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Regional > Spinals ppt (josh) > Flashcards

Spinals ppt (josh) Flashcards

1
Q

Other names for spinal anesthesia? (4)

A
  1. SAB
  2. Neuraxial block
  3. Conduction block
  4. intrathecal block
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2
Q

What factors make up the decison to use spinal or not to use spinal

A
  • Case selection
  • Surgeon
  • Pt selection
  • Spinal vs General
  • Spinal vs Epidural
  • Combined CSE
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3
Q

What cases are good for spinal anesthesia (this is off pabalate’s slides so not all inclusive)

A
  • OB, GYN
  • Urological
  • Orthopedics Upper/lower
  • Lower Abd
  • Vascular
  • Post op pain management
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4
Q

Condtraindications to Spinals

ABSOLUTE

A
  • PT REFUSAL (thats for you jake)
  • Sepsis or infection at injection site
  • Coagulopathy or anticoagulation
  • Elevated ICP or Cerebral edema
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5
Q

Condtraindications to Spinals

RELATIVE

A
  • Pt appropriateness
  • Local infection near site
  • Hypovolemia
  • CNS Disease
  • Chronic Back pain
  • Prior Lami
  • Prior SAB with difficulty
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6
Q

Pt selection:

use spinals cautiously in pt’s with what?

A
  • Mabitz type I, or II
  • 3rd degree HB w/o pacemaker
  • Fixed volume cardiac states (IHSS, Severe Aortic Stenosis)
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7
Q

have studies shown any difference b/t morbidity or mortality b/t GA and Regional in HEALTHY patients

A

Nope

(when i wrote this i had dr. monaghan in my ear saying “ hmm (with his right index finger and head both pointing to the right) now that sounds like a great reasearch idea, if anyone is interested see me after class”

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8
Q

does regional have a lower risk of thrombophelbitis compared to general?

A

Yep

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9
Q

your probally saying why? why is there a lower incidence of thrombophlebitis? well answer it… why is there a lower incidence??

A

postulated to be due to a lower incidence of venous stasis and a higher blood flow r/t vasodilation of the lower extremities!!!!

BAAAAAAMMMM!!!

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10
Q

Does data support one anesthestic over another? ex spinal vs Epidural vs GA

A

Negativo

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11
Q

but… why is there speculation that spinal anesthesia better?

A

b/c they say spinal anesthesia is much less styressfull to a pt’s physiology than GA

( this s not an accurate speculation don;t be that provder)

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12
Q

Spinal vs Epidural vs General:

as a result of that last speculation that spinal anesthesia is much less stressful to a pt’s physiology than GA what usually occurs? or what pt’s usually get spinals?

A

there is an increase in spinals with patients with SIGNIFICANT co-existing diseases, especially the elderly

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13
Q

Spinal vs Epidural vs General:

so as stated in the last to sides the overall assumption is that sick pt’s tolerate Spinals better than GA!!! don’t always beleive that.

(this is just for info)

A

per his slide it states

comfort factor- pt is too sick for GA but will tolerate a Spinal w/o significant problems (be careful with this assumption)

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14
Q

Spinal vs Epidural vs General:

what pt’s may benefit most from spinal anesthesia? (5)

A
  • Asthma/COPD/ long pulm hx/ heavy smokers
  • Fear of GA
  • OB C-section
  • Hx of thrombophelbitis ot incresed risk
  • Any pt with obviously diff airway (undergoing a sx that is suitable for spinal)
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15
Q

SPINALS vs EPIDURALS

Advantages of SPINAL

A
  • Quicker to perform
  • less painful to pt
  • fast onset
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16
Q

SPINALS vs EPIDURALS

disadvantages of SPINAL

A
  • fixed duration
  • PDPH
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17
Q

SPINALS vs EPIDURALS

Advantages of Epidural

A
  • Continuous Infusion
  • postoperative pain management
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18
Q

SPINALS vs EPIDURALS

EPIDURAL disadvantages

A
  • More painful
  • Longer to perform
  • slower onset

(exact opposite of spinals advantages)

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19
Q

SPINAL A&P

give me the basic 6 Anatomy parts when doing a spinal

A
  1. Spinal cord
  2. Vertebral body
  3. Ligaments (supraspinous, interspinous, ligamentum flavum)
  4. Spinal cord (L1-L2)
  5. Subarachnpid Space
  6. CSF fluid
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20
Q

SPINAL A&P

The ___________ of the Parietal lobe, is primarily responsible for receiving painful stimuli

A

Postcentral Gyrus

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21
Q

SPINAL A&P

the ________ of the parietal lobe is responsible for motor function and mavement away from painful stimuli

A

Precentral gyrus

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22
Q

just to see locations

A
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23
Q

SPINAL A&P:Awesome facts

CSF total volume?

