Epidurals

Question 1

where does epidural work?

Answer 1

ant and post nerve roots & dorsal ganglia, and to a lesser extent ant/post rootlets and the spinal cord itself

Question 2

distance from skin to epidural space?

Answer 2

typically 4-6cm, can be 2-9 though so be careful

Question 3

what to do if you think epidural catheter is intravascular? (blood doesnt clear)

Answer 3

must remove catheter, try again one interspace higher

Question 4

what happens to epidural veins in preganancy?

Answer 4

become engorged, they are more lateral than midline in teh epidural space

Question 5

what size is tuohy needle?

Answer 5

18g

Question 6

who is more likely to get PDPH?

Answer 6

young people

Question 7

epidural catheter size?

Answer 7

19 or 20 guague

Question 8

how far to thread epidural catheter into epidural space?

Answer 8

3-5cm

Question 9

typicall epidural volume vs spinal volume?

Answer 9

epidural: 10-20cc
spinal: 1-2cc

Question 10

how much LA do you give in epidural to acheive the level you want?

Answer 10

give 1-2cc per segment blocked.

Question 11

which direction does the LA go in the epidural space?

Answer 11

both caudad and cephalad

Question 12

when is epidural dosing decreased?

Answer 12

elderly, obese, pregnancy

Question 13

physically how do you administer epidural meds?

Answer 13

give 3-5cc, wait 3-5min, give 3-5cc, wiat 3-5min, repeat until full dose given

Question 14

how long does chloroprocaine last?

Answer 14

50-70min

Question 15

how long does prilocaine last?

Answer 15

90-130min

Question 16

how long does lidocaine last?

Answer 16

90-150

Question 17

how long does mepivicaine last?

Answer 17

120-160

Question 18

how long does bupivicaine last?

Answer 18

200-260

Question 19

very important things to prepare for when give spinal or epidural?

Answer 19

airway mgmt and hypotension

Question 20

what is usually the largest interspace?

Answer 20

L2-L3

Question 21

where does epidural needle feel more secure and less flimsey?

Answer 21

in the interspinous ligament / ligamentum flavum, it will also feel more anchorded at this point. This is where you take out the stylet and connect saline/air filled syringe

Question 22

what do each of your hands do when performing an epidural?

Answer 22

non dominant: controls how much the needle is advanced

dominant hand: check syringe for loss of resistance

Question 23

what might you hit right before the epidural space?

Answer 23

the crunchies

Question 24

what must you do every time before you inject anything in epidural space?

Answer 24

aspirate! look for blood and CSF

Question 25

what is a test dose?

Answer 25

used to make sure you are not in an epidural vein. looking for HR to increaes 10-20bpm. Dont do during a contraction obviously

Question 26

if epidural is actually intrathecal, what movemement might the patient have a hard time with?

Answer 26

gas pedal

Question 27

medication doses for a test dose?

Answer 27

3ml of 1.5% Lidocaine (45ml) with 1:200,000 epi

Question 28

what might patieint feel if the test dose lidocaine is given in the intrathecal space?

Answer 28

may feel legs getting warm and heavy. stop injecting!

Question 29

totoal time for dosing and set up of an epidural?

Answer 29

20-30min

Question 30

what level is sacral hiatus?

Answer 30

S4

Question 31

in what pt population is the caudal epidural used?

Answer 31

pediatrics

Question 32

how to do a caudal block?

Answer 32

ID sacral hiatus, and sacral cornu which is 2: above the coccyx. use 22g short beveled needle at 45 degrees to the skin. you will feel pop or loss of resistance getting through the tough ligament. drop needle angle, adavance a couple cm and inject the drug

Question 33

how long does it take to get a good caudal block?

Answer 33

15min

Question 34

what surgeries are caudal blocks good for?

Answer 34

perineal surgeries used in peds with GA good for adults in perineal/rectal surgeries

Question 35

peds caudal epidural dosing?

Answer 35

0.5-1ml/segment

Question 36

what dermatome level needed for upper abd surgery?

Answer 36

T4

Question 37

what dermatome level needed for intestinal, gynecologic, and urologic?

Answer 37

T6

Question 38

what dermatome level needed for TURP?

Answer 38

T10

Question 39

what dermatome level needed for vaginal delivery or hip surgery?

