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Advanced Principles A > Test 3: Labor Anesthesia & Analgesia Part 2 > Flashcards

Test 3: Labor Anesthesia & Analgesia Part 2 Flashcards

1
Q

What five layers will a Tuohy needle pass through to get to the epidural space?

A
  1. Skin
  2. Subcutaneous Tissue
  3. Supraspinous Ligament
  4. Interspinous Ligament
  5. Ligamentum Flavum
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2
Q

What layers will a needle pass through to get to the subarachnoid space?

A
  1. Skin
  2. Subcutaneous Tissue
  3. Supraspinous Ligament
  4. Interspinous Ligament
  5. Ligamentum Flavum
  6. Dura
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3
Q

What levels of the spine will a Continous Labor Epidural be placed at?

What is the most common level?

A
  • L2-3
  • L3-4
  • L4-5 (Most common level)
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4
Q

What are the advantages of a CLE?

A
  • Continuous analgesia
  • No dural puncture required (there should be NO CSF leak)
  • Catheter for C-section use
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5
Q

What are the disadvantages of a CLE?

A
  • Slower onset of analgesia (10-15 mins)
  • Larger amount of LA/opioids required (volume base block)
  • Risk of sacral “sparing” or slow blockade
  • Great risk for maternal LAST
  • Greater fetal drug exposure
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6
Q

What catheter length will a provider typically leave in the epidural space?

A

4-6 cm of catheter in the epidural space

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7
Q

When performing an epidural technique, is there evidence that supports using air vs saline when finding loss of resistance?

A

No evidence to support one over another

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8
Q

What are the risks of using air to find loss of resistance?

A
  • Risk of patchy block
  • Risk for pneumocephalus
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9
Q

What is the standard test dose for an epidural placement?

A

3 mL of Lidocaine 1.5% w/ 1:200K Epinephrine

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10
Q

What does 1:200,000 Epinephrine mean?

A
  • 1 gram of Epinephrine diluted in 200,000 mL solution
  • This comes out to 5 mcg/mL.

The math.
1 gram of epinephrine/200,000 mL
1000 mg of epinphrine/200,000 mL
1,000,000 mcg of epinephrine/200,000 mL
5 mcg/mL

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11
Q

What is the purpose of performing a standard test dose when placing an epidural?

A

Recognize malpositioning of the epidural catheter

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12
Q

Where can the epidural catheter be malpositioned?

A
  • Intrathecal space
  • Intravascular space
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13
Q

When should you not perform a test dose d/t the risk of a false positive result?

A

Do not perform a test dose when a parturient is undergoing contractions. You will not know the source of the elevated HR.

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14
Q

What symptoms will be present if the test dose enters the intravascular space?

A
  • ↑ HR by 20 bpm within 60 secs
  • Lidocaine 150 mg IV will cause tinnitus, circumoral numbness, dizziness
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15
Q

What symptoms will be present if the test dose enters the intrathecal space?

A
  • Motor blockade in 3-5 minutes (warm legs)
  • Risk of high spinal
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16
Q

What symptoms do you want with an epidural test dose?

A
  • Nothing
  • This is a good indication that the catheter is in the epidural space
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17
Q

What is a Combined Spinal Epidural (CSE)?

A

A single shot of intrathecal (spinal) medication followed by placement of an epidural catheter

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18
Q

What are the advantages of Combined Spinal Epidural?

A
  • Rapid onset (2-5 mins)
  • Low doses of LA/ opioids
  • Continuous analgesia w/ epidural catheter
  • Epidural catheter to use for C-section
  • Decrease the incidence of failed epidural
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19
Q

What are the disadvantages of Combined Spinal Epidural?

A
  • ↑ Risk of fetal bradycardia (d/t degree of sympathetic blockade and maternal hypotension)
  • ↑ Risk of PDPH
  • ↑ Risk of postpartum neuraxial infection
  • Uncertain of “correct” epidural catheter placement until block regression
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20
Q

What is a Dural Puncture Epidural?

A
  • Similar to a Combined Spinal Epidural, but no medication injection
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21
Q

What are the advantages of Dural Puncture Epidural?

A
  • Faster onset than an epidural without a dural puncture
  • Transdural migration of meds injected into epidural space
  • More rapid sacral analgesia than traditional epidural
  • Decrease risk of maternal hypotension/ fetal bradycardia compared to CSE
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22
Q

What are the disadvantages of Dural Puncture Epidural?

A
  • Increase risk of PDPH
  • Increase risk of postpartum neuraxial infection
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23
Q

What are the advantages of a single shot spinal/ intrathecal?