A

150 mL

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24
Q

SPINAL A&P:Awesome facts

total of 150 mL total CSF fluid how much is in the spinal cord at any given time?

A

30-50 mL

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25
Q

SPINAL A&P:Awesome facts

CSF pH?

A

approximately 7.32

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26
Q

SPINAL A&P:Awesome facts

CSF is secreted at a rate of what?

A

30 mL/hr

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27
Q

SPINAL A&P:Awesome facts

CSF is secreted at a rate if 30 mL/hr by ______ Cells of the ____ ____

A
  • Epindymal
  • Choroid plexus
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28
Q

SPINAL A&P:Awesome facts

CSF is replaced once ever __-___ hours

A

3-4 hrs

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29
Q

SPINAL A&P:Awesome facts

th spinal cord starts and ends where?

A
  • starts- FORAMEN MAGNUM
  • ends L1
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30
Q

SPINAL A&P:Awesome facts

the spinal Canal starts and ends where?

A
  • Starts- FORAMEN MAGNUM
  • Ends- SACRAL HIATUS
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31
Q

SPINAL A&P:Awesome facts

what is beyond L1

A

the cauda equina

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32
Q

SPINAL A&P:Awesome facts

how many vertebral bodies are there?

A

33

(24 separated by intervetebral disk)

7 cervical

12 thoracic

5 lumbar

5 sacrum

4 coccxygeal

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33
Q

SPINAL A&P:Awesome facts

how many spinal nerves are there?

A

31 (pairs)

cervical-8

thoracic-12

lumbar-5

Sacral-5

coccygeal-1

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34
Q

SPINAL A&P:Awesome facts

the 31 pairs of spinal nerves carry what?

A

motor and sensory information

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35
Q

SPINAL A&P:Awesome facts

the spinal cord is composed of what 2 types of matter

A

gray

white

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36
Q

SPINAL A&P:Awesome facts

Gray matter is composed of what 2 things?

A

neuronal cells

unmylinated fibers

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37
Q

SPINAL A&P:Awesome facts

a large number of ________ are found in the GRay Matter

A

interneurons

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38
Q

SPINAL A&P:Awesome facts

what is contained in the white matter?

A

various tracts

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39
Q

SPINAL A&P:Awesome facts

what are the 2 tracts contained in the white matter?

A

Ascending

descending

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40
Q

SPINAL A&P:Awesome facts

what is the Ascending tract contained in the white matter of the spinal cord made up of?

A
  • dorsal white matter
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41
Q

SPINAL A&P:Awesome facts

what does the Ascending tract contained in the white matter of the spinal cord made contain (it’s purpose)?

A

Ascending SENSORY tracts

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42
Q

SPINAL A&P:Awesome facts

what is the Descending tract contained in the white matter of the spinal cord made up of?

A
  • Lateral and Ventral white matter
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43
Q

SPINAL A&P:Awesome facts

what does the Descending tract contained in the white matter of the spinal cord contain?

A
  • Descending MOTOR tracts
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44
Q

Label this

A
  1. Posterior Longitudinal ligament
  2. Dura Matter
  3. Ligamentum Flavum
  4. Supraspinous ligament
  5. Interspinous ligament
  6. Subdural spaace
  7. Arachnoid mater
  8. Pia mater
  9. Cord
  10. Subarachnoid Space
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45
Q

Lable this

A
  1. Dural sac
  2. Epidural vein
  3. interlaminar space
  4. Lamina
  5. Ligamentum Flavum
  6. Supraspinous Ligament
  7. Intraspinous ligament
  8. Spinous Process
  9. Transverse process
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46
Q

SPINAL A&P: Spinal Cord Roots

What Carries all AFFERENT signals heading INTO the spinal cord and brain

A

DORSAL ROOT

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47
Q

SPINAL A&P: Spinal Cord Roots

What carries all EFFERENT signals heading out to the periphery

A

VENTRAL ROOT

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48
Q

SPINAL A&P: Spinal Cord Roots

the doral root and ventral root fuse together to form what?

