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Advanced Anesthesia Nursing 2 > Spinals > Flashcards

Spinals Flashcards

1
Q

History

A
  • First spinal
    • Cocaine
    • 1885-1890
  • Large evolution since then
    • A little technique
    • A lot of needle design
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2
Q

Preparation

A
  • Assessment of patient
    • Thorough History
    • Medication History
    • Surgical History
    • Type of Surgery
    • Informed Consent
      • Lots of misconceptions, may require discussion
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3
Q

Anesthetic Prep:

#1 Resuscitation Equipment

A
  • # 1 Resuscitation equipment
    • Monitors
    • Equipment (Spinal or Epidural)
    • Working IV
    • Medication
    • O2
    • Sedation
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4
Q

Equipment

A
  • Trays
    • Cleaning solution
      • Betadine
      • Chloroprep
    • Syringes
    • Needles
      • Spinal
      • Local
      • Introducer
    • Medications
    • Fenestrated Drape
    • Filter
    • Catheter?
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5
Q

Needles

A
  • Types
    • Pencil Point
      • Better feel, less trauma
    • Cutting
      • Place Longitudinal
    • Stylet
      • Prevents introduction of dermal cells
        • Can lead to dermoid spinal cord tumor
    • Sizes
      • 90-145 mm
      • 22-27 guage
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6
Q

Needles:

Pictures

A
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7
Q

Contraindications

A
  • Absolute
    • PATIENT REFUSAL
    • Lack of Cooperation
    • Uncorrected coagulopathies
    • Infection at the site of block
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8
Q

Factors Affecting Spinals

A

Factors Affecting Spinals

  • Uptake and Spread from Subarachnoid space
    • Concentration of LA in CSF
    • Surface area of nerve tissue exposed
    • Lipid content of nerve tissue
    • Blood flow to nerve tissue
  • Distribution
    • Baricity
    • Position
    • Dose
  • Level
    • Baricity
    • Position
    • Dose
    • Site of injection
    • Age?
    • Speed of injection
    • Volume
    • Concentration
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9
Q

Baricity

A

Baricity

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10
Q

Physiologic Changes

A

Physiologic Changes

  • Liver
    • If MAP maintained no changes
  • Cardiovascular
    • Sympathectomy
      • Dependent on block height
    • Hypotension and Bradycardia most common
      • Venodilation and Arterial dilation
      • Treat with fluid bolus
        • Preload or Co-load?
      • Treat with vasopressors
        • Ephedrine or Neosynephrine?
  • Respiratory
    • Little effects with normal lung physiology
    • Major effect with high spinal
    • Feeling of dyspnea
      • Related to inability to feel chest move
        • Maintain with reassurance
          • ­If they can talk they can breath
  • GI
    • Sympathetic innervation from T6-L2
      • Increased secretions
      • Sphincters relax
      • Bowel constricts
    • Nausea and Vomiting about 20%
      • Atropine to treat after high spinal
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11
Q

Dosages

A

Dosages

LA doses for spinals (suggestions) Not currently approved by FDA

Preservative free Onset (min) Duration (min) Dose (mg)

2-Chloroprocaine 60 40 (20-40) (30-100)

Lidocaine 3-5 60-90 25-50(25-100)

Tetracaine 3-6 70-180 5 -20

Bupivicaine 5-8 90-150 5-20

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12
Q

Positioning

A

Positioning

  • Proper Table height
  • Patient Comfort
  • Sitting - Ease of identification
    • Stool or footrest
    • Neck flexed and lower back pushed out
  • Lateral
    • Back parallel to edge of bed
    • Knees flexed to abdomen and neck flexed
  • Prone
    • Can be used if pt in this position for surgery
      • Iso or Hypobaric solutions
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13
Q

Technique

A

Technique

  • ID iliac crests
    • L4-5
  • Clean Skin
  • Drape
  • ID level to block
  • Local
    • Use local needle as finder
  • Approach
    • Median
    • Paramedian
    • Taylor
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14
Q

Midline Approach

A

Midline Approach

  • Introducer placed
    • Caution with thin pts
    • Slightly cephelad 10-15 degrees
  • Spinal needle placed through introducer
    • Resistance at all layers
      • Most likely at ligamentum
      • Then “Pop” through dura
  • Remove stylet and check for CSF flow
    • Smaller gauge may take longer
    • If no flow rotate needle
      • May be up against something
  • After Freeflow CSF
    • Attach syringe
      • Aspirate CSF
      • Slow injection (0.5 mL/sec)
      • Aspirate again?
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15
Q

Complications during placement

A

Complications during placement

  • Bone contacted
    • Withdraw needle and stylet to skin and redirect
      • Moving introducer inside can cut
      • Tough ligaments won’t allow needle to move well inside
  • Parasthesia
    • Stop advancing
    • Remove stylet and check for CSF
  • Blood
    • Not usually a problem unless excessive
    • Reattempt
  • Position
    • May use table to alter block during first few minutes
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16
Q

Paramedian

A

Paramedian

  • Good for calcified intraspinous ligament or difficult positioning
  • Needle inserted
    • 1 cm lateral and 1 cm inferior to space
    • Angle needle medially and cephelad
  • Ligamentum Flavum
    • 1st resistance
  • If lamina contacted walk off bone
17
Q

Management

A

Management

  • Assess VS regularly
  • Supplement as needed
  • Offer reassurance
  • Pt to void prior to discharge
18
Q

Complications

A

Complications

  • Neurologic Injury
    • 0.03% occurance
      • Needle introduction to nerve or cord
      • Spinal cord ischemia
      • Bacterial contamination
      • Hematoma
  • Cauda Equina Syndrome
    • Microcatheters
    • 5% lido, repeated dosing
  • Arachnoiditis
    • Infection
    • Myelograms from oil based dyes
    • Blood
    • Neuro irritant
    • Surgical interventions
    • Intrathecal steriods
    • Trauma
  • Meningitis
    • Bacterial or aseptic
    • Use Strict sterile technique
  • PDPH
    • Up to 25% incidence
    • Worse when head up, relief when supine
    • Treatment
      • Fluids
      • Caffeine (500mg 1-2 doses)
      • Bed rest
      • Analgesics
      • Sumatriptan
    • May take up to 1-6 weeks to resolve
    • Epidural Blood Patch
      • Mainstay of invasive treatment
        • 1st effective up to 64% OB and 95% non-OB
        • 2nd effective up to 90%
  • Spinal Hematoma
    • Incidence 0.00063%
      • Anticoagulation, increased age, female, hx of GI bleed, length of therapy
    • Medical Emergency
      • Neurologic symptoms
      • Immediate neuro consult and MRI
  • High Spinal
    • Monitor and treat appropriately
      • Airway and Pressor support
  • Cardiovascular collapse
    • Bradycardia usually 1st
      • Treat aggressively

Advanced Anesthesia Nursing 2 (4 decks)

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