Epidural

Question 1

Difference between spread of epidural vs spinal

Answer 1

Baricity only applies to local in CSF which epidurals are not…

Question 2

Parasympathetic innervation in spinal cord

Answer 2

Craniosacral

Question 3

Placement difference between epidural and spinal

Answer 3

Epidural can be placed at lumbar, thoracic and cervical

Question 4

Indication of correct epidural placement

Answer 4

Note the loss of resistance
-with saline syringe!!

Question 5

Most commonly used epidural needle

Answer 5

Touhy

Blunt, curved

Question 6

Main Advantage of epidural

Answer 6

Continuous or re-bolusing

Question 7

Mechanism of cleaning with chlorhex vs betadine

Answer 7

Chlorhex-scrub

Betadine-drying

Question 8

Trick with the chloraprep

Answer 8

Flip it upside down so it doesn’t drip on you

Question 9

What did we miss about the tray set up with spinals»

Answer 9

Uncap your needles!!

Question 10

How to not accidentally inject the test does

Answer 10

Either ALWAYS draw the whole thing up or don’t use it

Question 11

Loss of resistance technique associated with higher pdph

Answer 11

Air

Question 12

LOR fluid technique

Answer 12

Should be able to to compress bubble but not inject saline in ligamentum flavum

If air bubble can not be compressed w/o
injecting fluid, needle placement is most
likely in the interspinous ligament or off
midline in paraspinous muscle

Question 13

What we use markings for on the epidural catheter

Answer 13

How much is in the space and if it migrated (what’s it taped at)

Question 14

What is the thick line on the epidural catheter for?

Answer 14

Everything after this point is the length actually inserted into the epidural space

Question 15

Common test dose for epidural and what it will do in different spaces

Answer 15

3ml of 1.5% lidocaine and 15mcg epi

-epi will act on intravascular space

-lidocaine will tell you if you have a spinal

Question 16

Why is EA different from SAB in dosing?

Answer 16

We are not injecting into fluid!!!

Question 17

Volume required per spinal segment for epidural band

Answer 17

1-2ml

Question 18

If inserting L4 and you want a T6 block, what volume of local do you need?

Answer 18

At least 12cc t6-L4=12 spaces

Question 19

Impact of age on epidurals

Answer 19

Greater spread in older patients

Question 20

If you trend your patient with a continuous epidural what is going to happen?

Answer 20

Nothing
Position matters less with epidurals

Question 21

Dose of epidural

Answer 21

Determines density of block

Question 22

Volume of epidural determines:

Answer 22

Spread

Question 23

Rate of epidural dosing

Answer 23

3-5cc of LA every 3 minutes until you hit your level

Question 24

Why do we dose epidurals incrementally?

Answer 24

To avoid serious complications!

Question 25

Thing you do before every SINGLE injection with epidural

Answer 25

Aspiration to prevent systemic toxicity

Question 26

What increases speed of onset of motor and sensory block?

Answer 26

Dose increase

Question 27

Short acting LA spread time vs long acting

Answer 27

15-20 minutes 20-25 min

Question 28

Block duration determinants

Answer 28

Short-Chloroprocaine Intermediate- lidocaine or Mepivacaine Long-Bupivacaine, Ropivacaine

Question 29

Where does the local disperse to from the epidural space?

Answer 29

The epidural veins

Question 30

Density is determined by

Answer 30

Concentration of LA

Question 31

Dermatomal spread of epidural is determined by:

Answer 31

Volume of Local

Question 32

Treating hypotension from epidural

Answer 32

Fluid and ephedrine

Question 33

High block impact on respiratory physiology

Answer 33

May not be able to forcibly exhale

Question 34

Nausea is associated with blocks higher than:

Answer 34

T5

Question 35

Sympathetic blockade T6-12 produces what?

Answer 35

Unopposed parasympathetic vagal activity -secretions, relaxed sphincters, bowel constriction

Question 36

What procedures can we use lumbar epidurals?

Answer 36

Any procedure below the diaphragm

Question 37

Thoracic epidural considerations

Answer 37

Higher risk of spinal cord injury and technically difficult Paramedian technique frequently used

Question 38

Cervical block consideration

Answer 38

Not common, typically done in pain clinics

Question 40

What do we not feel on paramedian approach?

Answer 40

Supra or intraspinous ligament

Question 41

Layers passed during paramedian approach in thoracic epidurals

Answer 41

Paraspinous muscle until you hit bone or ligamentum flavum

Question 42

Lower abdominal procedures

Answer 42

Colectomy • Abdominal AAA • Bowel resection • Nephrectomy

Question 43

Upper abdominal procedures

Answer 43

• Esophagectomy • Splenectomy • Hepatic resection • Pancreatectomy

Question 44

Thoracic epidural dosing

Answer 44

3-6 ml of LA followed by infusion (3-5cc/hr) Usually dilute (0.125% Bupivacaine)

Question 45

Classic opioid addition to thoracic epidural

Answer 45

2 mcg/ml of fentanyl

Question 46

What would be indications of Subdural catheter?

Answer 46

THESE ARE NOT SAFE, TAKE OUT May be unilateral May have greater hemodynamic consequences at high doses

Question 47

Disadvantages to CSE

Answer 47

Higher risk of sub arachnoid catheter placement Increased PDPH Inability to test catheter at time of insertion

Question 48

How much blood for a patch and what do you need to get it?

Answer 48

20 ccs A second person -inject through tuohy