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614 General Principles Of Anesthesia > Week 12 Spinals, Epidurals, and Locals > Flashcards

Week 12 Spinals, Epidurals, and Locals Flashcards

1
Q

Spinal and epidural are considered ________ _________.

A

Neuraxial Blocks

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2
Q

In the history of epidural anesthesia, what occurred in the 1950s?

A
  • Popularized epidural anesthesia in the 1950s
  • Touhy Needle introduced in 1949
  • Lidocaine available in 1950s
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3
Q

In the history of epidural anesthesia, what occurred in the 1960s?

A

By the 1960s it was popular amongst the obstetric population

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4
Q

Today neuraxial blocks are widely used for:

A
  • Labor analgesia;
  • Caesarian section;
  • Orthopedic procedures;
  • Perioperative analgesia
  • Chronic pain management

(He said even Urology cases)

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5
Q

Neuraxial blocks in anesthesia use (3)

A
  • Alternatives to general anesthesia

or

  • Used simultaneously with general anesthesia

or

  • afterward for postoperative analgesia.
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6
Q

Neuraxial techniques have proven to be safe when well managed. However, the is still risk of complications ranging from:

A
  • self-limited back soreness to debilitating permanent neurological deficits and even death
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7
Q

Benefits of neuraxial blocks:

A

Reduce the incidence of:

  • Venous thrombosis & pulmonary embolism
  • Cardiac complications in high-risk patients
  • Bleeding & transfusion requirements & vascular graft occlusion
  • Pneumonia & respiratory depression following upper abdominal or thoracic surgery in patients with chronic lung disease
  • An earlier return of gastrointestinal function
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8
Q

Epidural is the reversible chemical blockade of ________ ________ produced by the injection of a LA drug into the epidural space

A

neuronal transmission

It interrupts transmission of sensory, autonomic, and motor nerve fiber transmission in the anterior and posterior nerve roots

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9
Q

Epidural anesthesia interrupts transmission of sensory, autonomic, and motor nerve fiber transmission in the _______ and _______ nerve roots.

A

anterior;

posterior

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10
Q

More benefits of epidural anesthesia:

  1. Avoidance of larger doses of anesthetics and opioids
  2. amelioration of the _________ state.
  3. improved oxygenation from decreased splinting.
  4. enhanced ___________ (Hint: GI).
  5. suppression of ________ _________ response to surgery.
  6. ______-______ increases in tissue blood flow.
A

hypercoagulable

peristalsis

neuroendocrine stress

sympathectomy-mediated

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11
Q

Epidural benefit:

Reduction of parenteral opioid requirements, which decreases – (4)

A
  • Atelectasis
  • Hypoventilation
  • Aspiration pneumonia
  • Reduction of ileus duration
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12
Q

Postoperative epidural analgesia reduces the time to __________; and preserves _________ reducing cancer spread according to some studies

A

Extubation;

Immunity

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13
Q

Benefits of epidural anesthesia in OB:

A
  • Widely used for women in labor and during vaginal delivery.
  • C-sections are most performed under epidural or spinal anesthesia: both blocks allow a mother to remain awake for the birth of her child.
  • Some studies show it is less maternal M&M than GETA (largely d/t incidence of aspiration and failed intubation)
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14
Q

Epidural Anesthesia advantages:

A
  • Predictable
  • Can provide a segmental blockade
  • Reduce risk of thrombosis
  • PT can remain fully conscious
  • Analgesia into the post-operative period
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15
Q

Epidural Anesthesia
disadvantages:

A
  • May require 10-20 minutes to establish a level
  • Sympathetic blockade
  • Surgeon complains “It takes to long”
  • Time-consuming to perform
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16
Q

Vertebral column is made up of ____ Vertebrae

Cervical:
Thoracic:
Lumbar:
Sacral:
Coccygeal:

A

33

Cervical: 7 (C1-C7)
Thoracic: 12 (T1-T12)
Lumbar: 5 (L1-L5)
Sacral: 5 fused (S1-S5)
Coccygeal: 4 fused to form the coccyx

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17
Q

T/F: Vertebrae differ in shape and size at the various levels

A

True

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18
Q

____ cervical vertebra (_______)- lacks a body and has unique articulations with the base of the skull

A

1st

atlas

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19
Q

______ cervical vertebra (_______)- has atypical articular surfaces

A

2nd

axis

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20
Q

All _______ thoracic vertebrae- articulate with their corresponding _______.

