Exam 1 Spinal & Epidural Neuraxial Anesthesia [5/28/24] Flashcards
(68 cards)
1
Q
What cannot be given through the spinal?
A
Reglan and Zofran `
3
2
Q
What are the clinical Indications for neuroaxial anesthesia?
A
- Surgical procedures involving the lower abdomen, perineum, and lower extremities
- Orthopaedic surgery [alot of spinals]
- Vascular surgery on the legs
- Thoracic surgery (adjunct to GETA) [usually epidurals]
S5
3
Q
What are the 6 benefits for neuraxial anesthesia?
A
Reduces the following:
1. Postoperative ileus
2. thromboembolic events
3. PONV
4. Respiratory Complications
5. Bleeding
6. Narcotic Usage
S6
4
Q
List the other benefits of neuraxial anesthesia.
A
- Great mental alertness
- Less urinary retention*
- Quicker to eat, void, and ambulate
- Avoid unexpected overnight admission from complications of general anesthesia
- Quicker PACU discharge times*
- Preemptive anesthesia
- Blunts stress response from surgery
S7
5
Q
If using neuraxial anesthesia, and the pt needs to be put to sleep but needs to maintain respiratory drive what can be administered?
A
- Propofol
- 100-300 mcg/kg
S7
6
Q
What are the relative contraindication for neuroaxial anesthesia
A
- Deformities of spinal column [issues w/positioning]
- Preexisting disease of the spinal cord [residual weakness]
- Multiple Sclerosis, post polio syndrome
- Chronic headache/backache
- Inability to perform SAB/Epidural after 3 attempts
S8
7
Q
Why are chronic headaches/backaches a relative CI for neuroaxial anesthesia?
A
- A complication of neuroaxial anesthesia is post-dural puncture heacache.
- if pt has backpain, and we are sticking needes in the back it might worsen the pain
S8
8
Q
What are the absolute CI for neuroaxial anesthesia?
A
- Coagulopathy
- Patient refusal
- Evidence of dermal site infection
- known coag disoder or on anticoagulants
- Severe or critical valcular heart disease
- HSS [idiopathic hypertrophic subaortic stenosis]
- Operation >duration of LA
- Increased ICP
- Severe CHF
Contraindicated Patients Don’t Seem Happy Or Invincible Systematically
S9-10
9
Q
What are the coagulation problems that are absolute contraindications for neuroaxial anesthesia
A
- INR > 1.5
- PLT < 100,000*
- PT, PTT, BT x 2
10
Q
List the factors involved in the coagulation cascade
* Intrinsic
* Extrinsic
* Common
A
- Intrinsic: 12, 11, 9, 8
- Extrinsic: 3, 7
- Common: 10, 5, 1, 2,13
S9
11
Q
PT/INR measures?
PTT measures?
A
- PT/INR = extrinsic
- PTT = intrinsic
S9
PT = PLAY TENNIS OUTSIDE = EXTRINSIC
PTT = PLAY TABLE TENNIS INSIDE = INTRINSIC
12
Q
What does the bleeding time look at?
A
- Examines PLT activation and adhesion.
- longer BT = problem with PLTs.
S9
13
Q
What severe valvular heart diseases are absolute CI for neuroaxia anesthesia?
A
- Aortic stenosis <1cm2
- Mitral stenosis <1cm2
S10
14
Q
List the valve area for AS for the following:
* Mild
* Moderate
* Severe
* Critical
A
- Mild: >1.5 [greater than or equal to]
- Moderate: 1.0 - 1.5
- Severe: 0.7 - 1.0
- Critical: < 0.7
cm2
15
Q
What is the average course of valvular aortic stenosis in adults
A
- Age 35-40: increasing obstuction, myocardial overload
- Age 60: onset of severe symptoms **
- Age 63: average age of death.
S10
16
Q
What are the s/sx of severe or critical AS? What are its survival rates?
A
- Angina - 5yrs
- Syncope - 3yrs
- Heart failure - 2 yrs, the worst [NYHF 3 or 4]
S10
17
Q
What is the death spiral that occurs due to AS?
A
- hypotension causes myocardial ischemia
- ischemia contractile dysfunction
- decreases CO
- worsening hypotension
- increased ischemia
S10
18
Q
Compare & Contrast the following characteristics of spinals and epidural:
* Onset
* Spread
* Nature of block
* Motor block
* Hypotension
A
S11
19
Q
Compare & Contrast the following characteristics of spinals and epidural:
* Onset
* Duration
* Placement level
* Difficulty of placement
* Dosing
* Concentration
* LA toxicity
* Gravity influence
* Manipulation of dermatome spread after dosing
A
S10
20
Q
What is the placement and needle size for spinals?
