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Anesthesia Concepts > Upper Regional > Flashcards

Upper Regional Flashcards

1
Q

Advantages: can avoid __ __ if used as primary anesthetic. Reduced opiates (imp for __ and __ __ pts). Avoiding general/intubate imp for pts with __ to __ __ disease and __ disease)

A

General anesthesia
Copd and morbidly obese
Moderate to severe cardiac, pulmonary

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2
Q

Biggest advantage of blocks

Other advantages: reduced __. Improved __ __

A

Reduced post op pain

PONV, PT

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3
Q

Disadvantages

Risk for __ and __ damage, risk for __, risk of __ __ __

A

Nerve and vessel, infection, local anesthetic toxicity

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4
Q

Contraindications: __ __ most imp. Inability to __ __. Inability to __. __ complications, need to __

A

Pt refusal
Follow directions
Coagulate
Neurologic, document

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5
Q

Contraindications
__ at site
___
Lack of __, __, and __

A

Infection
Septicemia
Time, prep, experience

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6
Q

MS MAIDS stands for in preparation

A 
Means of PPV 
Suction
Monitors
Airway
IV access
Drugs
Special equipment
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7
Q

Drugs needed

A

Emergency drugs, lipid rescue, sedation drugs

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8
Q

Lipid rescue initial focus:
__ management
___ suppression. __ preferred, avoid __ if having CV instability
Alert nearest facility having __ __ capability

A

Airway
Seizure, benzos, Propofol
Cardiopulmonary bypass

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9
Q

Lipid rescue: management of cardiac arrhythmias
__ and __
Avoid __, __ __ __, __ __, or __ __
Reduce individual __ doses to

A

Bls and acls
Vaso, ca channel blockers, beta blockers, local anesthetic
1

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10
Q

Lipid rescue: lipid emulsion 20% therapy
Bonus __ml/kg over __ __ about __ mls
Continuous at __ml/kg/min about __ml/min
Repeat bolus once or twice for consistent __ __
Increase infusion to __ml/kg/min if __ remains low
Continue infusion for at least __ minutes before attaining cv stability
Recommended upper limit: __ml/kg over first __ minutes

A

1.5, 1 minute, 100
0.25, 18
Cardiovascular collapse
0.5, BP
10
10, 30

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11
Q

Steps: gather __, __, and __ check
Draw up __ __, __ and __
Meet pt, ___ discussed, __ __, and __
Verify __ and __

A

Supplies, equipment, safety
Local anesthetic, adjuncts, anxiolytics
RBA, consent signed, IV
Site and initial

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12
Q 
Next steps:
\_\_ and \_\_ on pt 
\_\_ \_\_ performed 
\_\_
Perform \_\_ and \_\_
\_\_ pt until \_\_ to \_\_
A 
O2 and monitors 
Time out 
Sedate
Block, document 
Monitor, roll back, or
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13
Q

Procedure varies with

A

Location

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14
Q

Usual settings nerve stim
Decrease to __ma after nerve response localized
Nerve response

A

1 ma, 0.1 ms, 2 hz

  1. 5, withdraw
  2. 3-0.5
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15
Q 
Local that is long and most common 
Local that is long acting 
Local that is short acting 
Shortest acting local 
Very long local
A 
Ropivicaine 0.5%
Bupivicaine 0.5-0.75%
Mepivicaine 1.5%
Lidocaine 1-2%
Liposomal bupivicaine
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16
Q

Epi mainly used as a __ __. Epi will increase HR > __bpm

Concentrations of epi in local

A

Vascular marker, 10

1: 200,000
1: 400,000

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17
Q

Clonidine: __ __.