A

12;

Rib

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21
Q

_______ vertebrae- have a large anterior cylindrical body

A

Lumbar

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22
Q

When all vertebrae are stacked vertically the hollow rings become the ________ _______ (where the cord and its coverings sit)

A

spinal canal

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23
Q

Individual vertebral bodies are connected by :

A

intervertebral disks

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24
Q

Spinal Ligaments- (superficial to deep):

A
  1. Supraspinous
  2. Interspinous
  3. Ligamentum flavum
  4. Posterior longitudinal
  5. Anterior longitudinal
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25
Q

The spinal canal contains the cord with:

A
  • coverings (meninges)
  • fatty tissue, and
  • venous plexus
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26
Q

Meninges- 3 layers:

A
  • pia mater,
  • arachnoid mater and
  • dura mater (contiguous with cranial counterparts)
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27
Q

meninge closely adherent to the spinal cord

A

Pia mater

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28
Q

meninge closely adherent to the thicker and denser dura mater

A

Arachnoid matter

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29
Q

Where is the CSF contained?

A

contained between the pia and arachnoid mater in the subarachnoid space

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30
Q

where is the Epidural space (potential space)?

A

within the spinal canal bounded by the dura and the ligamentum flavum

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31
Q

The spinal cord extends from the ____ to the _____ in adults.

and in children?

A

Extends from the foramen magnum to the level of L1 in adults

In children the spinal cord ends at L3 and moves up with age

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32
Q

Lower spinal nerves form the :

A

cauda equina (horse’s tail)

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33
Q

Performing lumbar (subarachnoid) puncture below L1 in adults and L3 in children usually avoids potential needle trauma to the cord; damage to the _______ _________ unlikely

A

cauda equina

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34
Q

MOA of neuraxial blockade:

A

Interruption of efferent autonomic transmission at the spinal nerve roots

Sympathetic Blockade

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35
Q

The physiological responses of neuraxial blockade

S/S:

A

decreased sympathetic tone/ unopposed parasympathetic tone.

drop in BP
decrease in HR
arterial vasodilation- decreased SVR

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36
Q

As a primary anesthetic, neuraxial blocks are most useful in:

A
  • lower abdominal
  • inguinal
  • urogenital
  • rectal
  • lower extremity surgeries
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37
Q

Upper abdominal procedures such as gastrectomy have been performed with spinal or epidural anesthesia- but:

A

can be difficult to safely achieve adequate sensory levels for patient comfort

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38
Q

T/F: Epidurals are good choice for patients with coexisting pulmonary disease.

A

True :)

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39
Q

Pre-op considerations for neuraxial blocks:

A
  • Discuss the plan with the surgeon.
  • Discuss the proposed surgery and explain the epidural technique in detail.
  • Do not coerce the patient into an epidural anesthetic
  • Do a full pre-operative assessment and interview
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40
Q

Most important pre-op labs to have before epidural procedure?

A

Coags!!! Specially platelets

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41
Q

Informed consent for neuraxial block considerations:

A
  • Make sure you document that you have discussed the advantages & disadvantages of the anesthetic
  • Discuss risk
  • GA is plan B
  • Document
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42
Q

Pre-op meds considerations for neuraxial blocks:

A
  • Pt should be NPO
  • Do not over-sedate the patient
  • OB patients are not sedated
  • Midazolam (titrate to effect)
  • Opioids
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43
Q

Epidural is indicated for (6)

A
  • “balanced” regional/general anesthesia
  • Pt has a full stomach
  • Upper airway anomalies
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44
Q

Contraindications for neuraxial blocks: absolute

A

Epi I RAP CHICAS

  • I nfection at the site
    |
  • R efusal from patient.
  • A ortic/mitral stenosis or asymmetric septal hypertrophy
  • P sychiatric disease - Severe
    |
  • C oagulopathy
  • H erpetic infection
  • I ncreased ICP
  • C NS disease - Preexisting
  • A llergy to LA
  • Septicemia or bacteremia
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45
Q

Contraindications for neuraxial blocks: relative

A

my Epi Relatives love CHOC MUSH

  • C lotting/blood abnormalities (Minor) ( ASA or mini heparin doses / Check coags ).
  • H A (chronic) or backache
  • O besity/ deformities of the spinal column
  • C hronic HTN (Untreated)
  • M ultiple attempts
  • U mbilicus - surgeries above it.
  • S urgery of unknown duration
  • H IV infections
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46
Q

Neuraxial Block patient preparation:

A
  • Baseline VS & Pt must have an IV
  • Standard monitors
  • Equipment to provide positive pressure ventilation
  • Supportive meds
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47
Q

In the history of epidural anesthesia, what occurred in the 1950s?

A
  • Popularized epidural anesthesia in the 1950s
  • Touhy Needle introduced in 1949
  • Lidocaine available in 1950s
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48
Q

Benefits of epidural anesthesia in OB:

A
  • Widely used for women in labor and during vaginal delivery.
  • C-sections are most performed under epidural or spinal anesthesia: both blocks allow a mother to remain awake for the birth of her child.
  • Some studies show it is less maternal M&M than GETA (largely d/t incidence of aspiration and failed intubation)
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49
Q

In an epidural midline approach - what layers do you penetrate with needle?

