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Spring 2020 - APA Foundations 1 > Management of Regional, Spinal, & Epidural Anesthesia - Quiz 5 > Flashcards

Management of Regional, Spinal, & Epidural Anesthesia - Quiz 5 Flashcards

1
Q

Which Local Anesthetics are Esters?

A

Procaine

Cocaine

Chloroprocaine

Tetracaine

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2
Q

Which Local Anesthetics are Amides?

A

Lidocaine

Mepivacaine

Bupivicaine

Etidocaine

Ropivacaine

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3
Q

What is the general structure of Local Anesthetics?

A

Aromatic Lipophlic Ring

+

Intermidiate Chain (Ester/Amide)

+

Amine

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4
Q

Local anesthetics with a ______ pKa will have a faster onset b/c a larger portion of the molecule is uncharged/non-ionized

A

Local anesthetics with a lower pKa value will have a faster onset b/c a larger portion of the molecule is uncharged/non-ionized

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5
Q

What is the Mechanism of Action of Local Anesthetics?

A

Directly stops influx of Na+ to block nerve conduction by inhibiting the propogation of action potentials

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6
Q

How does a lot of Protein binding affect Local Anesthetics?

A

Prolong Duration of Effect

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7
Q

What kind of nerve fibers are more easily blocked?

A

Thin, Myelinated nerve fibers are more easily blocked

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8
Q

A-Alpha Fibers

A

Biggest Diameter

Most Myelination

Fastest Conduction

Motor Function & Propioception

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9
Q

A-Beta Fibers

A

4-15µm Diameter

Second Fastest Conduction

Motor, Touch & Pressure Sensation

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10
Q

A-Gamma Fibers

A

4-15µm Diameter

Muscle Spindles & Reflex

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11
Q

A-Delta Fibers

A

3-4µm Diameter

Slowest Conducting A Fiber

Pain & Temperature Sensation

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12
Q

B Fibers

A

4µm Diameter

Slower Conduction & Less Myelination than A FIbers

Preganglionic Autonomic Nerves

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13
Q

C Fibers

A

1-2µm Diameter

Slowest Conduction

Pain & Temperature Impulses

Unmyelinated

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14
Q

What is the Order of Anesthesia with Local Anesthetics?

A
  1. Sympathetic Block, Vasodilation, ↑Skin Temp
  2. Loss of Pain & Temp Sensation
  3. Loss of Proprioception
  4. Loss of Touch & Pressure Sensation
  5. Motor Paralysis
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15
Q

How are Local Anesthetic Metabolised?

A

Esters: Cholinesterase (1 min half life)

Amides: Liver (2-3 hr half life)

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16
Q

What is Baricity in regards to Local Anesthetics?

A

LA Classification based on their density relative to Density of CSF

EX: Hypobaric, Isobaric, Hyperbaric

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17
Q

What is Epinephrine’s affect on Local Anesthetics?

A

↓Systemic Toxicity

↓Rate of Absorption

↓Bleed

↑Block Intensisty

Helps evaluate test dose

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18
Q

When should Epinephrine not be added to Local Anesthetics?

A

Blocks in places w/ poor circulation

Bier Block

Pt hx of uncontrolled HTN, CAD, Arrhythmia, Hyperthryoid, utero-Placental Insufficiency

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19
Q

How does Sodium Bicarb affect Local Anesthetics?

A

↑pH –> ↑non-ionized concentration

↑Rate of Diffusion & Speeds Onset

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20
Q

How much Bicarb should be added to Lidocaine, Mepivacaine, and Bupivacaine?

A

Lidocaine & Mepivacaine
1 mEq per 10mL

  • *Bupivacaine**
    0. 1 mEq per 10 mL
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21
Q

What is the result of adding an Opioid to Local Anesthetics?

A

Adding 50-100mcg of Fentanyl would be synergistic

Shorten Onset

↑Intensity

↑Duration of Block

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22
Q

How can Systemic Toxicity d/t accidently IV injection of Local Anesthetics be avoided?

A

Aspirate before Injecting

Epi Test Dose

Proper Technique

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23
Q

What are the early signs of CNS toxicity from Local Anesthetics?

A

Lightheadedness

Tinnitus

Metallic Taste

Blurry Vision

Toung & Lip Numbness

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24
Q

What are the later signs of CNS toxicity from Local Anesthetics?

A

Muscle Twitching

Loss of Consciousness

Grand Mal Seizure

Coma

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25
Q

What is the treatment for CNS Toxicity from Local Anesthetics?

A

Give O2

Versed 1-2mg

Thiopental 50-200mg

Propofol

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26
Q

What are the symptoms of CV Toxicity from Local Anesthetics?

A

↓Contractility

↓Conduction

Loss of Vasomotor Tone

CV Collapse (Especially from Bupivacaine/Etidocain)

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27
Q

What is the treatment for CV Toxicity from Local Anesthetics?

