Epidural Anesthesia ( Newby's Take)

Question 1

An epidural block can be performed at what levels?

Answer 1

1. Lumbar
2. thoracic
3. Cervical
4. Caudal

Question 2

Epidurals have a wide rage of uses what are some areas of heathcare where the application of epidurals can be helpful

Answer 2

• operative anesthesia
• odstetric anesthesia and Analgesia
• Postop pain control
• chronic pain management

Question 3

In the overall scheme of things an epidural can be used in different ways (think way to administer it)

Answer 3

1. “Single shot”
2. catheter that allows intermittent boluses or continuous infusion

Question 4

Epidural Anesthesia:

a big advantage of epidural is that muscle blockade can range from _______ to ________

Answer 4

None to complete

Question 5

Epidural Anesthesia:

everything (related to muscle blockade, pain control, etc) can be regulated and changed by what 4 factors?

Answer 5

1. Drug Choice
2. LA concentration
3. Dosage
4. Level of injection

Question 6

Epidural Anesthesia:

the epidural space surrounds the Dura Mater in what directions?

Answer 6

• posterior
• laterally
• Anteriorly

Question 7

Epidural Anesthesia:

the nerve roots travel in the dura mater and exit the spinal cord where (position not location)

Answer 7

Laterally

Question 8

Epidural Anesthesia:

So we learned that the epidural space surrounds the Dura matter posteriorly, laterally, and anteriorly. The nerve roots travel iin this space and exit the spinal cord laterally. n the nerve roots then exit the ___1___ and travel peripherally to become peripheral nerves carrying both ___2__ and __3___ pathways

Answer 8

1. Foraman
2. Afferent
3. Efferent

Question 9

Epidural Anesthesia: Anatomy

What other 4 things (besides nerve roots) does the epidural space include

Answer 9

1. Fatty connective tissue
2. Lymohatics
3. Venous plexus (Batson’s)
4. Septa and Connective tissue bands

Question 10

what is segmental blocks?

epidural or spinal?

Answer 10

epidurals are segmental blocks

Question 11

why are spinals not considered segental blocks?

Answer 11

bc they block above and below

Question 12

what is one of the most important aspects of placing an epidural?

Answer 12

getting the right spot! Remember epidurals are segmental blocks

Question 13

Label this

Answer 13

1. Meninges
2. Spinal Cord
3. Spinal Nerve
4. Epidural Space
5. Vertebra

Question 14

Epidural Anatomy: Name the structures found in the locations:

• Superior
• Inferior
• Lateral
• Anterior
• Posterior

Answer 14

• Fusion of the dura with the foramen magna
• Sacro-coccygeal membrane
• Vertebral pedicles and intervertebral foraminae
• Posterior longitudinal ligament and vertebral bodies
• Vertebral laminae and ligamentum flavum

Question 15

Label this

Answer 15

1. Dural sac
2. Epidural vein
3. Interlaminar space
4. Lamina
5. Ligamentum Flavum
6. Supraspinous Ligament
7. Intraspinous Ligament
8. Spinous Process
9. Transverse Process

Question 16

LA or other solutions injected into the epidural space (steroids, Narcs) spread Anatomically.

So how is horozontal spread?

Answer 16

• is to the region of the dural cuffs with diffusion into the CSF and Leakage through the intervertebral foramen into paravetebral spaces

Question 17

LA or other solutions injected into the epidural space (steroids, Narcs) spread Anatomically.

how is longitudinal spread?

Answer 17

preferentially cephalad in direction

Question 18

odd fact he stated!

Clinidine binds where in r/t the synaptic cleft?

Answer 18

Presynaptically

Question 19

What are 6 possiable sites of anesthetic action?

Answer 19

1. Paravertebral Nerve roots
2. intradural spinal roots
3. Dorsal and Ventral Spinal roots
4. Dorsal Ganglia
5. spinal cord
6. Brain (by diffusion)

Question 20

Epidural physiology:

What facilitates the rapid diffusion of LA from the Epidural Space, throught the dura and into the CSF surrounding the nerve roots?