A
  • Skin
  • Subcutaneous tissue and fat
  • Supraspinous ligament
  • Interspinous ligament
  • Ligamentum flavum
  • Epidural space
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50
Q

For an epidural you palpate the patient’s back to find the:

and which sites do you use?

A

Superior aspects of the iliac crest and the spinous process
L4 or L4-5

Use the largest and most superficial interspace you can find
L2-3

(according to VP- we use L4 - L5)

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51
Q

Draw up the LA to be used for the skin wheal in a _____ ml ______ syringe

Draw ______ ml of preservative free saline into the ____ ml _______ syringe

A

3; plastic

2-3; 5ml glass

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52
Q

In an epidural: Raise a skin wheal with the ______ -gauge needle

A

27

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53
Q

Ligamentum flavum is normally _____ cm from the skin

A

4 cm

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54
Q

In an epidural paramedian approach - what layers do you penetrate with needle?

A
  • Skin
  • Subcutaneous tissue and fat
  • Paraspinous muscle
  • Ligamentum flavum
  • Epidural space
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55
Q

With the Paramedian technique how do you point the needle?

A

Direct needle medially and cephalad

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56
Q

Touhy Needle (Epidural needle) characteristics:

A
  • 3.5 inches long
  • 17-18 gauge
  • With inner stylet: prevents occluding the lumen with tissue.
  • with rounded tip: prevent puncture of the dura and easier to thread the catheter
  • Markings along the shaft of the needle are in 1 cm increments
  • 9 cm from the tip of the needle to the proximal edge of the hub
  • 11 cm to the distal edge of the hub
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57
Q

Markings on the Epidural Catheter

1st. marking= _______ cm

Each marking after that is _____ cm

2nd double marking= _____cm

Thick mark is ______cm.

3rd triple mark is _______cm.

A
  • 1st marking= 5 cm
  • Each marking after that is 1 cm
  • 2nd double marking= 10 cm
  • Thick mark is 11 cm

When inserted to this point you are at the tip of the needle in the epidural space

  • 3rd triple mark= 15 cm

Single hole at the end vs multiple ports on its distal side

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58
Q

Skin to Epidural Space:

_______ cm in 60% of patients

_______ cm in 25% of patients

_______ cm in 10% of patients

> ________ cm in 5% of patients

A
  • 4-6 cm in 60% of patients
  • 2-4 cm in 25% of patients
  • 6-8 cm in 10% of patients
  • > 8 cm in 5% of patients
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59
Q

Usually leave _____ cm of the catheter in the epidural space.

A

3-4 cm

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60
Q

Things to keep in mind with the epidural catheter: (4)

A
  • When advancing the catheter, the patient may feel transient paresthesia
  • Catheter may puncture the dura and you will get CSF (may not aspirate CSF).
  • Be careful removing the needle with the catheter.
  • An antibacterial filter is attached to the end of the catheter
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61
Q

T/F: A negative aspiration ensures you are not in a vessel or the subarachnoid space

A

False! - it does NOT

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62
Q

Test dose for epidural

and

what level of block would be produced if inadvertently injected in CSF?

A

3 ml of 1.5-2% Lidocaine with 1:200,000 epinephrine

This dose will only produce a T10 block if injected in the CSF

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63
Q

What should you ask a patient during a test dose?

A

to report symptoms of “feeling different, ringing in the ears or metallic taste in the mouth”

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64
Q

During test dose, if it is an intravascular injection what symptoms would you see?

A
  • Increase in HR of 15-20 bpm for 2-3 minutes
  • Systemic toxicity- numb tongue, dizziness, ringing in the ears
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65
Q

During test dose, if it is a subarachnoid injection what symptoms would you see?

A

Immediate onset of sensory and motor block in the buttocks and lower extremities (T10 block)

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66
Q

During test dose, if injection is in the subdural what would happen?

A

Produces a High block

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67
Q

T/F onset of epidural is faster than the spinal

A

False - Epidural onset takes longer (~10- 20 mins)

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68
Q

Evaluation of patient after an epidural involves:

A
  • After repositioning evaluate patient for 10-30 minutes
  • Measure BP every minute for the first 3-5 minutes then every 2-3 minutes until the block is set.
  • Determine the level of blockade every 2-3 minutes with an alcohol sponge and then a sharpened device until the level is set.
    Check level every 30-45 minutes
  • Evaluate BP, ECG, and pulse ox
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69
Q

The distribution of the LA in the epidural space is dependent on:

A

the volume injected

Positioning will not aide in distribution of the local

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70
Q

The primary objective of the epidural is to block the_________ fibers located in the ______ _______.