A

Give O2

Volume

Pressors

Inotropes

Cardioversion

Takes a while to treat

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28
Q

What are the Categories of Regional Anesthesia?

A

Central/Neuraxial
Spinal, Epidural, Caudal

Peripheral

Pain Management

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29
Q

The use of Neuraxial blockade is found to ________ post-op mortality & morbidity

A

The use of Neuraxial blockade is found to reduce post-op mortality & morbidity

(Overall its better… less complications, earlier return of GI fxn)

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30
Q

How is a Neuraxial block achieved and what are the advantages?

A

Inject LA into CSF in the Subarachnoid/Intrathecal Space

Easy to Perform

Uses less LA

Less Discomfort on Placement

More Intense Block

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31
Q

What are some indications for a Spinal?

A

Surgery of Lower Abdomen, Lower Extremities, & Perineum

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32
Q

Wat are Absolute Contraindications to Spinal?

A

Pt. Refused or Lack of Cooperation

↑ICP

Pre-existing Coagulopathy

Skin Infection @ Site

Hypovolemia

Spinal Cord Disease

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33
Q

What are some Relative Contraindications to Spinal?

A

Fixed Cardiac Output

Sepsis

Difficult Airway

Indeterminate Neuro Disease

34
Q

When should NSAIDs be stopped before Neuraxial Interventions?

A

No Contraindication

35
Q

When should Plavix & Abciximab be stopped befor Neuraxial Interventions?

A

7 Days Before

36
Q

When should Ticlopidine & Tirofiban be stopped before Neuraxial Interventions?

A

14 Days

37
Q

When shoudl Eptifibatide be stopped before Neuraxial Interventions?

A

4-8 hours before

38
Q

What are symptoms of a Spinal/Epidural Hematoma?

A

New Lower Limb Numbness & Weakness

New Back Pain

New Bowel/Bladder problems

39
Q

Why is timing important for treating Spinal/Epidural Hematoma?

A

Must be surgically decopressed in < 8 hours for best outcomes

40
Q

What is the minimal segmental level of Spinal Anesthesia for Lower Extremities?

A

T12

41
Q

What is the minimal segmental level of Spinal Anesthesia for Hip, Bladder, Vaginal, & Prostate surgeries?

A

T10

42
Q

What is the minimal segmental level of Spinal Anesthesia for Testes, Ovaries, & Lower Extremities?

A

T8

43
Q

What is the minimal segmental level of Spinal Anesthesia for Lower Intraabdominal?

A

T6

44
Q

What are the Vertebral Column Regions?

A

7 Cervical

12 Thoracic

5 Lumbar

5 Sacral

4 Coccygeal

45
Q

What are the three Intralaminar Ligaments that Binds vertebrae together?

A

Supraspinous - Apices of Spinous Processes

Interspinous - Spinous Processes

Ligamentum Flavum - Caudal Edge to Cephalad Edge

46
Q

How far does the Spinal Cord extend during Fetal Life?

A

Extends length of Vertebral Canal & ends at L3 at birth.

47
Q

Which direction does the Spinal Cord form as it reaching Adult Position?

A

Forms Cephalad until reaches Adult Position of L1 by 2 y.o.

48
Q

What structures form the Cauda Equina?

A

Conus Medularis

Lumbar, Sacral, & Coccygeal Nerve Roots

49
Q

Why are Spinal Needles placed below L2?

A

Mobility of Spinal Nerves reduce needle trauma

50
Q

What are the 3 Meninges that cover the Spinal Cord?

A

Pia Mater

Arachnoid - b/t dura & pia

Dura Mater - tough fibrous sheath

51
Q

What is found in the Subarachnoid and is clear & colorless?

A

Cerebrospinal Fluid

52
Q

What is the Total Volume of CSF and how much of it is in the Spinal Canal?

A

Total CSF: ~ 140 mL

Spinal Canal CSF: 30-80 mL

53
Q

How much CSF does the body produced per day?

A

500 mL/day made by the choroid plexuses of cerebral ventricles.

54
Q

What is the Specific Gravity of CSF?

A

1.004 - 1.009

55
Q

What Factors affect Level of Spinal Block?

A
  • Drug Dose
  • Site of Injection
  • Baricity of LA
  • Pt. Position during and after injection
  • Drug Volume
  • Turbulence of CSF
    • increases spread (rapid injection, coughing, movement)
  • Intra-Abdominal Pressure
    • Preggos, Obese, Ascities, Abd. Tumors
  • Spinal Curve
56
Q

How does Intra-Abdominal Pressure affect Level of Spinal Block?

A

Pressure on Inferior Vena Cava = Epidural Venous Engorgement and reduces CSF volume

LA spreads farther

57
Q

What is the most common Local Anesthetic solution for Spinal Anesthesia and how does it work?