Answer 20

the dural cuffs or sleeves have arachnoid villi and granulations that reduce the THICKNESS of the dura matter thus facilitating transfer

Question 21

the dural cuffs or sleeves have arachnoid villi and granulations that reduce the THICKNESS of the dura matter thus facilitating rapid diffusion of the LA from the epidural space through the dura and into the CSF surrounding the ther roots. then the LA diffuses into the nerve root it self, producing anesthesia to where?

Answer 21

that PARTICULAR dermatome (remember again segmental)

Question 22

B/c Epidural anesthesia is ______ dependent, relatively large volumes of LA are needed to achieve a block that spans several dermatomes.

Answer 22

DIFFUSION

Question 23

Max spinal Volume

Epidural volume

Answer 23

1. 2 ml
2. up to 15 ml

Question 24

with an epidural the Block ONLY gets as high or low as you regulate it by what?

Answer 24

VOLUME

Question 25

With epidurals _____ affects spread, so to get more levels give more \_\_\_\_\_

Answer 25

Volume volume

Question 26

With Epidurals: The #1 factor to get action of epidural at a certain site is what? The #2 factor is How much spread or how many dermatomes this is affected by what?

Answer 26

1. location 2. Volume

Question 27

an epidural is not like a spinal in which everything distal to the level of the block is affected, an epidural is a differential block dependent on the ______ and \_\_\_\_\_\_\_\_?

Answer 27

volume site of injection

Question 28

Label this motha fucker

Answer 28

1. Spinal cord 2. Pia mater 3. Arachnoid mater 4. Dura Mater 5. Conus Medullaris 6. Cauda equina 7. Ligamentum flavum 8. Epidural space 9. Internal filum terminale 10. Distal dural sac 11. External filum terminale 12. Coccyx 13. Sacrum 14. Aorta

Question 29

Epidural Advantages: the epidural tech has the advantage of better control of ____ and ____ blockade

Answer 29

level and sympathetic blockade

Question 30

Epidural Advantages: the epidural tech allows for the placement of a continuous catheter which is especially useful forwhat 4 things?

Answer 30

1. cases of unpredictable duration 2. prolonged postop analgesia 3. Chronic pain control 4. Obstetric Analgesia and Anesthesia

Question 31

What is teh spread of epidural anesthesia termed?

Answer 31

rostral spread the distribution of an opioid within the cerebrospinal fluid during epidural administration; it is determined by fat and water solubility properties of the narcotic

Question 32

to be able to choose the most appropriate anesthetic dose, concentration and volume of LA the anesthetist must be familiar with the variables that affect spread and duration of Epidural anesthesia. what has more variables spinal or epidural?

Answer 32

Epidural

Question 33

Baricity plays a very _SMALL_ or _LARGE_ factor in Epidurals

Answer 33

Small

Question 34

Unlike epidurals what is the key factor in spread and distribution of the block with spinal anesthesia

Answer 34

Baracity

Question 35

What are 9 factors that affect the level of an epidural block? emphisise the 2 most important factors

Answer 35

1. ***_injection site_*** 2. Dose 3. ***_Volume_*** 4. concentration 5. position 6. Age 7. Height and weight 8. pregnancy 9. Speed of injection

Question 36

Ulinke spinal anesthesia the epidural produces a segmental block that spreads both ____ and \_\_\_\_

Answer 36

Caudally Cranially (i think cephalad is a better term)

Question 37

Based on the fact that Ulinke spinal anesthesia the epidural produces a segmental block that spreads both Caudally and Cranially what is te most important determinant of the spread of an epidural block?

Answer 37

Injection site!! God damn I think he states this 4 million fucking times in his god damn slides it better be a fucking question of the damn fucking test

Question 38

The injection site should be where for an epidural?

Answer 38

in the middle of the range of dermatomes that need to be anesthetized and closest to the main nerve roots involved

Question 39

Caudal epidural blocks are largely restricted to _____ and _____ \_\_\_\_\_\_ dermatomes

Answer 39

Sacral Low Lumbar

Question 40

Thoracic levels can be reached by caudal approach only if _______ are given, and then the block is patchy at best bc of the distance that the anesthestic must travel

Answer 40

Large volumes 30mL

Question 41

Lumbar LA injections of \_\_mL tend to spread caudad to include all the sacral dermatomes

Answer 41

10 mL

Question 42

Lumbar injection of \_\_mL volumes produce much better quality sacral blocks and can also extend cranially to include the midthoracic levels

Answer 42

20mL

Question 43

Thoracic injections tend to produce a _______ segmental band of anesthesia with minimal lumbar spread

Answer 43

symmetric

Question 44

When using a thoracis approach, it is prudent to decrease your volume by about ____ to \_\_\_\_% to prevent cranially spread.