A

afferent;

dorsal roots

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71
Q

Site of action of Local:

A
  • Ultimate target are the spinal nerves & roots
  • The dura serves as a barrier to diffusion of Local
  • Most is absorbed into the circulatory system some will stay in the epidural space and the rest will enter the spinal nerves and nerve roots
  • The Local will spread horizontally and longitudinally once in the epidural space
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72
Q

Distribution of the LA

Blockade of fibers occurs quickly.
Blockade is ___ __________ higher than sensory

A

2 dermatomes

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73
Q

Distribution of the LA in epidural:

  1. A quick drop in BP may be an early sign that a “_________” is setting up.
  2. Rapid decrease in BP cause :
  3. These effects will be accentuated in which patients:
A
  1. spinal;
  2. nausea or dizziness.
  3. hypovolemic pt’s

Cardioaccelator fibers

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74
Q

Distribution of the LA in epidural:

Temperature & Light Touch

A
  • Unmyelinated C & myelinated A-delta fibers.
  • Loss of these follows autonomic blockade.
  • Assess with Alcohol sponge
  • Loss of temperature correlates with sensory loss
  • May report lower extremity feels warm
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75
Q

Distribution of the LA in epidural:

Initial Motor Impairment & Touch

A
  • Myelinated A-beta & A-gamma.
  • Follows loss of temperature and touch discrimination
  • Onset of motor weakness and impaired perception of strong tactile stimulation
  • Use a sharpened device or pinch method to assess level
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76
Q

Distribution of the LA:

Profound Motor & Proprioception

A

Myelinated A-alpha fibers

Profound motor block develops with loss of proprioception

Feel “Phantom Limb”

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77
Q

How to Assess motor block:

A

Lift shoulders of the bed (T6-T12)

Raise knees (L2-3)

Flex toes (L4-L5)

Dorsiflex feet (S1-S2)

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78
Q

Epidural Desired Level of Block
Will be determined by:

A
  • The volume and concentration of drug.

and

  • The level of the epidural catheter placement.
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79
Q

Injection of 10-15 ml of LA into the epidural space in the lumbar area will produce a ___________ level in the average sized patient

A

T7-9

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80
Q

What is an inadequate block and what can you do?

A

The concentration or volume of the drug may have been too weak to penetrate spinal nerves

If the block does not reach the desired level, you can give a top off dose:
- One-half of the initial volume can be reinjected

  • Wait 10-15 minutes before reinjection
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81
Q

_________ is the key factor in the height of the block (in epidurals)

A

Volume

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82
Q

The guideline for dosing an epidural in adults is _________ ml per segment to be blocked.

Adjust the guideline for shorter patients (______ in.) or taller patients (__________in.).

A

1 - 2;

< 5 ft. 2;

> 6 ft. 2

’“**T10 block from L3-4 injection: 6-12 ml of local anesthetic. **

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83
Q

Epidural:

The ______, _______, and _______ _______ administered will vary with the level and duration of block desired.

A

The type, volume, and total dose

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84
Q

LA drugs reversibly interrupt nerve impulse conduction by interfering with_________ conductance.

A

sodium ion

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85
Q

Local Anesthetic
Potency

A
  • Equal to lipid solubility
  • Higher lipid soluble, the more readily it penetrates neuronal membranes
  • Better able to penetrate A-alpha motor fibers
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86
Q

Local anesthetic
Rate of onset:

A
  • Determined by pKa
  • Weak bases
  • pKa near physiologic ph will move more readily into nerve membranes

The neutral (non-ionized) form is most readily able to penetrate the neuronal membrane

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87
Q

Local anesthetic
DOA:

A
  • Determined by potency and protein binding
  • Highly protein-bound agents are less available for systemic absorption
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88
Q

Most common LAs:

A
  • Bupivacaine (Marcaine)
  • Ropivacaine
  • Lidocaine
  • Mepivacaine
  • 2-chloroprocaine
89
Q

Distribution and Uptake of LA

The spinal nerves in the epidural space are larger and covered by _______ and ______ matter.

It takes ________ times the dose (mass) of LA to accomplish the same blockade as a spinal

A

arachnoid; dura

6-8

90
Q

what three factors influence the level of DOA of LA in an epidural?

and which has biggest influence of level of blockade

A
  1. volume: larger = greater vertical spread.
  2. dose: increase= intense analgesia/ prolonged DOA.
  3. concentration: increase= faster onset/ more intense block

___________________

Volume

91
Q

Vasoconstrictors such as Epinephrine can help:

A

Be a marker for intravascular injection

Prolong duration of action of Locals

92
Q

effect of vasoconstrictors on the DOA of LA

A

prolong

93
Q

epi in LA is usually a __________ dose

A

1:200,000

94
Q

The closer the injection site is to the spinal nerve to be blocked, the _______ rapid the onset of analgesia

A

more

95
Q

Slowly titrate LA into the epidural space ( _____ ml increments every _____`)

Pt. may complain of?

A

3-5ml every 60 seconds.