A
  • Rapid onset of analgesia
  • Immediate sacral analgesia
  • Low local anesthesia & opioid dosages
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24
Q

What are the disadvantages of a single shot spinal/ intrathecal?

A
  • Limited duration of analgesia (based on LA/opioid selection)
  • ↑ Risk of maternal hypotension/fetal bradycardia
  • ↑ Risk of PDPH
  • ↑ Risk of postpartum neuraxial infection
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25
Q

Labor intrathecal = _____________

A

Spinal analgesia

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26
Q

When will a Continuous Spinal be used?

A
  • Not typically done electively
  • Used after intentional dural puncture with Tuohy needle (“wet tap”)
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27
Q

What are the advantages of a continuous spinal?

A
  • Continuous analgesia
  • Low dose of LA/opioid
  • Rapid onset of analgesia
  • Can use if the patient requires a C-section
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28
Q

What are the disadvantages of a continuous spinal?

A
  • Large dural puncture → PDPH
  • Risk of mistaken identity! (spinal vs epidural catheter).
  • Label this catheter CLEARLY
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29
Q

What are the most commonly used LA in epidurals?

A
  • Bupivacaine
  • Ropivacaine
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30
Q

What causes visceral labor pain?

A
  • Lower uterine segment distention
  • Cervical dilation
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31
Q

What causes somatic labor pain?

A
  • Descent of fetus into the birth canal
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32
Q

What are the advantages of using Bupivacaine as a LA in epidurals?

A
  • Differential block (preserves A-α motor neurons)
  • Long duration of action
  • Lack tachyphylaxis
  • Safe (low toxicity, limited placenta transfer)
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33
Q

What are the disadvantages of using Bupivacaine as a LA in epidurals?

A
  • Slow onset time (10-15 mins, latency improved with a lipophilic opioid)
  • Risk of CV and neurotoxicity
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34
Q

Concentration and dose of bupivacaine is dependent on what factors?

A
  • Provider
  • Practice setting
  • Parturient ht/wt
  • Stage and progression of labor
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35
Q

What is the initial concentration and dose of bupivacaine for an epidural?

A
  • 0.0625 to 0.25%
  • 10-20 mL depending on concentration
  • Lower centration=large volume
  • Followed by a maintenance infusion.
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36
Q

Does Ropivacaine or Bupivacaine have a greater differential sensory-motor blockade?

A

Ropivacaine

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37
Q

What are the advantages of using Ropivacaine as a LA in epidurals?

A
  • Greater differential sensory-motor blockade than bupivacaine
  • Less risk for toxicity than Bupivacaine
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38
Q

What are the disadvantages of using Ropivacaine as a LA in epidurals?

A
  • Slow onset time (10-15 mins, latency improved with a lipophilic opioid)
  • CV and neurotoxicity
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39
Q

What is the initial concentration and dose of ropivacaine for an epidural?

A
  • 0.1-0.2% concentration
  • 10-20 mL depending on concentration
  • Lower concentration = larger volume
  • Followed by a maintenance infusion
40
Q

Why is lidocaine not routinely used for labor analgesia?

A
  • Poor differential block with significant motor involvement
  • Risk of tachyphalaxis
  • Increase placental transfer/ ion trapping
41
Q

When would Lidocaine be used for labor analgesia?

A
  • Identifying non-functional catheter
  • Need for rapid sacral analgesia
  • Instrumented vaginal delivery/ perineal repair
  • Emergent operative delivery
42
Q

Why is 2-chloroprocaine not typically used for labor analgesia?

A
  • Rapid onset = Short duration of action
  • Poor differential blockade
  • Interferes with the action of bupivacaine and opioids
43
Q

When would chloroprocaine be useful?

A
  • Emergent instrumented/ operative delivery/ perineal repair.
  • 2-3% chloroprocaine (10 mL)
44
Q

Opioids can decrease the dose of local anesthetics by _________ % (range).

45
Q

What type of opioid will have a faster onset with neuraxial anesthesia?

What type of opioid will have a slower onset with neuraxial anesthesia?

A
  • Lipophilic, Faster onset (fentanyl, sufentanil)
  • Hydrophilic, Slower onset (morphine)

Despite a slower onset, morphine in epidural can be good for postop pain.

46
Q

What are the benefits of using opioids as an adjuvant agent with LA in epidurals?

A
  • Direct action at spinal/ supraspinal opioid receptors
  • Decrease latency
  • Prolongs duration of analgesia
  • Improves quality of analgesia (more dense/complete block)
47
Q

What are the advantages of using clonidine as an additive for an epidural?