Answer 44

30-50%

Question 45

when doing a thoracic epidural you want to use less volume to minimize crainial spread b/c what don't you want to anesthetized and where is it located????? HMMMM

Answer 45

Cardiac Accelerator C4

Question 46

is it generally feasable to produce surgical anesthesia in the low lumbar or sacral nerve distributions when using a thoracic injection site?

Answer 46

NOPE

Question 47

Thoracic injections are ideally suited for procedures of where?

Answer 47

chest upper abd postop thoracotomy

Question 48

within the range typically used for surgical anesthesia drug CONCENTRATION is relatively unimportant in determining what?

Answer 48

block spread!

Question 49

What is the #1 way to tell density of block?

Answer 49

Concentration

Question 50

\_\_\_\_\_ and _____ are important variables in determining both spread and quality of the epidural block obtained

Answer 50

Dose and Volume

Question 51

Epidural: Dose, Volume , Concentration if the drug CONCENTRATION is held constant, increasing the volume of LA (thus increasing the dose) results in significantly greater what?

Answer 51

Spread

Question 52

Epidural: Dose, Volume , Concentration if the drug CONCENTRATION is held constant, increasing the volume of LA (thus increasing the dose) results in significantly greater Spread. Dose = what

Answer 52

dose = volume x concentration

Question 53

Epidural: Dose, Volume , Concentration if the drug CONCENTRATION is held constant, increasing the volume of LA (thus increasing the dose) results in significantly greater Spread. For example notice the dose increases and VOLUME increases but the concentration remains the same thus you get a greater spread without changing the concentration give me the doses 15 ml and 20 mL of 0.25 % Lidocaine

Answer 53

15mL x 2.5 mg/mL =37.5 mg 20 mL x 2.5 mg/mL = 50 mg

Question 54

so after everything I just went over we now know that the CONCENTRATION of the LA generally affects the _____ of the block not the \_\_\_\_\_\_

Answer 54

DENSITY SPREAD

Question 55

Epidural: Dose, Volume, and Concentrations So continued from all the info we now know. 1. a small volume of a more concentrated LA will produce what in a block? 2. Now take that same DOSE and double the volume and what will happen?

Answer 55

1. Very limited but very STRONG 2. SPREAD increases but weaker block

Question 56

Epidural: Dose, Volume, and Concentration the increase in block level is NOT in direct proportion to volume increase. Thus Doubling the VOLUME will NOT double the block spread. it is a NON-linear relationship and doubling the volume will only increase the level about \_\_\_-\_\_ the origional # of segments

Answer 56

1/3-1/2

Question 57

Epidural: Dose, Volume, and Concentration the same relationshiop exist with DOSE; doubling the dose will usually only increase the level block the same ___ -\_\_\_ of the origional segments blocked

Answer 57

1/3-1/2

Question 58

Epidural: Dose, Volume, and Concentration recommended amts of LA differ as to which level is being injected: 1. Cervical/thoracic doses are ___ - __ mL per segment 2. Lumbar level doses are \_\_\_-\_\_\_\_mL per segment

Answer 58

1. 0.7-1 2. 1.25-1.5

Question 59

Epidural: Dose, Volume, and Concentration why do the volumes get smaller the more crainial you are in the epidural space? for ex why give 0.7- 1 mL per segment in thoracic and 1.25-1.5 in the lumbar

Answer 59

due to the narrowing of the spinal canal as iot progresses cranially

Question 60

Epidural: Dose, Volume, and Concentration \*\*\*\*\*\* remember this slide\*\*\*\* using a lower concentration anesthetc can sometimes give u a differential block! the lower the concentration means the dose is lower and there is less LA to penetrate the nerve roots so the block acts more ________ an the nerves, differentially blocking sensory and pain fibers over larger muscle fibers in the center os the nerves

Answer 60

periperally

Question 61

Epidural: Dose, Volume, and Concentration Based off the last slide!! 1. Bupivicaine 0.25%, 20mL tends to provide what type of block? 2. then if Bupivicaine 0.5% 20 mL is given what type of block is provided?