Headache (HA)

this does not detect intravascular injection

96
Q

T/F: **level and duration of action? (For epidurals)

  1. Patient position does NOT affect it.
  2. Extremes of age affects spread.
  3. Height does not affect the dose.
A

True :)

False

True

97
Q

for epidural LA dose, what would you do for each population

elderly
obese
Parturient

A

E- half dose
O- decrease d/t larger cephalad spread
P- 1/3 dose needed from non-pregnant (d/t engorgement of epidural veins/ hormones).

98
Q

If the pt. has an adequate level but not a solid block, redose with a top-up dose or

A

20% of the initial volume

During the anesthetic do not allow the level of blockade to recede

99
Q

If the pt. has an adequate level but not a solid block and they are redosed, what will happen to the intensity and height of the block

A

intensity increase

height remains the same

100
Q

if epidural level has regressed 1-2 dermatomes, redose with:

A

1/2 to 1/3 initial volume.

101
Q

Dermatome level for C- section:

A

T4 level ( nipple area )

102
Q

Dermatome level for knee or hip sx:

A

T10 ( umbilicus )

103
Q

Dermatome level that is considered dangerous area:

A

C4- C5, *even T1 ( Cardiac accelerators ).

104
Q

CNS S/S of LA toxicity (7)

A

Nobody Drinks Like Drew Drinks Vodka And Club

  1. numbness of tongue and lips
  2. dizziness
  3. lightheadedness
  4. disorientation
  5. drowsiness
  6. visual & auditory disturbance
  7. convulsions
105
Q

CV S/S of LA toxicity (3)

A
  1. ecg changes
  2. CV depression
  3. cardiac arrest
106
Q

what is it called when an intended epidural is given into spinal space

A

high spinal and its very dangerous

107
Q

treatment for CV collapse from LA toxicity

A

IV 20% lipid emulsion

108
Q

in LA toxicity, what 4 meds should be avoided

A
  1. vasopressin
  2. Ca2+ channel blocker
  3. beta-blocker
  4. LAs
109
Q

spinal are the reversible chemical blockade of neuronal transmission produced by injection of a LA into CSF contained in the _______

A

subarachnoid space

110
Q

t or F: the advantages of spinals are similar to epidurals

A

T

only differences is the smaller dose of LA = less toxicity

111
Q

spinals produce a (sympathetic/parasympathetic) blockade 100% of the time, which can cause?

A

sympathetic

hypotension

112
Q

what can be given prophylactically for a spinal

A

phenylephrine

113
Q

T or F: spinal anesthesia is a good choice for major intraabdominal procedures

A

F- not a good choice

Good choice for procedures of the mid to lower abdomen and lower extremity

114
Q

in pts with pulmonary disease, spinal level should not exceed what level

A

T4

115
Q

T or F: spinal anesthesia is a good choice for major intraabdominal procedures

A

F- not a good choice

116
Q

9 absolute contraindications for spinal

A
  1. pt refusal
  2. severe psych disease
  3. CV disease
  4. severe hypovolemia
  5. CNS disease
  6. blood clotting anomalies
  7. infection at site
  8. septicemia/bacteremia
  9. allergy to LA
117
Q

10 relative contraindications of spinal

A
  1. HIV
  2. Surgery of unknown duration
  3. untreated chronic HTN
  4. procedure above the abdomen
  5. obesity
  6. deformity of spinal column
  7. chronic HA/backache
  8. bloody tap
  9. multiple attempts
  10. minor blood clotting abnormalities
118
Q

procedural site for spinal

A

one of four intervertebral spaces L2-S1 (popular site L2-3 or L3-4)

119
Q

if pt is in lateral position for spinal insertion, would surgical side be up or down if using a hyperbaric solution

A

surgical side down!

120
Q

when preparing a spinal, what two structures will differe between midline and paramedian approach

A

midline- supraspinous ligament & interspinous ligament
paramedian- paraspinous muscle & ligamentum flavum

121
Q

how often should you check BP after spinal admin

A

Q3-5 minutes until block is set

122
Q

how frequently should you assess the progress of the spinal block after administration until block achieved and then how frequently after that

A

every mintute until block achieved

Q30-45 min

123
Q

two ways to test if spinal is working

A
  1. Alice/hemostats?
  2. alcohol sponge
124
Q

earliest sign spinal is working

A

drop in BP followed by nausea and dizziness

125
Q

after spinal admin, loss of temp and light touch signals that what fibers are blocked . How can we assess this

A

C and A-delta

alcohol sponge

loss of these follows autonomic blockade

126
Q

in spinal admin, motor impairment and touch and managed by what fibers

A

A-beta and A-gamma

127
Q

which comes first in spinal

loss of motor & touch OR loss of light touch and temperature

A

loss of light touch and temperature

128
Q

:)

A
129
Q

which dermatomes are you assessing if you ask pt to dorsiflex feet

A

S1-S2

130
Q

which dermatomes are you assessing if you ask pt to flex his toes

A

L4-L5

131
Q

which dermatomes are you assessing if you ask pt to raise their knees

A

L2-L3

132
Q

which dermatomes are you assessing if you ask pt to lift shoulders off bed

A

T6-T12

133
Q

a block at S2-S5 is referred to as a ___________.
There (is/is no) effect of ANS.