A

the main nerve root the exits the spinal cord at the particular level

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49
Q

Lable this

A
  1. Ganglion of sympathetic trunk
  2. Dorsal root and Ganglion
  3. Spinal Cord
  4. Ventral root
  5. Preganglionic fibers
  6. post gangliionic fibers
  7. Gray ramus
  8. White ramus
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50
Q

SPINAL A&P: Spinal Cord Roots

The _______ is the primary site of action of the LA, both with spinal and epidurals. the only doifference is WHERE the root is being anesthetized, either subarachnoid or in the epidural space

A

NERVE ROOT

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51
Q

SPINAL A&P: Nerves

Nerve type and fiber determine the order of block> the order of block is what?

A
  1. Sypathetic/Parasympathetic
  2. Sensory
  3. Motor
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52
Q

SPINAL A&P: Nerves

Sympathetic/parasympathetic nerves

  • what size fibers?
  • what are the 3 fibers?
  • what are their pathways?
A
  • Small
  • C, B, preganlionic
  • Afferent and efferent
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53
Q

SPINAL A&P: Nerves

Sensory fibers

  • what size fibers?
  • what are the 3 fiber?
  • what are the pathways?
A
  • Small and middle intermediate
  • C, A-delta, A-beta
  • Afferent and Efferent
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54
Q

SPINAL A&P: Nerves

Motor nerves

  • What size fibers?
  • what are the 3 fibers?
  • what are the pathways?
A
  • large thick
  • A-alpha, A-Beta, A-gamma
  • Efferent and afferent
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55
Q

2 division of the peripheral nervous system?

A

Somatic and autonomic

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56
Q

SPINAL A&P: Somatic

contains sensory neurons for control of what?

A

skin, muscle, and joint movement

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57
Q

SPINAL A&P: Somatic

the motor fibers arise from the motor neurons in the ____ horn, their axons exiting the spinal cord via the Ventral root

A

Ventral

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58
Q

SPINAL A&P: Somatic

contains what pathway(s)?

A

afferent (incoming)

Efferent (outgoing)

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59
Q

SPINAL A&P: Somatic

which pathway is sensory neurons for pain, proprioception, pressure, touch, etc?

A

afferent

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60
Q

SPINAL A&P: Somatic

which pathway is motor neurons for skeletal muscle movement, both reflexive and purposeful?

A

efferent

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61
Q

SPINAL A&P: AUTONOMIC

2 divisions

A

sympathetic (stimulating)

Parasympathetic (relaxing)

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62
Q

SPINAL A&P: AUTONOMIC

the sympathetic nerves originate in the intermediolateral gray matter of __-__ spinal cord segments

63
Q

SPINAL A&P: AUTONOMIC

the parasympathetic nerves only originate in the ____ nerves or the _____ nerve?

A

Cranial nerves

Sacral nerves

64
Q

SPINAL A&P: AUTONOMIC

in the sympathetic system the preganglionic nerve fibers end where?

A

in the sympathetic chain in one of the many sympathetic ganglia

65
Q

SPINAL A&P: AUTONOMIC

in the parasympathetic system the preganglionic fibers actually end where?

A

IN the organ that they innervate

66
Q

SPINAL A&P: AUTONOMIC

another name for parasympathetic

another name for sympathetic

A
  • cranioscral
  • Thoracolumbar
67
Q

Just a pic to reference the last few slides

68
Q

SPINAL A&P: AUTONOMIC

the SNS is composed of what 3 receptors?

A

Alpha

Beta

Dopamine

69
Q

SPINAL A&P: AUTONOMIC

What are the primary NT of the SNS?

A

Norepinephrine

Dopamine

70
Q

SPINAL A&P: AUTONOMIC

what are the 2 receptors of the PNS

A

nicotinic

Muscarinic

71
Q

SPINAL A&P: AUTONOMIC

what is the primary NT of the PNS

A

acetylcholine

72
Q

SPINAL A&P: Nerves

spinal anesthesia interupts ______, _____, and _______ nervous system innervation

A

Sensory

Motor

Sympathetic

73
Q

SPINAL A&P: Nerves

the LA blocks the small C fibers of the sympathetic system first and gradually diffuses into the interior of the nerve where the large fibers are for _______ block followed by ____ block

A
  • sensory
  • Motor
74
Q

What is the goal of a spinal?