Answer 61

1. tends to provide a sensory block, but leaves the motor fibers intact so a pt can push when needed 2. provides a sensory block as well as a a motor block paralyzing the muscles at the levels of the block so NO pushing is going to be possible

Question 62

studies on epidural anesthesia r/t positioning showed that which position is better? sitting or lateral?

Answer 62

either it's your choice! data showed that here was little to no difference

Question 63

* Studies in epidurals have showed what in r/t age? * why? * what effect does this have on the dermatome coverage?

Answer 63

* showed that there is a greater spread in older pt's * b/c there is thought to be less comliant epidural space and dura mater * at most an increase in NO more than 3-4 dermatomes

Question 64

epidural and height and weight * what do the studies say concerning height and weight r/t epidural spread? * what is teh exception?

Answer 64

* no clinical signicicance * except for MAYBE in extremly tall \>6'6" or very short \< 4'10" or in morbidly obese

Question 65

Epidural anesthesia: Pregnancy what do studies say about epidural spread r/t pregnancy?

Answer 65

* some show greater spread at term and early pregnancy * other studies show no significant differences in spread of pregos vs non-pregos

Question 66

Epidural and spead of injection * what do the studies say about spread of epidural r/t speed of injection

Answer 66

* no study has shown it to make a difference * infact drugs should be injected slowly into the epidural space the avoid a rapid increase in CSF pressure, H/A, and increased ICP (spinals use spead for spread)

Question 67

Epidural anesthesia: speed of injection All slutions should be injected in increments of \_\_\_\_mL every _____ min and titrated to the disired level.

Answer 67

* 3-5 mL * 3 min

Question 68

Epidural anesthesia: speed of injection if a catheter had been placed and you are injecting through it, what needs to be done prior to every injection? and why?

Answer 68

* aspirated * to show no CSF is present

Question 69

Epidural anesthesia: speed of injection what is an advantage of an epidural of spinal r/t speed of injection

Answer 69

* gradual administration of medication slows rate of onset of level and controls development of sympathetic block * the spinal is all or none where epidural can be brought up slowly

Question 70

Epidural Anesthesia: Summary Drug Volume

Answer 70

* larger volume gives more spread than small volumes

Question 71

Epidural Anesthesia: Summary site on injection

Answer 71

* the epidural space increases in volume in the cervico-caudad direction * thus a given volume will produce greater spread in the cervical \> thoracic \> lumbar \> sacral * onset is fastest and most intense in the dermatomes nearest the site of injection

Question 72

Epidural Anesthesia: Summary raised abdominal pressures

Answer 72

* smaller volumes may be needed inpregnancy and morbid obesiyty

Question 73

Epidural Anesthesia: Summary patient position

Answer 73

* prolonged sitting position may reduce upward spread * earlier onset of block in dependent side in lateral position *

Question 74

Epidural Anesthesia: Onset of Blockade the onset of an epidural can usually be detected within ___ min in the dermatomes immediately surrounding the injection site

Answer 74

5 min

Question 75

Epidural Anesthesia: Onset of Blockade the time to PEAK effect differs somewhat among different LAs * shorter acting drugs usually reach their maximum spread in \_\_\_-\_\_\_ min * Longer acting LAs usually reach their maximum spread in \_\_\_-\_\_\_ min

Answer 75

* 15-20 min * 20-25 min

Question 76

Epidural Anesthesia: Onset of Blockade increaseing the ____ of LAs speeds the onset of both motor and sensory block

Answer 76

DOSE

Question 77

Epidural Anesthesia: Duration of Blockade the duration of the blockade depends on what 4 factors

Answer 77

1. The LA itself 2. Dose given 3. Pt age 4. Use of adrenergic agonist

Question 78

Epidural Anesthesia: Duration of Blockade your choice of LA is the most important factor in determining the _______ of the block

Answer 78

duration

Question 79

Epidural Anesthesia: Duration of Blockade name the LA \_\_1\_\_ is the shortest, \_\_2\_\_ and \_\_2\_\_ are intermediate, and \_\_3\_\_ and \_\_3\_\_ produce the longest lasting epidural blocks