A
  • Analgesic effect
  • ↓ LA requirements
  • Improves block quality/ duration
  • No motor blockade
48
Q

What are the disadvantages of using clonidine as an additive for an epidural?

A
  • Maternal hypotension/ bradycardia
  • Maternal sedation
49
Q

What is the initial dose of clonidine as an additive to an epidural?

A

75-100 mcg

50
Q

What is the optimum dose of dexmedetomidine as an additive to an epidural?

A

0.25-0.5 mcg/kg

51
Q

Effects of dexmedetomidine as an additive to an epidural

A
  • Suppresses C-fiber transmissions
  • Hyperpolarization of postsynaptic dorsal horn neurons
  • ↓ LA requirements
  • Shortens latency
  • Prolongs duration of block
52
Q

What will a higher concentration of dexmedetomidine result in?

A
  • Maternal sedation
  • Anxiolysis
53
Q

Continuous epidural concentration and infusion dosages for Bupivacaine

A
  • 0.05-0.125% Bupivacaine
  • 8-15 mL/hr
54
Q

Continuous epidural concentration and infusion dosages for Ropivacaine

A
  • 0.08-0.2% Ropivacaine
  • 8-15 mL/hr
55
Q

What are the advantages of a PCEA?

A
  • Patient self-administers based on need
  • Significant decrease in repeat dosing by provider
  • Decreased motor blockade
56
Q

What are the disadvantages of a PCEA?

A
  • Pump programming errors
  • Mistake on bolus dose volume
  • Mistake on lockout interval
  • Mistake on background infusion rate
  • Mistake on max allowable dose/hour
  • Non-patient initiated boluses
  • Inappropriate clientele
57
Q

Background infusion benefits

A
  • Better analgesia & increased maternal satisfaction
  • Less attentiveness required by pt
58
Q

Background infusion disadvantages

A
  • Increased total drug dose
  • Increased risk of motor blockade
59
Q

What are the effects of 8-12 mL bolus of LA (+/- opioid) in an epidural?

A
  • Dense motor blockade
  • ↑ Risk of hemodynamic instability
60
Q

What is the spinal/ intrathecal dosing for LABOR based on?

A
  • Provider judgment
  • Hospital/anesthesia dept policy
  • Height of patient/ level of anesthesia required
61
Q

If the intrathecal dose of 0.75% bupivacaine for a 5’6” female requiring a T10 block is 1.7 mL, how much mg of bupivacaine infused in the intrathecal space?

A
  • 12.75 mg of bupivacaine

7.5 mg/mL x 1.7 mL = 12.75 mg

62
Q

What are the effects of opioids used as a solo agent for a spinal?

A

Produce analgesia w/o numbness, motor blockade, and sympathectomy

Opioids are more commly used as an additive to a spinal

63
Q

Opioids will block afferent inputs from what fibers to the spinal cord?

A
  • Myelinated A-δ
  • Unmyelinated C-fibers
64
Q

Will opioids affect efferent impulses?

65
Q

Bupivacaine dosages for spinal anesthesia

A
  • Hyperbaric 0.75% (Less extensive sensory block)
  • Isobaric 0.5% (Longer duration of action)
66
Q

What LA is not typically used for spinal analgesia in the US?

A

Ropivacaine (Isobaric 0.5%)

67
Q

What is the dosage and effect of dexmedetomidine as an additive to spinal analgesia?

A
  • 2.5-10 mcg
  • Decrease latency
  • Prolongs analgesia
68
Q

What is the dosage and effect of epinephrine as an additive to spinal analgesia?

A
  • 2.25-100 mcg
  • Prolongs analgesia
  • Higher doses will result in motor blockade (100-200 mcg)
69
Q

What is the continuous spinal infusion rate of bupivacaine?

A

0.0625 – 0.125% bupivacaine @ 1–1.5 mL/hr

70
Q

What is the continuous spinal infusion rate ropivacaine ?

A

0.1–0.2% ropivacaine @ 1–1.5 mL/hr

71
Q

Post-intervention management of neuraxial anesthesia for labor pain

A
  • Quality of analgesia
  • Progress of labor
  • Sensory level (Ice vs. “Pin Prick”)
  • Intensity of motor blockade
  • Maternal vital signs
  • FHR tracings
  • Patient teaching/managing expectations is very important
72
Q

What can be done if a patient complains of pain with a Continous Labor Epidural (CLE) or a Combined Spinal Epidural (CSE)?