A

Anesthesia to a region of the body

(i hope ypou got that)

75
Q

levels of a block

?

?

?

(fill in motor, sympathetic, motor)

A
  • sympathetic
  • Sensory
  • motor
76
Q

if i give a spinal at T-6 tell me where the levels are: for ex motor, sensory, sympathetic

A

T-4–sympathetic

T-6— Sensory

T-8—- Motor

77
Q

Segmental level of block required:

what sx are good with a T-4 to T-6 block

A

Intraabdominal

78
Q

Segmental level of block required:

what sx are good with a T-6 to T-8 block

A

GU, low abdominal

79
Q

Segmental level of block required:

what sx are good for a T-8 to T-10 block

A

GU, A/R, Legs

80
Q

Pic for reference

81
Q

pic for reference

82
Q

get ready for pure awesomeness know these next few slides for sure

A

drop your socks grab your cocks lets go

83
Q

tell me the cutaneous level and significance of each segmental level (basically if you block is here where on the body are you assessing and what does it mean)

C8

A
  • Fifth digit
  • All cardiaaccelerators fibers blocked (T1-T4) (their fucked)
84
Q

tell me the cutaneous level and significance of each segmental level

T1-T2

A
  • Inner aspect of arm and forearm
  • some degree of cardioaccelerator blockade
85
Q

tell me the cutaneous level and significance of each segmental level

T3

A
  • Apex of axilla
  • Easily determined landmark
86
Q

tell me the cutaneous level and significance of each segmental level

T4-T5

A
  • Nipple
  • possibility of carioaccelerator blockade
87
Q

tell me the cutaneous level and significance of each segmental level

T7

A
  • tip of xiphoid
  • Splanchnics may be blocked (T5-L1)
88
Q

tell me the cutaneous level and significance of each segmental level

T10

A
  • Umbilicus
  • Sympathetic nervous sytem blockade to legs
89
Q

tell me the cutaneous level and significance of each segmental level

T12

A
  • inguinal ligament
  • No sympathetic nervous system blockade
90
Q

tell me the cutaneous level and significance of each segmental level

S1

A
  • outer aspect of foot
  • Confirms block of the most difficult nerve root to anesthetize
91
Q

How to remember those last slides

A
  • Start with C8 (highest level) end with S1 (lowest landmark)
  • (since u started with C8 there are 8 landmarks)
  • C8= thumb S1 equals foot
  • travel up from thumb to groin with corrosponding points
  • ex C8 thumb/ Thoracic strts forarms- axillia-nipple- xiphoid- umbilicus- inguinal liament

I dunno may not help but I see it

92
Q

chart I used from his ppt

93
Q

Spinals: Systemic Effects

CV- hypotension is directly proportional to degree of what?

A

sympathetic blockade

94
Q

Spinals: Systemic Effects

think of what level when worring about CV effects

A

T4 (nipple line)

95
Q

Spinals: Systemic Effects

what occurs above T-4 level?

A

brady

decreased CO

Decreased B/P

96
Q

Spinals: Systemic Effects

what occurs below T4 level

A
  • Dilate
  • Decreased SVR
  • Decreased VR
97
Q

where are the carioaccelerator fibers located?

98
Q

Spinals: Systemic Effects

Hypotension if more pronounced in what pt?

A

Dehydrated

elderly

Decreased VR

99
Q

Spinals: Systemic Effects

respiratory

Increasing hight of block may block what muscles

A

intercostals

100
Q

Spinals: Systemic Effects

respiratory

what resp diseases are most effected by spinals

A

ones with

  • SOB
  • high CO2
  • low O2
101
Q

Spinals: Systemic Effects

to prevent resp complications keep block below what level?

102
Q

Spinals: Systemic Effects

the phrenic nerve is resistant to what?

A

A alpha

(?????)

103
Q

Spinals: Systemic Effects

respiratory

what other muscles besides intercostals my be affected that can compromise respirations?

A

abdominals

104
Q

Spinals: Systemic Effects

Visceral

S2-4 causes what?

T5-L1 causes what?

A
  • atonic bladder
  • (blocks) sphinter tone
105
Q

Spinals: Systemic Effects

renal effects?