Use __-__ mcg/30 ml of local. What it does

A

Alpha agonist, 75-100, prolongs block for hours

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18
Q

Buprenorphine: __ __ __-__

Added to local for what

A

Mixed opioid agonist antagonist

Prolongs duration of action of local

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19
Q

Decadron. Add __mg to 30 ml of local. What it does

A

4, can prolong block for up to 10 hours

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20
Q

Linear probe shows __ structures
Curved probe has __ penetration

Hypoechoic= \_\_ and examples
Hyperechoic= \_\_ and examples
A

Shallow
Deeper

Black. Nerves, blood, fluid, air
White. Bone, nerves, vascular walls, connective tissue

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21
Q

Ultrasound can reduce __ to perform block, may use less __ of local anesthetic

Ultrasound vs nerve stim overall

A

Time, volume

No clear advantage in block effectiveness of either

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22
Q

What is raj test

A

Injecting 1 ml of local, should terminate muscle twitch

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23
Q

Repeat aspiration how often

A

Every 5 ml

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24
Q

What is the best monitor while injecting LA

A

Patient

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25
Q

Musculocutaneous reached which branches

A

C5,6,7

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26
Q

Axillary reaches which branches

A

C5,6

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27
Q

Radial reaches which branches

A

C6,7,8, T1

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28
Q

Median reaches which branches

A

C7,8,T1

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29
Q

Ulnar reaches which branches

A

C8,T1

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30
Q

Musculocutaneous nerve
Where it exits sheath: __ in the __, __ muscle
Motor for 3 to __ forearm
Sensory __ from __ to __

A

High in axillary, coracobrachialis
Biceps, brachial is, coracobrachialis
Flex
Lateral from elbow to wrist

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31
Q

Which nerve spared with an axillary nerve block

A

Musculocutaneous nerve

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32
Q

Axillary nerve
Leaves plexus at __ __ of __ muscle
Motor: 2 muscles
Sensory: __ __ and __ __ arm

A

Lower border of pectoralis
Deltoid and teres minor
Inferior shoulder, upper lateral

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33
Q

Radial nerve
Motor to 3
Sensory to __ arm and __. __ border of the __. __ and __ surface of the __

A

Posterior, forearm
Lateral, elbow
Thumb and dorsal, hand

34
Q

Median nerve
Motor: __ and __ muscles of __ and wrist __
Sensory: __ surface of __, __, and __ fingers
__ of thumb, index, and __ fingers

A

Flexor and pronation, forearm and flexion

Palmar, hand, index, middle. Tips, middle

35
Q

Ulnar nerve
Motor: this muscle which __ __
Sensory: __ __ and __ __ fingers

A

Flexor carpi ulnaris, abduct fingers

Little finger and medial ring

36
Q

Less common blocks 3

A

Bier block, wrist block, and touch up blocks

37
Q

Inter scalene block
Ideal for surgery of __ and __ __
___ sparing. Don’t use for procedures __ __

A

Shoulder, upper arm

Ulnar, below elbow

38
Q

Inter scalene contraindications
Absolute 2
Relative 2

A

Contra lateral recurrent laryngeal nerve palsy, phrenic nerve palsy

Brachial plexus pathology, impaired pulmonary function

39
Q

Inter scalene approach
Palpate__ border of SCM at level of __
Roll fingers __ palpated groove between __ and __ scalene

A

Posterior, c6

Posterior, anterior and middle

40
Q 
Inter scalene nerve stim 
Insert needle in \_\_ direction 
Twitch of \_\_ or \_\_ \_\_ 
How many ml LA
How deep
A

Caudad
Bicep, distal hand
30
1-2 cm

41
Q

Phrenic nerve often blocked with which block, what it leads to

A

Interscalene, hemidiaphragm paralysis

42
Q 
Ultrasound inter scalene 
Look for \_\_ nerve and \_\_ \_\_ sign 
Needle inserted \_\_ and \_\_ \_\_ 
Aim between \_\_ and \_\_ trunks 
\_\_ml inject
A

Hypoechoic, stop light
Lateral, in plane
Superior and middle
20

43
Q 
Interscalene complications 
\_\_ \_\_ most common. 3 signs 
\_\_ \_\_ \_\_ common
\_\_ \_\_ \_\_ block, rare, leads to \_\_ 
\_\_ injection rare 
\_\_/\_\_ injection and \_\_ rare
A 
Horners syndrome: ptosis, anhydrosis, mitosis 
Phrenic nerve block 
Recurrent laryngeal nerve, hoarseness
IV 
Subarachnoid, epidural 
Pneumothorax
44
Q

Supra clavicular block
Blocks __, __, and __ __
Carried out at __/__ level of brachial plexus
Can cover __ and __ nerves if done properly

