Exam II: Central Nerve Blocks Flashcards
Understanding of the ___ ___ of the vertebral body is necessary for consistent success in ___ in administration.
structural components, block
This is the best picture to appreciate needle advancement, but also note that___ connect the ___ ___ to the vertebral body and lamina connect the transverse process to the ___ process
pedicles, transverse process, spinous
Spinal needle___ ___ ___to aid evaluation of tip location within the subarachnoid space.
rotated 360 degrees
The spinal cord terminates at the level of___in most adults having continued from the base of the ___.
L2 , brain
This last portion of the cord is termed the ___ ___and is generally at the level of __.
conus medularis, L2
The___ of the cord is not abrupt but transitions into a collection of nerves called the ___.
termination, cauda equina
The importance of this structure is the lessened risk of ___ ___ injury when a needle is placed into the space, thus ___-____ blockade is ideally placed ___ this level.
direct cord, sub-arachnoid, below
The epidural space is ___to the dura and ___ to the ligamentum flavum is ___.
posterior, anterior, “potential”
Like the esophagus, it’s not an ___ supported structure like the trachea.
air-filled
Rather, it is a ___structure like an ___balloon.
collapsed, uninflated
This space contains: ___, ___, and ___where nerve roots pass ____.
[Epidural]
nerve, vessels, fat, outwardly
The epidural space is generally ___ deep to the skin and is widest at the ___ ___ and tapering to the narrow ___.
5cm, midline point, inwardly
Bordering the space are the ___ ___.
epidural veins
The three essential curvatures of the spine should be noted (3)
Lordosis, Kyphosis, Scoliosis
Lordosis, is:
the inward curving position noted naturally in the lumbar and cervical regions resulting in a posterior directed spine.
Kyphosis is:
the outward-curving position found in the thoracic region and when exaggerated results in the forward leaning position.
Kyphosis is:
the outward-curving position found in the thoracic region and when exaggerated results in the forward leaning position.
Scoliosis is:
a lateral transitioning development.
For lumbar placement, opposition of the ___ ___ allows the spinous processes to ___ for the widest point of access.
natural lordosis, “open”
Lumbar spinous processes are the least___deflected compared with ___ and cervical vertebrae.
downward, thoracic
Thus, ___ approaches are often uses for ___ ___ to avoid the steep spinous process approach.
paramedian, thoracic approaches
Consideration of the use of ___ ___ follows other anesthetic decision-making pathways.
central blockade
The use of a ____ should be used.
[Consideration of central blockade]
risk to benefit comparison
The ___ ___is not to be underestimated as a decision-making tool and the ___ ___ though easily normalized away through integration of electronic health records, should not be dismissed.
patient history, patient interview,
___ at the site of injection or near the CNS, coagulopathy or use of ___, neuromuscular disease (MS, MG, Increased ICP), ___ frailty, patient consent and ability to___both the block placement and procedure under blockade, and surgical requirements should be considered in the process.
Infection, anticoagulants, cardiac, tolerate
Specific cardiac diagnoses have special implications for ___.
SAB
___ and HOCM/ IHSS have ___ specific blood pressure regulation and a ___ can result in cardiac arrest with difficulty in resuscitation.
Aortic valve stenosis, SVR, sympathectomy
Various ___ have been applied to coagulation lab values for epidural and spinal blockade eligibility.
ranges
Some of these are loosely based on ___ values and ___ within an institution.
[Lab values]
historic, normalized
For example, some facilities use an activated clotting time, aspirin use, platelet count, and PT/PTT values in developing a ___ though no absolute standard is recognized.
contraindication
A significant matter for which anesthesia should be involved is the post-operative removal of ___ ___.
epidural catheters
Not only is there potential for ___ ___, but special techniques may be required for ___.
accidental retention, extraction
Additionally, the prevalence of post-operative ___ ___ warrants careful timing of removal such that previous and anticipated doses of anti-coagulants do not increase the risk of___ ___
VTE prophylaxis, epidural hematoma.