A

none

autoregulated

106
Q

Spinals: Systemic Effects

neuroendocrine

what level blocks adrenals

107
Q

Spinals: Systemic Effects

what affects thermoregulation?

(why do they get cold?)

A

vasodilation=hypotension

108
Q

Spinals: Drug and spinal levels

Distribution of LA in CSF is dependent on what 5 factors? (4 main)

A
  1. Baracity
  2. Contour of spinal cord
  3. Position of pt during and first few min post
  4. Dosage of LA
  5. Other
109
Q

Spinals: Drug and spinal levels

how do the following affect blockade

  1. DOSE
  2. VOLUME
  3. TURBULENCE
  4. BARICITY
A
  1. level (directly r/t dose)
  2. spread (r/t volume)
  3. increases spread
  4. density ratio
110
Q

Spinals: Drug and spinal levels

what are other factors that affect level of spinal anesthesia

A
  1. age
  2. CSF
  3. Curvature
  4. Drug volume
  5. IntraAbdominal pressure
  6. Needle direction
  7. Pt height
  8. Pregnancy
111
Q

Spinals: Drug and spinal levels

how do the following affect blockade

  1. intraAbdominal pressure
A
  • Î IVC pressure, î epid plexus, Low CSF volume = INCREASED spread
112
Q

Spinals: Drug and spinal levels: BARICITY

3 types of baricity?

A

hyperbaric Solutions

Hypobaric Solution

Isobaric Solution

113
Q

another name for baricity?

A

specific gravity

114
Q

Spinals: Drug and spinal levels: BARICITY

CSF has a baricity of what at normal body temp?

A

1.003-1.008

115
Q

Spinals: Drug and spinal levels: BARICITY

Hyperbaric are prepared by adding ______ in amounts sufficient to increase the density of the LA above that of CSF

A

Glucose (Dextrose)

116
Q

Spinals: Drug and spinal levels: BARICITY

Hyperbaric.

______ __% and ________ __% are usually premixed with dextrose and come in a hyperbaric solution in your tray?

A

Lidocaine 5%( I wonder if that is supose to be 0.5??)

bupivacaine 0.75%

117
Q

Spinals: Drug and spinal levels: BARICITY

hyperbaric

being heavier than CSF allows the solution to do what?

A

settle in the most dependent aspects of SA space

118
Q

Spinals: Drug and spinal levels: BARICITY

hyperbaric

the level is usually determined by what?

A

position of pt

119
Q

Spinals: Drug and spinal levels: BARICITY

hyperbaric

when supine the solution tends to gravitate to where? and what level?

A

thoracic kyphosis

T6

120
Q

Spinals: Drug and spinal levels: BARICITY

hyperbaric

what does a sitting position produce

A

a low sensory level of anesthesia

121
Q

Spinals: Drug and spinal levels: BARICITY

Hyperbaric

what does a “saddle block” do?

A

numbs the area that would normally by in contact with a saddle when riding a horse

122
Q

Spinals: Drug and spinal levels: BARICITY

Hypobaric is prepared how

A

by adding 6-8 mL of sterile H2O to the LA

123
Q

Spinals: Drug and spinal levels: BARICITY

with hypobaric solutions after injection the LA “____” since it is now lighter than the CSF

124
Q

Spinals: Drug and spinal levels: BARICITY

Hypobaric when is it used

A

rarely used other than in academic settings to demonstrate the tech

125
Q

Spinals: Drug and spinal levels: BARICITY

Isobaric solutions are created how?

A

by diluting the LA with CSF

126
Q

Spinals: Drug and spinal levels: BARICITY

when is Isobaric solutions usefull?

A

when you don’t need your block to go much higher than L1 (hip/knee sx)

127
Q

Spinals: Drug and spinal levels: BARICITY

When is isobaric solutions usually used?

A

rarely except in academic settings to demonstrate the tech

128
Q

Spinals: Drug and spinal levels: BARICITY

chart memorize if you want?

I would just know which are hyper/hypo/and iso baric

A

normal Baricity of CSF

1.003-1.008

129
Q

Spinals: Drug and spinal levels:

tell me the volume/ onset/ duration w and w/o epi

  1. Lido 5%
  2. tetricaine 0.5%
  3. Bupivacaine 0.5-0.75%
  4. Ropivacaine 0.5-0.75%
A

Volume onset w/o epi w/epi

  1. 1-2mL 2-4 min 45-60 60-90
  2. 1-3 mL 4-6 60-90 120-180
  3. 1-2 4-6 90 140
  4. 1-2 4-6 90 140
130
Q

chart for reference

131
Q

***************

Spinal level is determined by what???????