A

Hyperbaric Solution - contain Glucose

Flow to most Dependent part of CSF Column

58
Q

How do Hypobaric Solutions work?

A

Contain Sterile Water

Flows to Highest part of CSF Column

(Perineal procedures in Prone)

59
Q

What are the advantages of using Isobaric Solutions?

A

Predictable spread regardless of position

Increase dose = Increase Duration more than Spread

60
Q

What is the Paramedian approach to placing a Spinal?

A

For patients who can flex all the way or have Ossified spine ligaments

Place needle next to midline and aim upwards & towards the middle

61
Q

Which Spinous Process is aligned along the upper borders of the Iliac Crests?

A

L4 or L3-L4 Space

Spinals are usually between L2-L3, L3-L4, L4-L5 spaces

62
Q

What are the steps to Spinal Needle Placement?

A
  1. Place needle w/ bevel parallel to longitudinal fibers to reduce headache
  2. Advance until increased resistance then POP w/ loss of resistance
  3. Remove stylet - you should see free flow of CSF
  4. Withdraw & Reposition if there is paresthesia
  5. Rotate needle 90 degrees until good CSF flow
63
Q

How is the LA given once the Spinal Needle is placed?

A
  1. Aspirate CSF to confirm
  2. Slowly Inject LA
  3. Reaspirate to confirm placement in subarachnoid
  4. Gently remove needle
64
Q

How long does it take for fixation of Local Anesthetic?

A

20 minutes

65
Q

What is the sequence of Local Anesthetic Blockade?

A

Autonomic > Sensory > Motor

(each by 2 segments)

66
Q

What are possible CV complications to Spinal Local Anesthesia?

A

Hypotension & Bradycardia

67
Q

What are treatments for CV complications to Spinal Anesthesia?

A

500-1000cc before Spinal

Oxygen

Vasopressors

Atropine

Epinephrine

CPR

68
Q

What are the Pulmonary Effects of Spinal Anesthesia?

A

Minimal change to Tidal Volume

Dyspnea for pts w/ lung disease relying on accessory muscles

69
Q

What are the complications of Spinal Anesthesia?

A
  • Failure of Block
  • Post-Dural Puncture Headache
  • High Spinal
  • Nausea
  • Urinary Retention
  • Hypoventilation
  • Backache
70
Q

How wide is the Epidural space at Midline Lumbar and at the Mid-Thoracic Region?

A

Lumbar: 5-6 mm wide

Mid-Thoracic: 3-5 mm wide

71
Q

How does an Epidural Block work?

A

Acts directly on Spinal Nerve Roots

Gets access to CSF via uptake through dura

Slow Onset & Less Intense

Segmental Anesthesia

Selective Blockade

72
Q

How is Epidural Anesthesia different from Spinal Anesthesia?

A

Titratable for Pain or Anesthesia

Greater Control of Sensory & Motor Block than Spinal

73
Q

How does Epidural Anesthesia Spread?

A
  • Anatomically along Spinal Canal
  • Horizontally: Dural Cuffs & into CSF
  • Longitudinally:
    • Cephalad along Paravertebral trunks
    • Intradural Spinal Roots
    • Dorsal & Ventral Spinal Roots
    • Dorsal Root Ganglia
    • Spinal Cord
    • Brain
74
Q

Why must large amounts of Local Anesthetics be used for Epidurals?

A

Diffusion Dependent

This is why onset is so long

75
Q

Why should the needle always enter the Epidural midline regardless of approach?

A

Widest area to reduce risk of puncturing epidural vein, spinal artery & spinal nerve root.

76
Q

What is the Technique for Lumbar Epidural?

A

Loss of Resistance or Hanging Drop Technique

Use Long 25g Needle inserting upward to get into ligaments

77
Q

What is the Technique for Thoracic Epidurals?

A

Same as Lumbar, but insert Needle more upward

Needs smaller dose of local Anesthestic

78
Q

What is the Epidural Test dose and Why is it Given?

A

3mL of LA w/ 1:200,000 Epinephrine

No effect if placement is correct

If in CSF: Rapidly Behaves like Spinal

If in Epidrual Vein: 20-30% HR Increase

79
Q

What are Factors that affect Epidural Block?

A
  • Volume of LA
  • Age
  • Pregnancy
  • Speed of Injection
  • Position
  • Spread of Block
80
Q

What are the Adjuncts to Local Solution for Epidural?

A

Epinephrine

Opioid (Fentany/Duramorph)

Bicarb

81
Q

How does SNS block with Regional compare is Inhaled Anesthetics?

A

SNS block is Slower w/ less risk of abrupt hypotension

82
Q

What are ways to use Epidural Anesthesia?

A

Single Shot Epidural

Continous Epidural

Combined Spinal - Epidural

Combined Epidural - General

Caudal Anesthesia

Spring 2020 - APA Foundations 1 (10 decks)

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