to the spinal cord?

A

through virchow-robin spaces

insertion site of tiny blood vessels where local can get around the side of them

25
Q

which meds can increase duration of SAB? what dose for each?

A

epi 0.1-0.2ml of epi 1:1000 “epi wash”
Neo 0.5-2mg
clonidine (LA effect)

26
Q

what is added to LA to increase onset?

A

NAHCO3

27
Q

where are opiod receptors?

A

substantia gelatinosa and spinal cord

28
Q

what meds are MU opioid receptors responsive to?

A

morphine, meperidine, sufentanil, fentanyl, alfentanil

29
Q

What are MU2 receptors also responsible for?

A

decreased HR, RR, and euphoria

30
Q

SE of opioids?

A

N/V, itching, urinary retention

N/V is the number one complaint

31
Q

why is fentanyl widely used?

A

it adheres to lipoproteins in the spinal cord due to its high lipid solubility, less drug available to diffuse to respiratory centers

32
Q

fentanyl dosing in SAB? what can it be combined with?

A

10-25mcg
onset 5-10min
DOA 2-4hours

can be combined with morphine (must be preservative free)

33
Q

morphine dosing in SAB

A

0.1-.5mg
onset 60-90min
DOA 6-8hrs

34
Q

what should you be cautions with when using morphine in SAB?

A

delayed resp depression

35
Q

adequate dermatome levels for the following procedures?

upper abdmonial surgery
intestinal, gyn, urologic
TURP
vaginal delivery, hip surgery
thigh surgery and lower leg amputation
foot and ankle surgery
perineal and anal surgery

A

T4
T6
T10
T10
L1
L2
S2-S5 (saddle block)

36
Q

needle size for spinals?

A

22-27 gauge

37
Q

is quinke point needle cutting?

A

yes

38
Q

is whitacre needle cutting?

A

no, pencil point

39
Q

line accross iliac crests?

A

Tuffiers line

40
Q

spinal considerations in prone jacknife positions?

A

use hypobaric or isobaric
must aspirate CSF, it will not drip
rectal procedures

41
Q

what do you need to make sure happens with legs in the lateral position?

A

good flexion of the legs

42
Q

why is potential lumbar spine rotation importnat?

A

it may impede access to the spinal canal

43
Q

what LA is typically used for jack knife position?

A

tetracaine with water

caudal anesthesia can also be used, this is part of epidural space with a space in the sacral hiatus

44
Q

what size spinal needles need an introducer?

A

25-27 gauge

45
Q

what size needle no longer needs an introducer?

A

22gauge

46
Q

which way should bevel face on introducer needle for paramedian approach? midline?

A

up (why???)

to the side

47
Q

what structures are passed through for subarachnoid block in midline position? lateral or paramedian approach?

A

skin
subq tissue
supraspinous ligament
interspinous ligament
ligamentum flavum
epidural space
dura matter
arachnoid matter

lateral or paramedian approach does not pass through the supraspinous or interspinous ligaments

48
Q

how often should BP cuff be set when starting a spinal?

A

every 2 min

49
Q

when is paramedian approach done and how is it done?

A

for patients unable to flex and arch their back. also for paties who are belived to have calcified ligaments, or after a couple attempts at midline

walk laterally 1-2cm from spinous process as well as 1cm down, angle 45 degrees cephalad and 15 degress to midline. first resistance should be ligamentum flavum

50
Q

describe taylor approach

A

indications: difficult anatomy, kyphoscoliosos, scoliosis
it is a modified paramedian appraoch, but done at L5-S1 interspace

51
Q

pros of SAB?

A

fast acting
dense block - motor and sensory
small volume minimzes toxicity
less time and smpler to perform
less N/V, decreased stress response, decreased opioids
affects reticular activating system so pt can be somnolent

52
Q

cons of SAB?

A

hypotension is significant
cant prolong the block
lack of control with the level of the block

Anesthesia Principles II (14 decks)

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