Answer 79

1. Chlorprocaine 2. Lidocaine & Mepivicaine 3. Bupivacaine & Ropivacaine

Question 80

Epidural Anesthesia: Duration of Blockade Bupivicaine * is the opposite of what drug? * in low doses seems to have a preferential _____ block with minimal ____ effect * that is why it is an ideal drug for _____ analgesia. thus eliminating pain while preserving muscle function

Answer 80

* Etidocaine * sensory; motor * Obstetric (they can push)

Question 81

Epidural Anesthesia: Adrenergic Agonists what is the most common adrenergic agaent added to epidural LAs

Answer 81

epinephrine

Question 82

Epidural Anesthesia: Adrenergic Agonists epinephrine in a concntration of what is the most common adrenergic agent added to epidural LAs

Answer 82

5 mcg/mL 1:200,000 (I always have a little problem remebering the mcg conversion probally b/c I am a dumb ass but this is now how I remember it if anyone cares... 1:200,000 means in math 1,000 mg in 200,000 so if you do the math you get 0.005mg or 5 mcg/ml or you can convert it into mcgs up front and do the math as 1,000,000 mcg in 200,000 which then equals 5mcg/mL or just do it you way! I just need to show proof why I answer something)

Question 83

Epidural Anesthesia: Adrenergic Agonists Epinephrine 5mcg/ml, has been shown to prolong blocks of lidocaine and mepivicaine by as much as \_\_%

Answer 83

80

Question 84

Epidural Anesthesia: Adrenergic Agonists epinephrine has been shown NOT to significantly prolong bthe duration of anesthesia when added to concentrated solutions of ______ and ______ used for surgical anesthesia

Answer 84

bupivacaine Ropivacaine

Question 85

Epidural Anesthesia: Adrenergic Agonists as stated epinephrine does not increase the block when added to high concentrations of bupivacine and ropivacaine in surgical anesthesia, but what about when added to more dilute concentrations of bupivacaine used for OB

Answer 85

it has beenshown to incrase the duration and quality of block (but no one knows why?)

Question 86

Epidural Anesthesia: Adrenergic Agonists although NEVER proven why is it thought that epinephroine prolongs the duration of a block

Answer 86

throough vasoconstriction it slows systemic absorption and elimination

Question 87

It is often easier to deal with a block that is too high or too long than to cover uo for a block that is too low or not dense enough

Answer 87

justa little tip!! enjoy it, embrase it

Question 88

tip #2 i's always better to have a little more than a little less, especially with regional anesthesia

Answer 88

as in all great things in life

Question 89

Epidural Anesthesia: Technique what should always be immediatly avail when doing an epidural?

Answer 89

emergency equipment and monitors

Question 90

Name the positions as extension or flexion?

Answer 90

1. extension 2. flexion

Question 91

label the pic as extension or flexion

Answer 91

1. extension 2. Flexion

Question 92

Epidural Anesthesia: Technique Name the most commonly performed epidural in order from most common to least common

Answer 92

* Lumbar * caudal * thoracic * Cervical

Question 93

Epidural Anesthesia: Technique today most high thoracis and cervical epidurals are performed under what and by whom

Answer 93

* flouroscopic guidance * pain specialist

Question 94

Epidural Anesthesia: Technique as you can see from the diagram * the lumbar region is at or greater than a 90 degree angle * thoracic is more acute * and cervical is between the 2

Answer 94

Question 95

Epidural Anesthesia: Technique WHy is the lumbar region is by far the eastiest area to perform an epidural? (4 reasons)

Answer 95

1. angle of spinous process 2. larger spaces b/t spinous processes 3. easialy identifiable locations (illiac crest) 4. epidural width the greatest

Question 96

Epidural Anesthesia: Technique with a spinial the practicioner looks to find CSF to confirm by peircing the dura to find proper location. in an epidural where does the practicioner want to place the tip.

Answer 96

into the fat filled space DEEP to the ligamentum Flavum and SHALLOW the DURA

Question 97

Epidural Anesthesia: Technique is performed with what gauge neddles?