Surgical anesthesia is limited to ________, _________, & __________

A

saddle block
is no
perineum, perianal, genitalia

134
Q

A block at T10 (umbilicus) is referred to as a ________.

It blocks ______ &__________.

it produces _________ & __________.

What surgeries is it good for?

A

low spinal

s1-5 & L1-5

vasodilation and lowers BP

gynecologic, vaginal delivery, lower extremity surgery, TURP, cysto

(C-section is T4)

135
Q

A block at ______ is referred to as a high spinal.

It is used for ___________ surgery though the patient can still feel traction.

It can cause (vasodilation/vasoconstriction) and block _______________ fibers

A

T4 (nipple)
upper abdominal
vasodilation
cardio accelerator

136
Q

A block at C8, referred to as __________,

is a (high/low/total) spinal.

Pt may experience ________ that can lead to ____ &________.

A

little finger
total
difficulty breathing
respiratory & cardiac arrest

This is bad news friend you better grab airway eqt.

137
Q

which two spinal needles are “puncturing” needles

A

Quincke & whittacre

138
Q

name the 4 spinal needles

A

Quincke
Whittacre
Sprotte
Pencan

139
Q

what causes PDPH and how can it be prevented/exacerbated

A

CSF leak

choice in needle size

  • large (20 -22G) = more CSF but easier to use
  • smaller (25- 26G) = less CSF but more difficult to use
140
Q

LA solutions > 5% concentration are linked to ___________

A

neurotoxicity

141
Q

very (large/small) amounts are needed for spinals

A

SMALL

142
Q

T or F: LAs are the safest anesthetic we have and as a result are completely risk free

A

F- nothing is risk free

143
Q

Which LA does this describe for spinal use:

2 ml ampule of 5% solution premixed with 7.5% dextrose (hyperbaric). This mixtures has a risk for cauda equina syndrome

A. Lidocaine
B. Procaine
C. Tetracaine
D. Bupivacaine

A

A

144
Q

Which LA does this describe for spinal use:

2 ml ampule of 10% solution. Short DOA, low potency.

A. Lidocaine
B. Procaine
C. Tetracaine
D. Bupivacaine

A

B

145
Q

Which LA does this describe for spinal use:

2 ml ampule of 1% solution. Provides a more profound block than the other three listed

A. Lidocaine
B. Procaine
C. Tetracaine
D. Bupivacaine

A

C

146
Q

Which LA does this describe for spinal use:

2 ml ampule of 0.75% with 8.25% dextrose (*hyperbaric). The onset is 3-5 minutes. You must use a filtered needle with this
A. Lidocaine
B. Procaine
C. Tetracaine
D. Bupivacaine

A

D

147
Q

Bupivacaine has less motor block than

A

tetracaine

148
Q

spinal dose for normal duration total knee or hip replacement for T10 level

Lidocaine

Bupivacaine

A

L- 50-75 mg (of a 5% solution = 1-1.5 ml)

B - 8-12 mg (of a 0.75% soltuion = ~1-1.6 mL)

149
Q

how to we extend normal duration of spinal dose if, for example, you’re with a slow surgeon

A

epi-wash (100 mcg)–> extends ~ 1 hour

(0.1 - 0.2 mg)

150
Q

spinal dose for normal duration total knee or hip replacement for T4 level

Lidocaine

Bupivacaine

A

L- 75-100 mg (of a 5% solution = 1.5-2 ml)

B - 14-20 mg (of a 0.75% soltuion = ~1.8-2.6 mL)

151
Q

what LA is mainly used for D&C

A

Chloroprocaine 3% (VERY quick acting and short DOA)

152
Q

T or F: vasoconstrictors prolong the action of bupivacaine

A

F- do not prolong the action of bupivacaine… its just vasoconstricting to its not being taken away as quickly

153
Q

T or F: vasoconstrictors will prolong DOA of ester LAs

A

T

154
Q

2 vasoconstrictors used for spinals

A

epinephrine
phenylephrine (less common)

155
Q

Vasoconstrictors in the spinal space can: (6)

A
  • constrict blood vessels at the site and slow absorption of LA
  • produce analgesia
  • prolong DOA of ester LA ( tetracaine, procaine).
  • does prolong action of lidocaine
  • does not prolong action of bupivicaine
  • does not affect spread of block.
156
Q

intrathecal opioids will not produce analgesia. How can better anesthesia be provided/achieved

A

administer with LA

157
Q

Fentanyl Intrathecal Opioid:

Dose:
S/E:
Onset:
Duration:

A

15-25 mcg

Higher doses: resp. depression, itching , and urinary retention

5- 10 minutes

2- 4 hours.