A

Hand, forearm, upper arm
Trunk/division
Ulnar and radial (inferior trunk)

45
Q

Contraindications supra clavicular block
__ __ pathology
__
__

A

Brachial plexus
Pneumothorax
Coagulopathy

46
Q 
Suprascapular with nerve stim 
Look for \_\_ border of \_\_ head of SCM 
Identify groove between \_\_ muscles 
Needle inserted \_\_cm from \_\_-\_\_
Needle directed towards\_\_ away from \_\_
A

Lateral, clavicular
Scalene
1, mid clavicle
Axillary, midline

47
Q

Supra clavicular nerve stim
Motor response in __ or __. More distal response =
Depth
Motor response still at __ or less, inject
Volume

A

Hand, arm. More reliable block
2-4 cm
0.5 ma
30-40 ml

48
Q

Supra clavicular ultrasound
Probe over __ __
Visualize __ artery and plexus __ and __
Probe __ __

A

Supra clavicular fossa
Subclavian, lateral, superior
In plane

49
Q 
Complications supra clavicular 
\_\_ most associated with this block 
Sudden \_\_ and \_\_
\_\_ puncture 
\_\_ of \_\_ 
\_\_\_ \_\_
A 
Pneumothorax 
Cough and sob 
Vascular 
Hemiparesis of diaphragm 
Horners syndrome
50
Q

Phrenic nerve c__-__

A

3-5

51
Q 
Infraclavicular 
Used for procedures \_\_ to \_\_ 
Block is at level of \_\_ 
Nerves not as compact, increased \_\_ 
\_\_ risk of pneumo 
Blocks all \_\_ \_\_
A 
Distal, elbow 
Cords
Time to onset 
Decreased
Terminal branches
52
Q 
Infra clavicular w nerve stim 
\_\_ \_\_ and \_\_ arm 
\_\_ cm \_\_ and \_\_ cm \_\_ from \_\_ process
Needle direction is toward \_\_ pulse 
Needle: \_\_, \_\_ bevel, \_\_cm
A

Externally rotate, abduct
2 medial, 2 caudad, coracoid
Axillary
Insulated, b, 10

53
Q

Infra clavicular w nerve stim
Look for __/__ __ or __
If __ stim, needle too lateral
Volume

A

Finger or thumb extension or flexion
Bicep
30-40 ml

54
Q 
Infra clavicular ultrasound 
\_\_-\_\_mhz, \_\_ frequency 
Place probe \_\_ to clavicle 
Visualize \_\_ artery
Observe \_\_ and \_\_ cords, \_\_ if possible 
Direct needle to \_\_ cord
A 
5-12, high 
Inferior 
Axillary 
Lateral and posterior, inferior 
Posterior
55
Q

Infra clavicular ultrasound
Needle angle is __
Target __ cord first then __ cord
How much volume

A

Steep
Posterior, medial
15 at post 15 at medial

56
Q

Infra clavicular ultrasound
__ __ maneuver- disappears clavicle from ultrasound window
Leads to more __ angle of needle

A

Houdini clavicle

Shallow

57
Q

Infra clavicular complications
Puncture of __ __ and __. __-__ region
Risk of __ low

A

Axillary artery and vein. Non compressible

Pneumo

58
Q 
Axillary block 
_ \_\_ of plexus blocks 
Ideal for \_\_ or \_\_ surgery. Distal to \_\_ 
Blocks \_\_, \_\_, and \_\_ nerves 
\_\_ nerve requires separate block
A

Least risk
Hand or forearm, elbow
Ulnar, radial, median
Musculocutaneous

59
Q 
Nerve stim axillary block 
Arm \_\_ and \_\_ rotated 
Palpate \_\_ \_\_ 
Needle \_\_g, \_\_cm, \_\_ bevel 
Volume
A

Abducted and externally
Axillary artery
22, 4, b
30

60
Q

Axillary nerve stim
Insert __ or __ artery at __ degree angle
Observe for __ or __ __
Decrease to __ma or __

A

Above or below, 45
Finger or thumb flexion
0.5 or less

61
Q

Mcn block
Pull ___ __
Set to __ ma
Advance needle into __ until rigorous __ contraction