Answer 97

16 17 0r 18

Question 98

Epidural Anesthesia: Technique what tyoe tipped needle

Answer 98

blunted

Question 99

Epidural Anesthesia: Technique name the epidural needles

Answer 99

1. Standard Tuohy 2. Blunt tip 3. Crawform needle (thin walled) 4. Weiss winged needle

Question 100

Label

Answer 100

1. Dura 2. Spinal 3. Epidural 4. Touhy needle

Question 101

Epidural Anesthesia: Technique lets go name the steps!!!! start from the begining you are doing this mother fucker and need to own it

Answer 101

1. identify landmarks and plan interspace of insertion 2. position pt 3. sterile prep and drape with insertion site in center of drap (where hole is located) 4. Local anesthetic (lido 1% plain) 1-2 mL wioth 25 g skin needle 5. firmly place back of your NON-dominant hand against the patients skin below the epidural needle 6. grasp the needle (and eventually the hub once epidural space is found b/t your thinb and index finger of NON-dominant hand) (called the ***_Bromage grip)_*** 7. the epidural needle is placed bevel up and introduced into the skin 8. passed slowly throught th esupraspinous ligament and seated in the interspinous ligament before stylet is removed (\*\* you can tell the needle is in the interspinous ligament by letting go of the needle it should be supported in the same position, and not drop down) 9. After stylet removed the needle is advenced using the LOR tech 10. As the syringe/needle combo is advanced pressure is applied to the plunger of the syringe by "bouncing" or intermittently applying pressure to the plunger 11. the pattern is move-bounce-move-bounce-move-bounce until LOR is obtained 12. as the needle passes throught the ligamentum flavum, resistance increases and you may feel a distinct pop as you pass through it 13. once throught the LF you will experience an immediate LOR and then the tip of the needle will be in the epidural space 14. once the eidural space is reached pass your stylet throough the needle to make sure there is no tissue plugs possiably blicking the flow of CSF (with an inadvertent Dural punture) 15. Once in is confirmed begin by injecting a TEST DOSE of 3 cc of LA with epi (lido 1.5 w/epi) 16. watch monitor at look for HR increase within 30 sec (intravascular) 17. question the pt on ringing in ears metalic taste in mouth or cirum-oral numbness or punding in chest 18. wait 3 min to assess for numbness or weakness in LE (dural injection) 19. is all good give meds or pass catheter

Question 102

just some pics

Answer 102

Question 103

Just a pic

Answer 103

Question 104

Just a pic

Answer 104

Question 105

Label this

Answer 105

1. Ligamentum flavum 2. Epidura; Space 3. Dura 4. Cauda quina 5. Supraspinous ligament 6. Intraspinous ligament 7. Ligamentum flavum 8. Epidural space 9. Dura

Question 106

Epidural Anesthesia: Technique the local for skin is usually what? b/c it usually found in the kit and alays consitant

Answer 106

1-2 cc 1% plain

Question 107

Epidural Anesthesia: Technique what is the "grip" called when doing the epidural

Answer 107

Bromage grip

Question 108

Epidural Anesthesia: Technique the needle goes in with the bevel in what direction?

Answer 108

up

Question 109

Epidural Anesthesia: Technique when is the stylet removed

Answer 109

when in the intraspinous ligament

Question 110

Epidural Anesthesia: Technique what is used to obtain LOR

Answer 110

glass syringe filled with either 3-4 cc of air or NS or mixture of both

Question 111

Epidural Anesthesia: Technique once usuing LOR tech the needle should be advanced how much at a time and the retested for LOR

Answer 111

0.5-1cm at a time

Question 112

Epidural Anesthesia: Technique the syringe needle combo is advanced applying pressure the needle or syringe?

Answer 112

needle

Question 113

Epidural Anesthesia: Technique in younger pts in OB you may not notice a distinct "pop" what might you only notice

Answer 113

LOR

Question 114

Epidural Anesthesia: Technique once in the epidural space why do you replace the stylet?

Answer 114

to remove any tissue to asses for CSF leakage

Question 115

Epidural Anesthesia: Technique what is teh typical test dose

Answer 115

3 cc of lido 1.5% with epi

Question 116

Epidural Anesthesia: Technique if u inject intravascular you will see an increase in HR how fast

Answer 116

30 sec

Question 117

Epidural Anesthesia: Technique besides watching HR with test dose what might you want to ask the pt with the test dose?