132
Q

Spinals: Drug and spinal levels: Position

Supine with head slightly down will push your level up to where?

133
Q

Spinals: Drug and spinal levels: Position

supine and level will usually give you ehat level

134
Q

Spinals: Drug and spinal levels: Position

Supine with head slightly up will give you what level?

135
Q

Spinals: Drug and spinal levels:

what besides position can effect level of blockade

A
  1. scoliosis (alters low point)
  2. Hyphosis/Kyphoscoliosis (alter low point)
  3. Previous back sx (post surgical anatomic changes can effect level either higher or lower than expected)
  4. Any condition that lowers amt of CSF (can puch level up higher) (preg, ascites, large abd/pelvis tumors)
  5. Age related decreeases in CSF
136
Q

Spinals:procedures and tech

Name the anatomical structures from skin

A
  1. Supraspinous ligament
  2. Interspinous ligament
  3. Ligamentum flavum
  4. epidural space
  5. dura
  6. Arachnoid
  7. Aubarachnoid space (our target space)
  8. pia matter)
137
Q

Spinals: LA

what are the 4 most commonly used LA in regional anesthesia

A
  1. Lidocaine
  2. tetricaine
  3. Bupivacaine
  4. Ropivacaine
138
Q

Spinals: LA

LA MOA

A
  • Produce conduction blockade of neural impulses
  • prevent passage of Na+ ions through ion selective Na+ channels in nerve membranes
  • they bond to the Na+ channel itself and keep it in the active or open position
139
Q

Spinals: LA

what is commonly added to LA to prolong their duration

A
  • Epi
  • Phenylephrine
140
Q

Spinals: LA

what is the dose of EPi

A

0.1-0.2 mg

100mcg-200mcg

141
Q

Spinals: LA

phenylephrine dose

A

2-5 mg

2000-5000 mcg

142
Q

Spinals: LA

Epi and Phenylephrine can prolong spinal anesthesia by up to how much?

143
Q

Spinals: TECHNIQUES

3 main approaches

A
  1. midline
  2. Paramedian (lateral)
  3. Lumbosacral (taylor)
144
Q

Spinals: TECHNIQUES

what are the 2 mainanatomical landmarks you want to identify?

A
  1. spinous process
  2. iliac crest
145
Q

Spinals: TECHNIQUES

in 95% of pts the illiac crest corrasponds to what spinal level

146
Q

just a pic

147
Q

Spinals: TECHNIQUES

Give me the whole process of doing a spinal step by step

A
  • Open tray-needles-drugs
  • Check baseline VS
  • Glove and prep
  • Draw up drugs (sterile tray)
  • Localize skin
  • decide approach
  • Needle and Stylet advanced until “pop”
  • remove stylet- clear CSF flow x 4
  • ask about parasthesia
  • check swirl inject
  • asprate inject repeat repeat
  • remove needles and syringe together
  • assess pt
148
Q

Spinals: TECHNIQUES

how do u assess levels?

sympathetic

sensory

motor

A
  • temp
  • pain (sharp)
  • movement
149
Q

Spinals:

stategies for sucess?

A
  • pr cooperation
  • Positioning
  • Knowing landmarks
  • Localize well
  • sticking with it
  • Tell your pt it may not work
  • attemot to insert spinal w/o introducer if difficult
  • change position if not working
  • Make sure drug gets to pt
150
Q

Spinals:

how do u treat hypotension

A
  • IV fluids pressors
    *
151
Q

Spinals:

how to treat high spinals

A
  • treat symptoms
152
Q

Spinals:

what causes N/V

A

b/p vs Vagal

153
Q

Spinals:

Postop complications

A

Urinary

backpain

PDPH

154
Q

Spinals:

what to document

A
  • position an dmonitors
  • Skin prep
  • Landmarks
  • Skin localization
  • Needle (type, guage, length, introducer
  • SAB punctur #, CSF, Blood, Paresthesia
  • Drug- concentration, dose, lot #

Regional (24 decks)

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