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Anaethetics 2 > Regional Anaethesia > Flashcards

Regional Anaethesia Flashcards

1
Q

How can hypnosis be achieved in regional anaesthesia if necessary?

A

With sedation

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2
Q

What is regional anesthesia and what part of the triad does is supply?

A

It is anaesthesia that affects one part of the body and supplies the analgesia and muscle relaxant part of the triad

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3
Q

What are the 2 techniques of regional anaesthetics?

A

Central -neuraxial blocks (epidural, spinal and caudal blocks)
Peripheral- plexus blocks (brachial plexus and single nerve blocks)

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4
Q

What is a Bier’s block?

A

A intravenous regional block, where LA is injected directly into the veins of an arm

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5
Q

What is the check list for regional anaesthesia?

A

Secure IV access and fluid for infusion
Tilting table of trolley if patient vomits
Facilities for IPPV or a self inflating resus Ambu bag
Cylinder or pipeline wall O2 supply and face mask
Laryngoscopes, Kavil forceps, introducer, ETT, oral airways
Suction
Syringes, needles and drugs for resus
Defib
BP, ECG and O2

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6
Q

Indications for RA?

A

Surgical anaesthesia
In conjunction with GA
Post op pain management
Acute or chronic pain management

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7
Q

The max dose for 1% lignocaine neat in a 70Kg person?

A

10mg/1ml

70kg x 3mg

210mgkg/10mg

21mls

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8
Q

The max dose for 0,5% BUPIVACAINE neat in a 70Kg person?

A

0,5 % = 5mg/1ml

70kg x 2mgkg

140mg/5mgperml
28mls

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9
Q

How many grams/ declitre in 1%?

A

1g/ 100mls
1000mg/ 10mls
10mg/1ml

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10
Q

What are the contraindications do RA? (6)

A 
Patient uncooperative
Coagulopathy or bleeding disorders 
Infection trauma burns at site
Allergy to LA
Inadequate monitoring 
Patient refusal
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11
Q

What are the safe values of plts and INR for RA?

A

Plts > 74 x10

INR

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12
Q

Advantages of RA? (8)

A 
Pre-emptive analgesic
Post op analgesic
Less cardiac and resp depression 
Rapid post op recovery
Avoidance of airway instrumentation and their complications
Reduced complications of GA (nausea and vomiting, aspiration, inability to intubated/ or ventilate, MH)
Decreased DVT in ortho
Reduced surgical stress response
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13
Q

What are the disadvantages of RA? (5)

A 
Patient may want a GA
Skill 
Failure rate 
Time consuming 
Risk of systemic toxicity
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14
Q

Types of regional anaesthesia?

A

Topical application
Local infiltration
IV anesthesia (Bier’s)
Peripheral nerve blockade: Plexus or peripherL nerves
Neuraxial or central nerve blockade: spinal, epidural or caudal

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15
Q

Topical application types and examples?

A

Aerosolised (2-4% lignocaine in MacIntosh sprayer)
Cream: EMLA or Ametop
Direct application

Minor eye surgery
Laryngoscopy and bronchoscopy
Incision and drainage of quinsy (tonsillar abscess)
Crystoscopy
EMLA or Ametop cream
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16
Q

What is infiltrators anesthesia?

A

Injection of LA intradermally or subcutaneously for anaesthesia at site of surgery

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17
Q

How long as a bier block last?

A
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18
Q

What is the Bier block used for?

A

Surgery on hand, forearm (carpal tunnel release, reduction of Colle’s fractures and hand surgery)

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19
Q

How much LA does one use in a Bier block?

A

40ml 0,5% lignocaine in two 20ml syringes:

Draw up 5ml amp of 2%lignocaine into each 20ml syringe and mix with 15ml of normal saline

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20
Q

What is contraindicated in Bier’s block?

A

BUPIVACAINE because of cardia for toxicity

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21
Q

What size cannula do you use for Bier’s blocks?

A

22G

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22
Q

What colour are the cannula’s from 14G-24G

A 
14G- orange
16G- grey
18G- green
20G- pink
22G- blue
24G- yellow
26G- purple
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23
Q

How long does the Bier’s block take to work?

A

5-10minutes

24
Q

What is a nerve block?

A

Injection of LA in proximity of a specific peripheral nerve

25
Q

What are some examples of nerve blocks?

A

Digital nerve or “ring block”
Wrist block
Intercostal nerve block
Intra-orbital eye blocks for cataract
Femoral and/or sciatic nerve blocks for lower limb surgery
Ilio-inguinal nerve block for surgery on inguinal region

26
Q

What is a plexus block?

A

LA injected into proximity to nerve plexus

Onset of action is slow (up to 30min) but duration of many hours may be achieved (up to 16hours)

27
Q

What are the 3 neuraxial blocks?

A

Spinal (intrathecal or subarachnoid)
Epidural (periodical or extradural)
Caudal (sacral epidural)

28
Q

What is the applied anatomy and physiology of a neuraxial block?

A

Principle site of action is the NERVE ROOT

LA is injected into the CSF (spinal) or epidural spaces (epidural) and bathes the nerve root

29
Q

What type of blocks does neuraxial blocks elicit?

A

Sensory block: interrupts both somatic and visceral painful stimuli
Motor block: will produce skeletal relaxation
A differential block will occur due to different classes of nerve fibers
-sympathetic block (judged by temp) 2 see atones higher than the sensory block
- sensory block ( pain, pressure and light touch) 2dermatomes higher than the motor block
- motor block

30
Q

Layers that are pierced?

