Complications of neuraxial / epidural anesthesia - Exam 1

Question 1

Why does a post dural puncture headache occur?

Answer 1

-Dura puncture site doesn’t seal
-Continuous leak of CSF leads to reduced CSF volume
-The leak lowers the pressure in the brain area
-Brain sags and stretches the membranes
-Headache occurs

Question 2

Post dural puncture headache occurs __-__ days post puncture

Answer 2

2-3

Question 3

Which 3 patient factors increase your risk of PDPH?

Answer 3

Being younger
being female
being pregnant

Question 4

Using a needle with a _____ tip is more likely to result in PDPH

Answer 4

Cutting

Pencil points are better

Question 5

With an epidural, using ___ (air or saline) for LOR is more likely to cause PDPH

Answer 5

air

Question 6

Positioning the needle ____ to the spines long axis is more likely to cause Post dural puncture headache (PDPH)

Answer 6

perpendicular

Question 7

Post dural puncture headache (PDPH) treatments (5)

Answer 7

-Bed rest
-Caffiene
-NSAIDS
-Epidural blood patch
-Sphenopalatine ganglion block

Question 8

How does an epidural blood patch work?

Answer 8

-Inject 10-20 mL of the patient’s own blood into the epidural space

If 2 blood patches dont work, consider other causes of headache

Question 9

Blood patch is not reccomended within ___ hours of dural puncture.

___ hours has shown to be the standard

Answer 9

-24
-48 hours is standard

Question 10

T or F: With paresthesia from needle injury, the deficit usually follows the area where the paresthesia occured

Answer 10

True

Question 11

If spinal has not set up after ___-___ minutes, it may be necessary to redo the block

Answer 11

15-20

Question 12

If you have a failed spinal with a patchy block, should you repeat the block?

Answer 12

No, it may cause neurotoxicity
-Consider IV sedation or general anesthesia

Question 13

If you have a spinal with a unilateral block, what can you do to help the block?

Answer 13

Adjust the position

Question 14

What common bacteria is involved with post-spinal bacterial meningitis?

Answer 14

Streptococcus viridans

Question 15

With cauda equina syndrome, what nerves are affected?

Answer 15

L1-S4 + coccygeal nerves

Question 16

Factors that increase the risk of cauda equina syndrome?

Answer 16

-High concentrations of LA
-Microcatheters
-Whiticare 25/26 needle

Question 17

Treatment for cauda equina syndrome

Answer 17

-Supportive care
-If compression (disc, hematoma, etc.) is a factor then immediate laminectomy <6 hours

Question 18

This can occur with improper positioning as a result from nerves being stretched and results in temporary symptoms

Answer 18

Transient neurologic symptoms

Question 19

What factors increase risk of transient neurologic symptoms?

Answer 19

-Lidocaine 5%
-Surgical positions (ex. lithotomy)
-OUt patient surgeries and knee arthroscopy are associated with higher risks

Question 20

With TNS, pain usually starts within __ to __ hours after surgery

Answer 20

6 to 36

Question 21

Treatment for TNS

Answer 21

-NSAIDS
-Opioids
-Trigger point injections

Question 22

Why should you avoid pulling an epidural catheter quickly?

Answer 22

Retained catheter fragments

Question 23

What are the risk factors for epidural vein cannulation?

Answer 23

-Multiple attempts
-Pregnancy
-Catheter type (stiff is bad)
-Trauma to epidural vein during block procedure

Question 24

If your patient has a unilateral epidural block, should you lay them down on the numb side or the side that isn’t numb?

Answer 24

The non numb side facing down

**if LA is hyperbaric

Question 25

What is the most frequent symptom of LAST?

Answer 25

Seizures ## Footnote However, with bupivicaine cardiac arrest may come before the seizure :O

Question 26

Is LAST more common with peripheral or epidural blocks?

Answer 26

Peripheral

Question 27

CNS toxicity from LAST increases in these three patient conditions...

Answer 27

-Hypercarbia -Hyperkalemia -Metabolic acidosis

Question 28

Why does the risk for CNS toxicity in LAST decrease with hypocarbia?

Answer 28

Cerebral perfusion is decreased so drug delivery to the brain is reduced

Question 29

Why does the risk for CNS toxicity in LAST decrease with hypokalemia?

Answer 29

vRM lower --> Neurons less excitable --> Harder to depolarize

Question 30

Why does the risk of CNS toxicity in LAST decrease with CNS depressants (benzos, barbs)

Answer 30

Raises seizure threshhold

Question 31

Why does metabolic acidosis increase the risk of CNS toxicity with LAST?

Answer 31

It lowers the seizure threshhold and increases brain drug retention (ion trapping)

Question 32

The risk of CNS toxicity increases with hypercarbia. This is because it decreases ____ binding which increases the free fraction of LA available to enter brain

Answer 32

Protein ## Footnote Also increases cerebral perfusion --> increases drug delivery to brain

Question 33

In regards to LAST CV toxicity, which heart functions does the LA impact?

Answer 33

**Decreases**: Automaticity Conduction Velocity Action potential duration Effective Refractory period Depresses myocardium by affecting intracellular calcium regulation

Question 34

What two things are key factors in determining the extent of cardiotoxicity with LAs?

Answer 34

-LA affinity for voltage gated sodium channel -Rate of dissociation from the receptor during diastole

Question 35

Bupivicaine has a __ affinity for the voltage gated sodium channel and a ____ dissociation rate from the receptor during diastole

Answer 35

High Slow

Question 36

Cardiac resucitation is the most difficult with what LA drug?

Answer 36

**Bupivicaine** Bupivicaine > Levobupivicaine > Ropivicaine > Lidocaine | Order: Birds Like Red Leaves

Question 37

What 4 things are involved in the treatment of LAST?

Answer 37

1. Manage the airway 2. Treat the Seizures 3. Modified ACLS 4. Lipid Emulsion therapy

Question 38

How much propofol do i give a patient if they have LAST and are seizing?

Answer 38

omg trick question!!! NO propofol in LAST bc it weakens the heart

Question 39

Why are we cautious with our Epi dose during LAST resuscitation? How much do we use?

Answer 39

-Makes the resuscitation harder -Lowers the effectiveness of Lipid therapy -Less than 1 mcg/kg

Question 40

If our patient who has LAST has a ventricular arrythmia, what drug can I give them?

Answer 40

Amiodarone

Question 41

Max dose of Lipid Emulsion Therapy for LAST

Answer 41

12 mL / kg

Question 42

If your patient in LAST is unresponsive to modified ACLS and lipid therapy prepare them for ____

Answer 42

Cardiopulmonary bypass

Question 43

How does lipid emulsion therapy help with LAST (4 ways)?

Answer 43

Question 44

With an epidural or spinal hematoma, the cord ischemia is reversible if laminectomy is performed within __ hours _____ is a major symptom of this condition

Answer 44

8 PAIN

Question 45

What is arachnoiditis? What does it lead to?

Answer 45

Inflammation of the meninges. Leads to Extensive sclerosis of arachnoid membranes and constriction of vascular supply

Question 46

What 3 things can cause arachnoiditis?

Answer 46

Associated with: -Nonapproved admin of a drug into spinal or epidural space -Using non-preservative free solutions -Betadine contamination

Question 47

With ASA closed claims, what was higher: spinal cord injury rates or positioning injuries causing ulnar nerve damage?

Answer 47

Spinal cord injury