Week 3 Regional - Epidural Everything Flashcards
Central neuraxial blockade (CNB)-
spinal and epidural blocks (involve placement of LA onto or adjacent to the spinal cord
Central neuraxial blockades are used for a variety of reasons. Name some:
-surgical procedures, -treatment of acute and chronic pain syndromes, -labor analgesia-safe transition if C/S required -May be used in combination with other types of anesthesia (MAC, GA etc..for surgery) -Post-op pain relief
CNB’s are a Surgeon preference due to:
- procedure (urologic procedures, can monitor neuro status etc..)
Incidence rate of persistent paresthesia and sensory or motor dysfunction is
< 1%
Discussion with patient alleviates most:
fear/concern
Additional discussion with patients include talking about topics such as:
risks, inadequate anesthesia, additional medications, paresthesia, hypotension, dyspnea, high or total spinal, N/V, and allergic reaction …
CNB Postoperative complications:
backache, postdural puncture headache (PDPH), hearing loss, transient neurologic symptoms (TNS), infection, abscess, or hematoma formation
Absolute vs relative contraindications- somewhat controversial
-Increased intracranial pressure (ICP) -Skin infection at site of injection -Bacteremia/sepsis/shock -Hypovolemia -Spinal cord disease -Progressive neurological diseases (MS, etc) -hypertrophic cardiomyopathy or -severe aortic stenosis) -Coagulopathy. -“anticipated” length of surgery
what are transient neruologic symptoms (TNS) *from his notes
TNS is a painful condition of the buttocks and thighs with possible radiation to the lower extermities, beginning as soon as a few hours after spinal anesthesia and lasting as long as ten days. Pain can be mild to severe. However, unlike in cauda equina syndrome, TNS is exclusively a pain syndrome - there is no bowel or bladder dysfunction, and neurologic, MRI , and electrophysiologic examinations are normal.
what is Cauda equina syndrome (CES)? ffrom his notes
Cauda equina syndrome (CES) is a serious neurologic condition in which damage to the cauda equina causes acute loss of function of the lumbar plexus, (nerve roots) of the spinal canal below the termination (conus medullaris) of the spinal cord. CES is a lower motor neuron lesion
why is ICP contraindication for spinal/epidural?
Increased ICP- spinal/epidural increases risk of brain herniation if dura is punctures… also, addition of large volume of fluid into epidural or SA space could increase already elevated ICP
What are some anatomical concerns that may have you NOT place an epidural or a spinal?
Severe kyphoscoliosis arthritis ( -kyphosis and scoliosis), -osteoporosis-vertebral deformities and -fractures with narrowing of the spinal canal, -lumbar fusion (may make placement difficult)
Coagulation contraindications (2:
Controversial range.. 1. Plt < 100,000 2. PT, PTT and bleeding times greater than 2 times the normal values Assess herbal medications that may affect hemostasis (garlic, ginkgo, ginseng)
what herbal medications should we Assess for and why?
- that may affect hemostasis -garlic, -ginkgo, -ginseng “anything with a “G”’
Regional thrombophrophylaxis: Contraindication or not? When to stop/Restart before/after block. ASA or NSAIDs
no contraindication
d/c ticlid prior to block
14 days
d/c plavix prior to block
7 days
GP 11b/111a inhibitors (Aggrastat, Integrilin) d/c prior to block
8 hours
ReoPro d/c
24-48 hours
Heparin- Subcutaneous is it contraindicated in regional techniques?
No contraindication in BID dosing of < 10,000 units
Regional thrombophrophylaxis: Heparin-IV Contraindication or not? When to stop/Restart before/after block.
…Heparinize 1 hour after block, -remove catheter 2-4 hours after last dose
LMWH (lovenox) plan for regional
-delay procedure at least 12-24 hours after last dose… -remove catheter 2 hours before first dose
Warfarin- usually requires d/c
for 4-5 days before Because:block requires normal INR.. Remove catheter when INR is 1.5 or less)
block requires
normal INR..