Answer 39

T10

Question 40

what dermatome level needed for thigh surgery or lower leg amputation?

Answer 40

L1

Question 41

dermatome needed for foot and ankle surgery?

Answer 41

L2

Question 42

dermatome needed for perineal or anal surgery?

Answer 42

S2-S5 (saddle block)

Question 43

bupivicane concentration?

Answer 43

0.0625%-0.5%

Question 44

bupivicaine onset?

Answer 44

15-20min

Question 45

onset of 2 cholorprocaine?

Answer 45

5-15min

Question 46

onset of lidocaine?

Answer 46

10-20min

Question 47

onset of ropivicane, bupivicane, and levobupivicane?

Answer 47

15-20min

Question 48

what must you do if using depodur 15mg ER?

Answer 48

must do a test dose and flush with NS before using depodur. also meant to be used alone without LA

Question 49

Fentanly dose onset and doa?

Answer 49

50-100mcg onset 5-10min doa 2-6hr

Question 50

morphine dose onset and doa?

Answer 50

3-5mg (duramorph 5mg-10cc) onset 30min doa 12-24hr

Question 51

where do we want epidural opioids to end up?

Answer 51

get to the substania gelatinosa on spinal cord after getting through the dural cuff

Question 52

why might you need higher opiod doses in epidurals?

Answer 52

because of the epidural fat, lipphilic drugs may be sequestered there

Question 53

2 techniques for combined spinal/epdiural?

Answer 53

dural puncture epdidural technique needle through needle technique

Question 54

how far would you advance catheter into intrathecal space?

Answer 54

2-3cm

Question 55

how much fluid does spinal catheter hold?

Answer 55

0.25ml

Question 56

what was cauda equina syndrome related to?

Answer 56

microcatheters and hyperbaric lidocaine

Question 57

why is PDPH less with spinal catheter?

Answer 57

creates inflammation thought to plug the hole

Question 58

how to trouble shoot one sided block?

Answer 58

withdraw catheter one cm, put unaffected side in down position and re-dose

Question 59

what may be happening if getting parathesia with epidural placement?

Answer 59

could be in a root and not midline. if consistent parathesia pull out and start again

Question 60

where is an open ligamentum flavum most often seen?

Answer 60

between L1-L2

Question 61

what body response can make PDPH worse?

Answer 61

dilation of intracranila vessels to compensate for lost space

Question 62

S/S PDPH?

Answer 62

N/V, headache, feeling miserable, diplopia, photosensitive, extreme headache when sitting up

Question 63

when does PDPH prsent?

Answer 63

within 1-2 days, but can take up to 5 days

Question 64

how quickly will PDPH resolve without any tx?

Answer 64

usually 5-7days

Question 65

how to treat PDPH?

Answer 65

conservative first, bedrest, prone position, abd binder, IV fluids 3L/day caffeine sodium benzoate IV vasoconstrictor

Question 66

how does international calssification of headache disorders define PDPH?

Answer 66

onset within 15min of moving to the supine position with at least 1 of the following symptoms: headache, neck stiffness, tinnitus, photophobia or nausea

Question 67

differential dx for PDPH?

Answer 67

migraine, HTN, subarachnoid hemorrhage, meningitis, lactation headache, pneumocephalus (has postural component), brain tumor, sinusitis

Question 68

If caffeine and conservative measures for PDPH fail what do you do?

Answer 68

epidural blood patch

Question 69

how do you do an epidural blood patch?

Answer 69

aseptically draw up 10-20ml pt blood inject blood into epidural space 1 level lower than original puncture. need to inject 10-20cc, but 15 is optimum.

Question 70

common complaints with epidural blood patch?

Answer 70

pressure, back ache, hip fullness

Question 71

how effective our epidural blood patches?

Answer 71

get rid of 85-90% of PDPH on first try

Question 72

when can you repeat epidural blood patch?

Answer 72

in 24hours

Question 73

another symptom you may see with epidural blood patch?

Answer 73

bradycardia

Question 74

relative contraindications for epidural?

Answer 74

spinal pathology chronic headahce/backaches atempts failed after 3x

Question 75

epidural contraindications?

Answer 75

#1 pt refusall, or uncooperative pt infection or derm issues spetic shock high rapid blood loss case severe hypotension/hypvolemia increase ICP clotting issue severe AS or mitral stenosis (cant tolerate drop in BP)