Answer 117

* Ringing/buzzing in ears * metallic taste * circum-oral numbness * punding in chest *

Question 118

Epidural Anesthesia: Technique if you happen to inject the test dose in the dural space what might the pt have that you want to assess for? and how long does it take to show up?

Answer 118

* numbness or weakness or pins and needle sensation in LE * 3 minutes

Question 119

Epidural Anesthesia: Technique pros to advancing catheter first

Answer 119

* you can slowly raise the level of anesthesia and have better control and less incidence of sympathetic block

Question 120

Epidural Anesthesia: Technique cons of catheter placement first

Answer 120

* cath may not go into correct space * may come out on nerve root * may kink or coil * thus giving a useless epidural or patchy at best

Question 121

Epidural Anesthesia: Technique pros of injection first

Answer 121

* LA opens up and distends epidural space makiing it easier to pass catheter * if catheter fails you still have a complete block for a while

Question 122

Epidural Anesthesia: Technique regardless what tech is used as you pas the catheter the patient should be warned that while movement of catheter they may feel what? and why?

Answer 122

* electrical shock or funny bone feeling * b/c cath tip brushing up against nerve root or two as it is passed in epidural space

Question 123

Epidural Anesthesia: Technique as the cath is passes you may feel initially some rersistance at the tip, what should you do?

Answer 123

give a slightly stringer push

Question 124

Epidural Anesthesia: Technique the catheter should be inserted between what depths

Answer 124

3-5 cm no more than 3-5 black lines

Question 125

Epidural Anesthesia: Technique NEVER do what with the catheter?

Answer 125

pull back throught the needle once it has been inserted

Question 126

Epidural Anesthesia: Technique whay do you never want to pull the catheter back throught the needle?

Answer 126

* there is a possibility to catch the catheter on the needle tip and shear or cut the tip off * then it becomes a permanent new addition to the epidural space and will be there for the rest of the patients life!!! way to fuck that up

Question 127

what are the 2 most dreadful words by an SRNA performing an epidural?

Answer 127

WET TAP

Question 128

PDPH occurs in up to \_\_% of pts who have a dural puncture with a touhy needle?

Answer 128

75%

Question 129

WET TAP:Treatment how do you treat it with consevation tech

Answer 129

* IV fluids * analgesics * IV/PO caffine * lying flat in dark room

Question 130

WET TAP:Treatment what are invasive treatment tech

Answer 130

* epidural blood patch * although invasive it is effective 90% of the time

Question 131

Caudal anesthesia: used for what sx's

Answer 131

* anorectal sx in adults * pediactrics

Question 132

Caudal anesthesia: Caudal anesthesia involves needle ot catheter penetration of the ______ \_\_\_\_\_\_\_\_ covering the sacral hiatis

Answer 132

Sacrococcygeal ligament

Question 133

Caudal anesthesia: the sacral hiatus is created by the unfused __ and ___ lamina

Answer 133

S4 and S5

Question 134

Caudal anesthesia: the sacral hiatus can be felt as a grove or notch where?

Answer 134

aboove the coccyx and b/t 2 bony prominences, "the sacral Cornua

Question 135

Caudal anesthesia: pic of sacral hiatus

Answer 135

Question 136

Caudal anesthesia: how is the block performed?

Answer 136

* The posterior Superior Illiac Spines and the sacral Hiatus form a triange * pt placed prone or lateral decubitus * sterile prep * needle or cath is inserted at 45 degree angle to the skin until a "pop" is felt * then the angle is droped and advanced aspirating for blood or CSF Q 1-2 cm

Question 137

LAbel this pic

Answer 137

1. Sacrococcygeal ligament 2. Sacral hiatus 3. Sacral canal 4. Dural sac

Question 138

Label this

Answer 138

1. PSIS 2. PSIS 3. Sacral hiatus

Question 139

Caudal anesthesia: advantage for adults with anorectal procedures

Answer 139

can provide dense sacral sensory blockade with limited cephalad spread

Question 140

Caudal anesthesia: usual dose of anesthetic

Answer 140

15-20cc of 1.5-2% lidocaine with or w/o epi

Question 141

Caudal anesthesia: shuld be avoided in pt's with what

Answer 141

pilionidal cyst