A

Biceps laterally
2
Coracobrachialis, bicep

62
Q

Transarterial axillary block

Needle __ g __ cm __ bevel or __g __in

A

22, 4, b, 26, 1/2

63
Q

Transarterial axillary block

  1. Palpate __ and maintain __ pressure
  2. Insert needle into artery, aspirate blood
  3. Advance needle until __ __
  4. Inject __-__ ml
  5. __ needle
  6. Maintain pressure for __ min
A

Artery, distal, flow stops

30-40, withdraw, 5

64
Q 
Axillary ultrasound 
Probe: \_\_ frequency, \_\_
1. \_\_, arm \_\_ to \_\_ degrees
2. Visualize \_\_ and \_\_ nerves
3. Insert needle in plane 
4. Can use \_\_ \_\_ at same time 
5. Deposit \_\_ ml on \_\_ \_\_ or \_\_ ml in one injection 
6. Visualize \_\_, deposit \_\_ ml
A

High, linear

  1. Supine, abducted, 90
  2. Artery, hypoechoic
  3. Nerve stimulator
  4. 10, each nerve, 30
  5. Mcn, 10
65
Q 
Axillary complications
\_\_\_ \_\_
\_\_ 
\_\_ injection 
If arterial puncture:
A

Vascular puncture
Hematoma
IV injection

Convert to transarterial approach

66
Q

Bier block
Advantages: ideal for __ or __ cases that are under __ minutes
How it’s performed

A

Hand or forearm, 60

Without ultrasound or nerve stim

67
Q 
Bier block disadvantage 
Doesn't work if \_\_ \_\_
Limited block \_\_\_
Tourniquet \_\_
\_\_ \_\_ \_\_ risk
A

Obese arms
Duration
Pain
Local anesthetic toxicity

68
Q

Bier block

  1. __ placed in hand
  2. Arm is ___
  3. Inflate __ tourniquet
  4. __ __
A

Distal IV
Exsanguinated (elevated and wrap in esmarch bandage)
Proximal
Unwrap esmarch

69
Q

Bier block

  1. Verify no __ __ via __ __
  2. Inject __-__ ml of __% __ with no __ into IV
  3. Onset __-__ min
  4. Hold tourniquet for __ min to prevent toxicity
  5. Slowly deflate cuff
A

Arterial flow, pulse ox
25-50, 0.5% lidocaine, epi
5-10
30 min

70
Q

How to make 0.5% lidocaine

Inflate tourniquet above

A

Mix 25 ml of lidocaine 1% with 25 ml nacl to yield 50 mls

Arterial blood pressure

71
Q

Block eval

How to test: radial nerve

A

Push, arm extension

72
Q

How to test mcn nerve

A

Pull, arm flexion

73
Q

How to test median nerve

A

Pinch index finger

74
Q

How to test ulnar nerve

A

Pinch little finger

75
Q

Sympathectomy leads to vein __

A

Dilation

76
Q

Superficial cervical plexus block

Used for __ procedures of the __ and for __ __

A

Unilateral, neck,

Carotid endarterectomy

77
Q

Suprascapular nerve block

Used for what

A

Posterior shoulder pain

78
Q 
Inter scalene block
Part of plexus
Volume 
Indications
\_\_ sparing, \_\_
A

Roots/trunks
20-30
Shoulder
Ulnar sparing and shallow

79
Q 
Supra clavicular block 
Brachial plexus 
Volume 
Indications
Notes
A

Trunks/divisions
20-30
Upper, lower arm and hand
Ultrasound best, pneumo risk

80
Q 
Infra clavicular block 
Brachial plexus 
Volume 
Indications 
Notes
A

Cords
30 ml
Upper, lower arm and hand
Houdini clavicle

81
Q 
Axillary block 
Brachial plexus 
Volume 
Indications 
Notes
A

Branches
30 ml
Forearm and hand
Transarterial

82
Q 
Bier block 
Brachial plexus 
Volume 
Indications 
Notes
A

Branches
50 ml
Forearm and hand
Failure rate and LA toxicity

Anesthesia Concepts (12 decks)

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