The key point is that a non-compressible hemorrhage is ___, ___, and ___.
difficult to resolve, slow to be recognized, potentially catastrophic
The reliance on the ___ pathways to independently mitigate any ___ ___warrants the careful consideration of whether to proceed in the presence of a perceived or ___of normal blood clotting.
coagulation, vessel damage, potential impairment
See the reference article on the consensus statement regarding each of the specific coagulation manipulating agents and their respective ___ times that impact nerve blocks; particularly ___ ___.
“hold”, central blocks.
Complications that may arise from ___, ____, or ___parallel the anticipated impairment of the neurologically controlled systems.
CNS infection, hematoma, direct injury
___, ____, ___; changes in bowel or bladder function; or severe pain in the back warrant immediate evaluation.
Altered pain, temperature, motor function
A “total” spinal occurs when injected medications block nerves high into the ___or even ___levels.
thoracic, cervical
Blockade of sympathetic stimulation results in ___; bradycardia, hypotension, vascular collapse, and apnea accompany the loss of motor function of the ____ extremities.
unimpeded parasympathetic response, lower and upper
Loss of consciousness should be expected; presumably related to ___ ___.
cerebral hypoperfusion
Loss of consciousness should be expected; presumably related to ___ ___.
cerebral hypoperfusion
___, ___, and ___support should follow quickly with consideration of ___ response if the obstetric setting.
[Complications]
Airway support, oxygen, and hemodynamic, fetal
What are 6 adverse physiological responses for neuraxial anesthesia?
Urinary retention, high block, total spinal anesthesia, cardiac arrest, anterior spinal artery syndrome, and Horner syndrome.
Complications related to needle/catheter placement: B___, dural puncture/leak, postural puncture headache, diplopia, t___, neural injury, nerve root damage, spinal cord damage, caudal equine syndrome, bleeding, infra spinal/epidural hematoma, misplacement, ___/inadequate anesthesia, s___ block, inadvertent intravascular injection catheter shearing/retention.
Backache, tinnitus, no effect, subdural
What is a “Spinal headache”?
Post-Dural puncture headache/PDPH
PDPH occurs when ___ ___occurs and ___ ___ is inadequate resulting in CSF leakage.
dural puncture, dural closure
When ___ ___supersedes production, the “stretching” of the ____ results in a headache
CSF leakage, meninges
Classic symptoms include a worsening of the headache in ___position; when ____, the CSF pressure increases relieving the ____.
[PDPH]
the upright, supine, stretching
Incidence is ___ of spinals.
[PDPH]
1-2%
Incidence is ___ of spinals.
[PDPH]
1-2%
Conservative treatment involves (4)…
[PDPH]
rest, supine position, caffeine (oral or IV), and hydration.
If unsuccessful, an ___ ___ __ is performed resolving most cases (90%).
[PDPH]
epidural blood patch
Rarely is a ___ ___necessary, but can be used.
[PDPH]
second patch
If unsuccessful, more ____and/ or____pathologies must be considered.
[PDPH]
serious, permanent
____ volume of blood is used to “patch” the dura.
[PDPH]
20ml
Cutting needles mimic ____ in that they have beveled edge.
[Subarachnoid/spinal placement]
hypodermic
A ____ inside the needle reduces the likelihood of coring of tissue during____.
[Subarachnoid/spinal placement]
stylet, insertion
___-___ needles are popular and have a ___ shaped tip that are designed to separate without cutting tissues
[Subarachnoid/spinal placement]
Non-cutting, cone
Generally, ____ gauge needles are used to reduce the chance of a ___ ___from dural holes.
[Subarachnoid/spinal placement]
small, CSF leak
Baricity reflects the response of the ___ to the native ___.
[Baricity]
injectate, CSF
____ indicates in “sinks” whereas ___ stays in the same location and ____ floats.
[Baricity]
Hyperbaric, isobaric, hypobaric