A 
Skin and subcut tissue
Supra spinous and interspinous ligaments
Ligament in flavum
Epidural space
Dura mater
CSF
31
Q

Indications for neuraxial?

A 
Lower abdo
Inguinal
Urogenitsl
Rectal 
Lower extremities
32
Q

Absolute contraindications of neuraxial?

A 
Local infection
Coagulopathy
Severe hypovolaemia/ shock 
Raise a ICP or IC disease
Fixed cardiac output- severe AS, MS, HOCM
Allergy to LA
Patient refusal
33
Q

Relative contra-indication for a neuraxial?

A 
Sepsis
Uncooperative patient
Pre-existing neuro deficit (peripheral neuropathy)
Severe spinal deformities
Prior back surgery
Complicated surgery
34
Q

What are the complications of a neuraxial block? (10)

A

Hypotension (block of sympathetic outflow at T1-L2) elevate legs, ephedrine 5mg
High block (causes hypotension, bradycar, CVS collapse or arrest, difficulty breathing and apnoea)
Post-rural puncture headache ( leak of CSF from puncture site- use pencil point needle to prevent)
Meningitis or epidural abscess (traction on meninges)
Epidural haematoma ( remove in

35
Q

Post op care of neuraxial?

A

Avoid injury

Check block receding (regain motor function

36
Q

What is a spinal?

A

Inject small volume of LA into CSF blocking nerve roots as the pass into the subarachnoid space (foramen- S2)

37
Q

What are spinals used for?

A 
Amputation of leg
Hip surgery and fracture repair
Trans urethral resection of prostate or bladder
Vaiginal sugary and hysterectomy
C/S and TL
 Minor rectal surgery
38
Q

How is a spinal pre-Ed?

A 
Pre:
Aseptic
18G or 16G and 1l crystalloid given or 500ml colloid
Monitoring
Performed siting or lateral position
Sterile pack opened
Draw up drugs
Clean and drape large area back 
Site =L3-L4(level of iliac crests)
LA infiltrate of skin with 2% lignocaine and 25G small brown needle
39
Q

What are the steps of a spinal?

A

Spinal needle= 25G pencil point needle

Introduce needle through skin in midline and direct CEPHALAD
Pierce dura with slight loss of resistance, remove styler and confirm CSF
Once dura is pierced attach syringe and draw back to ascertain free flow CSF and inject LA over 10secs (aspirate occasionally)

40
Q

What needles can you use for spinals?

A

25G pencil point needle- whitacre

22G Quincke needle (causes post-dural headaches)

41
Q

Major factors that influence height of block?

A 
Baricity of solution
Posture of patient
Volume of solution 
Mass of drug injected 
Volume of CSF
42
Q

Minor factors influencing the height of the block?

A 
Level of the injection
Height
Age
Weight
Speed of injection 
Induced turbulence
Posture
43
Q

What agents are used for spinals?

A

Hyperbaric with dextrose: heavy BUPIVACAINE

Isobaric: plain BUPIVACAINE or lignocaine

44
Q

How does specific gravity affect LA?

A

Solutions with a higher specific gravity, relative to CSF, will fall in the dural sac of a patient in the upright position (“heavy” solution)

45
Q

Why is fentanyl or morphine added to agents in spinals?

A

To extend duration and enhance analgesia

46
Q

How was a epidural work?

A

Epidural space surrounds dura mater. Nerve roost travel through this space as they leave the spinal cord.

The space contains fatty connective tissue, lympathics and a venous plexus

LA is injected into the epidural space at the lumbar and thoracic levels

47
Q

Advantages over spinal

A

TOP UP doses of constant infusions may be administer via a epidural catheter

Graduated blocks can be performed, where level of anaesthesia is increased slowly preventing hemodynamic instability

48
Q

What needle is used for epidurals?

A

16 or 18 G Tuohy needle with blunted bevel reducing risk of dural puncture

49
Q

What technique is used to identify the epidural space?

A

Loss of resistance technique

50
Q

When do you know you are in the epidural space?

A

Sudden ease of injection of a little saline or air from a syringe (with a freely movable plunger) attached to the Tuohy needle occurs once the space is entered

51
Q

What are the uses for a epidural ?

A 
Thoracic epidural for thoracic surgery with a GA
"" for analgesia in patients with multiple rib fractures to aid breathing 
Abdo sugary plus G
Labour analgesia
C/S
Operations on hips and lower extremities
Post-op analgesia
Chronic pain management
52
Q

What is a caudal block?

A

It is a sacral epidural, mostly done in paeds with a GA

53
Q

What are caudal blocks used for im adults and what’s the problem with caudal blocks in adults?

A

Used for chronic pain management. Caudal space is difficult to reach in adults

54
Q

Indications of a caudal in paeds?

A

Major abdo surgery
Major ortho surgery of lower limbs
Urgenital surgery

55
Q

How are caudals performed?

A

Lateral position
Find sacral hiatus and 2 posterior iliac spines= equilateral triangle
Palate the sacral cornuae (horns) on either side of the hiatus
Insert caudal needle, angled caudally with the needle bevel facing the patient
One pop or loss of resistance is felt passing the sacro-coccygeal ligament
LA is injected
Aspirate regular to exclude blood and CSF

56
Q

Does of drug for caudal?

A

Adults 25-30ml 0,5% BUPIVACAINE lasts 6-8hrs

Children: vol in ml mg of 0,25%
Lumbo sacral 0,5
Thoraco lumber 1,0
Mid thoracic 1,25

Anaethetics 2 (10 decks)

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