158
Q

Duramorph is :

Onset:
Dose:
DOA:

A

Morphine (preservative-free)

  • 60 - 90 minutes
  • 0.1- 0.5 mg
  • Profound analgesia for 18-27 hours.

most commonly used

159
Q

intrathecal fentanyl and duramorph dose

A

F- ~ 20 mcg (15-25 mcg)

D- 0.15 mg (common in OB)

160
Q

about how long should spinal last

A

~ 2 hours

161
Q

3 most important factors for determining distribution of LAs for spinal

A
  1. baracity
  2. pt position during/just after
  3. dose of LA
162
Q

density of CSF =

A

1.004- 1.008

163
Q

determines where spinal LA will distribute

A

Baracity

164
Q

solution is hyperbaric… what is its density in relation to CSF

A

> CSF

> 1.008

most commonly used SINKS

165
Q

solution in hypobaric… what is its density in relation to CSF

A

< CSF

< 1.008

FLOATS up to the least dependent area. Good for lateral position sx.

166
Q

Li

A
167
Q

what is used to make a solution hyperbaric

A

dextrose

168
Q

you want to achieve a saddle block… what baracity LA will you adminster

A

hyperbaric

169
Q

T or F: you can achieve a high spinal after an isobaric solution LA administration by placing pt in trendelenberg

A

F- isobaric do NOT spread with position changes and are ideal when repositioning may be required

Limited clinical application/ Difficult to obtain a high level

170
Q

spinal level normally fixed in ________ minutes of positioning patient.

A

5-10

most evident with hyperbaric solutions

171
Q

4 CV complications following a spinal

A
  1. block sympathetic fibers
  2. block cardioaccelerator fibers
  3. cause hypotension/bradycardia
  4. BP decrease by 15-20% in most healthy pts
172
Q

3 ways to treat hypotension following spinals

A
  1. prevent with preload/prophylactic admin of 1-2L crystalloids
  2. supplementary O2
  3. treatment (slight trendelenberg, bolus crystalloid, ephedrine 5-10mg IV)
173
Q

S/S of PDPH

A

N/V
photophobia
tinnitus
dizzy
cranial nerve palsies

symptoms are postural

174
Q

3 treatment therapies for PDPH

A
  1. resolves in 5-7 days
  2. conservative therapy x24 hours
  3. epidural blood patch
175
Q

when administering an epidural blood patch for PDPH, where should you adminsiter it

A

blood moves cephalad so one interspace below

176
Q

all LAs are weak (acids/bases)

A

Bases

177
Q

how are LAs classified

A

according to structure

178
Q

for amide LAs, the amine group is (hydrophobic/hydrophilic) and the aromatic end is (lipophobic/lipophilic)

A

hydrophilic
lipophilic

179
Q

amides metabolized by

A

microsomal P-450 system

180
Q

Put in order: amide LAs order of metabolism

ropivacaine
lidocaine
Prilocaine
bupivacaine
mepivacaine

A

prilocaine>lidocaine>mepivacaine>ropivacaine>bupivacaine

181
Q

ester LAs metabolized by

A

pseudocholinesterases, hydrolysis is very rapid

182
Q

procaine and benzocaine is metabolized by ______

A

PABA (p-aminobenzoic acid)

183
Q

CSF lacks esterase enzymes so termination of action of ester depends on

A

redistribution to bloodstream

184
Q

short cut way to tell the difference bewteen amides and ester LAs

A

I before C = Am**I*des

185
Q

name some amide LAs

A
  • bupivacaine
  • lidocaine
  • ropivacaine
  • etidocaine
  • mepivacaine
186
Q

name some ester LAs

A

cocaine
procaine
tetracaine

187
Q

_______ end of ester LA is lopohilic and penetrates lipid bilayer of nerve membrane

A

aromatic

188
Q

_________ part of amide LA is hydrophilic and remians of either side of nerve membrane

A

hydrophilic ring

189
Q

which is hydrophobic and which is hydrophilic (the ends only)

A
190
Q

allergy or cross sesntivity occurs with (amide/ester) linkage

A

ester

191
Q

Nerve fibers classified according to what 3 things

A
  1. size
  2. conduction velocity
  3. function
192
Q

Ester LAs are rapidly metabolized in plasma by __________ into the metabolite __________. Amides are slowly destroyed by ______________

A

cholinesterase

PABA

liver microsomal P450 enzymes

193
Q

Na+ channels are membrane-bound proteins composed of ________ subunits and ________ subunits. LAs bind to a specific region on (alpha/gamma) subunits and inhibit membrane (depolarization/repolarization), thus inducing anesthesia

A

1 alpha
2 betas

alpha

depolarization

194
Q

(transmission/transduction) of electrical impulses along nerve membrane signal (transmission/transduction) along nerve fibers

A

transmission
transduction

195
Q

sensitivity of nerve fibers to LA is determined by _________, __________, and other factors

A

axonal diameter
myelination

196
Q

RMP = _________ by active transport and passive diffusion. Na+/K+ pump transports ___ Na+ out of cell for every ____ K+ into cells

A

-60 to -70 mV

3

2

197
Q

onest of action of LA depends on what two things

While the DOA of LA depend on what two things

A

ONSET: lipid solubility & pKa

DOA: lipid solubility & potency

198
Q

T or F: pH is pKa at which fraction of ionized and nonionized drug is equal

A

F – pKa is pH at which….