A
  • Intervention based on sensory level and progress of labor
  • Assess location of epidural catheter
  • Fentanyl 50-100 mcg for hotspots
  • 1-2% Lidocaine 5-10 mL
  • 2-3% Chloroprocaine 5-10 mL
73
Q

What can be done if a patient complains of pain with a single shot spinal/ intrathecal?

A
  • Redo intrathecal (Not recommended d/t risk of PDPH)
  • Place epidural & dose per initial CLE guidelines
74
Q

What can be done if a patient complains of pain with continuous spinal?

A
  • Assess location of intrathecal catheter
  • Use spinal/intrathecal dosing guidelines
75
Q

What is the cause of hypotension with neuraxial anesthesia?

A
  • Sympathetic blockade
  • Peripheral vasodilation
  • Increased venous capacitance
  • Decreased venous return
76
Q

If neuraxial anesthesia causes SBP < 90-100 mmHg or 20-30% decrease in baseline SBP (AND/OR FETAL DISTRESS), what is the treatment?

A
  • IV fluid
  • Positioning
  • Vasopressors
77
Q

What is the most common side effect if an opioid is administered during neuraxial anesthesia?

A
  • Pruritus

D/t central mu-receptors
Unrelated to histamine release, benadryl will not help alleviate itchiness.

78
Q

What is the most effective treatment to pruritis d/t opioids?

A
  • Centrally acting mu-receptor antagonist (Naloxone/ Naltrexone)
  • Partial Opioid Agonist- Antagonist (Nalbuine/ Butorphanol)
79
Q

Dose of Naloxone to treat pruritus secondary to opioids.

A

40-80 mcg IV bolus or 1-2 mcg/kg/hr

80
Q

Dose of Naltrexone to treat pruritus secondary to opioids.

81
Q

Dose of Nalbuphine (Nubain) to treat pruritus secondary to opioids.

A

2-5 mg IV bolus

82
Q

Dose of Butorphanol (Stadol) to treat pruritus secondary to opioids.

A

1-2 mg IV bolus

83
Q

How do you prevent dural puncture (wet tap) when performing an epidural?

A
  • ID ligamentum flavum while advancing Tuohy
  • Appreciate probable depth of epidural space (5-6 cm)
  • Advance Tuohy b/t contractions
  • Maintain control of needle-syringe always
  • Clear Tuohy of blood clots
84
Q

What are treatments for a dural puncture?

A
  • Intrathecal cath or replace with epidural cath
  • Do not reinject CSF from syringe – risk for contamination/pneumocephalus
  • Epidural blood patch if headache develops (gold standard) vs. conservative treatment (caffeine, laying down)
85
Q

Why is 0.75% Bupivacaine not available for an epidural block?

A

↑ Risk for CV toxicity

86
Q

What is the most likely cause of intravascular catheter cannulation during an epidural?

A

Engorgement of epidural veins

87
Q

If intravascular catheter cannulation occurs during an epidural, what signs and symptoms will the patient experience if LA is injected?

A
  • Tinnitus
  • Circumoral Numbness
  • Restlessness
  • Difficulty Speaking
  • Seizures
  • LOC
88
Q

What is the treatment for LAST?

A
  • Intralipids (1.5 mL/kg over 2-3 minutes)
  • BZD for seizures
89
Q

Too much medication in the intrathecal space can cause a “high spinal”, what are the signs and symptoms?

A
  • Agitation / dyspnea / inability to speak
  • Profound hypotension → loss of consciousness
  • Apnea
90
Q

Treatments for a High Spinal?

A
  • Assist ventilation
  • Volume resuscitation
  • Vasopressors
91
Q

Where are the Cardioacceleartor Fibers?

92
Q

Pinky and Hand-Numbness will indicate that the LA is at what level?

93
Q

Diaphragmatic paralysis will indicate that the LA is at what level?

94
Q

The sub-dural space is between what two structures?

A

Space between the dura mater and arachnoid mater (extends intracranially)

95
Q

What will be seen with a subdural block?

A
  • Unexpectedly high blockade with patchiness
  • Profound Hypotension
  • Minimal motor blockade (Onset time 10-20 minutes)
  • Cranial > caudal spread
  • May involve cranial nerves (Horner’s syndrome)
  • Apnea / LOC possible
96
Q

What are other side effects and complications of neuraxial anesthesia for labor pains (long list)?

A
  • Delayed gastric emptying if opioids are administered
  • N/V
  • Hypotension
  • Shivering
  • Back pain
  • Excessive motor block
  • Urinary retention
  • Maternal fever
  • FHR abnormalities in 6-8%
  • Meningitis
  • Epidural hematoma/abscess
  • Neuro deficits

Advanced Principles A (17 decks)

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