199
Q

Vasoconstrictors such as Epinephrine can help:

A

Be a marker for intravascular injection

Prolong duration of action of Locals

200
Q

less potent & less lipid soluble have (slower/faster) onset than more potent more lipid soluble agents

A

faster

201
Q

Quick summary of LAs MOA

A
  • slows down speed/stops generation of AP
  • bind to Na+ channels
  • inhibit Na+ influx in the neuronal cells
202
Q

3 factors affecting LAs action

A
  1. lipid solubility ]
  2. influence of pH
  3. vasoconstrictors
203
Q

T or F: epinephrine prolongs a bupivacaine block by increasing the volume of bupivacaine present in space

A

F – literally the slopiest written question to date so my apologies

epinephrine vasoconstricts the vessels which decreased the rate of systemic absorption So That (VP voice) the local hangs out a bit longer :)

204
Q

increased lipid solubility = (slower/faster) nerve pentration & onset of action

A

faster

205
Q

A. a lower pKa (7.6-7.8) is (slower/faster) acting

B. give examples of low pKa anesthetics

C. a higher pKa (8.1-8.9) is (slower/faster) acting

D. B. give examples of higher pKa anesthetics

A

A. faster

B. lidocaine & mepivacaine

C. slower

D. procaine, tetracaine, & bupivacaine

206
Q

t or F: vasoconstrictors synergize the vasoconstricting effects of LAs

A

F – vasoconstrictors antagonize the vasodilating effects of LAs

207
Q

2 medications that affect LA action

A

opioids – synergistic analgesia & attenuation of C-fibers

a-2-adrenergic agonist – clonidine inhibitory effect on peripheral nerve conduction & analgesia via supraspinal/spinal adrenergic receptors

208
Q

rate of systemic absorption of LAs is related to ______ & ________

A

blood flow & vascularity

209
Q

decreased absorption of LAs with the use of vasoconstrictors (reduces/increases) peak concentration of LA in blood, (enhances/ inhibits) quality of anesthesia, and (shortens/prolongs) DOA and (increases/limits) toxicity

A

reduces

enhances

prolongs

limits

210
Q

pharmacokinetics of LAs determined by what 3 things

A
  1. tissue perfusion
  2. tissue blood partition coefficient
  3. tissue mass
211
Q

early S/S of CNS LA toxicity

late S/S of CNS LA toxicity

excitatory S/S

A

circumoral numbness
tongue paresthesia
dizziness
tinnitus
blurred vision

___________

clonic-tonic seizures

___________

restlessness, agitation, nervousness

Highly lipid soluble LA produce seizures at lower blood concentration

212
Q

disadvantages of spinal anesthesia:

A
  • Hypotension
  • Intense motor blockade that may last for hours post-op
  • “takes too long”
213
Q

T or F: spinal anesthesia is a good choice for major intraabdominal procedures

A

F- not a good choice

Good choice for procedures of the mid to lower abdomen and lower extremity

214
Q

Fentanyl Intrathecal Opioid:

Dose:
S/E:
Onset:
Duration:

A

15-25 mcg

Higher doses: resp. depression, itching , and urinary retention

5- 10 minutes

2- 4 hours.

215
Q

Respiratory effects of LAs:

A

Relax bronchial smooth muscles
Phrenic nerve paralysis
Depression of hypoxic drive

216
Q

Cardiovascular effects of LAs: (7)

A
  • Depress myocardial automaticity
  • Unintentional IV injection of bupivacaine may produce severe CV toxicity
  • Left ventricular depression, AV block, arrhythmias
  • Decreased cardiac excitability and contractility
  • Decrease conduction rate
  • Increased refractory rate
  • Hypotension
217
Q

Local Anesthesia Toxicity

A

Related to absorption from the site

(Review LAST s/s)

218
Q

The distribution of LAs occurs in 3 phases describe:

A

Highly vascular tissue (lungs and kidneys) then less vascular tissue (muscle and fat), then drug is metabolized

219
Q

Major CV toxicity requires _____ times the local anesthetic concentration in blood as that requires to produce seizures

A

3

614 General Principles Of Anesthesia (14 decks)

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