A
- Placement:L4-L5
- Smaller needle: 25-27g
S12
21
Q
What is the placement and needle size for epidurals?
A
- Placement: anywhere there is epidural space
- bigger needle: 18-19 g
- can do epidurals by thoracic but draw back is accidentally hitting the spinal cord.
S12
22
Q
Positioning affects epidurals or spinals?
How would you postion a pt with right hip pain?
A
- Affects epidurals
- pain in right buttock - turn to right side to have LA stay on that side.
S12
23
Q
How many total vertebras do we have?
* Total:
* Cervicle:
* Thoracic:
* Lumbar:
* Sacrum:
* Coccyxs:
A
- Total: 33
- Cervicle: 7
- Thoracic: 12
- Lumbar: 5
- Sacrum: 5
- Coccyx: 4
S14
24
Q
What are the 4 curvatures of the spine?
A
- Normal
- Scoliosis
- Kyphosis
- Lordosis
S14
25
Each vertebra, except for ____, is divided into two main parts:
* The____ segment, known as the body.
* The ____ segment, called the vertebral arch.
* C1
* anterior
* posterior
| slide 15
26
what 2 structures link the anterior and posterior segments?
the lamina and pedicle
| slide 15
27
The vertebral foramen is a crucicial space within the verbra why?
houses the spinal cord, nerve roots, and the epidural space, which is a protective cushioning area around the spinal cord.
| slide 15
28
The ____ processes stick out to the sides (lateral), while the ____ processes stick out towards the back (posterior).
* transverse
* spinous
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29
what attach to the spinous and transverse processes to help stabilize and support the spine?
muscles
| slide 16
30
Cervical and thoracic spinous processes tilt ____, requiring a needle approach from ____.
* downward (caudal direction)
* above (cephalad approach)
| slide 17
31
Lumbar spinous processes stick out directly ____, which makes it easier to reach the spaces around the spinal cord, such as the ____ & ____ spaces.
* backwards (posterior)
* epidural and intrathecal spaces.
| slide 17
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These are the soft pads between each vertebra that act as shock absorbers.
intervertebral disc
| slide 18
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These are the openings between the vertebrae where spinal nerves exit the spine.
intervertebral foramina
| slide 18
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whati s the function of the facet joints?
They help guide and limit the spine's movement, keeping the back's motions controlled.
| slide 19
35
# surface landmarks
where is the superior aspect of the iliac crest?
L4
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where is the posterior superior iliac spine?
S2
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37
what is tuffier's line [intercristal line]?
This horizontal line runs across the top edges of the hip bones (iliac crests) and matches the L4 vertebra
| slide 20
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Tuffier's Line helps identify the correct spaces between vertebrae for inserting spinal anesthesia needels.
* The space above this line aligns with the ____ vertebrae.
* The space below this line aligns with the ____ vertebrae.
* L3 - L4
* L4-L5
| slide 20
39
in infants up to one year the intercristal line corresponds with the ____ intervertebral space
L5-S1
| slide 20
40
The sacrum is a triangular-shape section of fused vertebra (5). The lamina of ____ is incomplete and bridged only by ligaments.
S5
| slide 22
41
Sacral Hiatus
* location?
* covered by?
* purpose?
* Located at the base of the sacrum and aligns with the S5 vertebra.
* Covered by the sacrococcygeal ligament.
* Acts as an access point to caudal anesthesia
| slide 22
42
Sacral Cornua
* The projections of the articular processes are known as cornu
* The sacral cornu are the “horns” or bony protuberances that guard the area of the ____
* Landmark for ____ anesthesia
* sacral hiatus
* caudal
| slide 22
43
Components of the spinal cord?
* starts at the medulla oblongata
* conus medullaris
* caurda equina
* dural sac
* filum terminale
| slide 23/24
44
the spinal cord has a ____ origin, starting in the ____.
* rostral origin
* medulla oblongata
| slide 24
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* What is the conus medullaris?
* where does it end in adults?
* where does it end in infants?
* where the spinal cord tapers off at the end
* In adults, it ends between the L1 and L2 vertebrae. (L1 in most textbooks)
* In infants, it ends at L3.
| slide 23
46
* what is the cauda equina?
* what does it consist of?
* A bundle of spinal nerves extending from conus medullaris to the dural sac.
* Consists of nerve roots from L2 to S5 vertebrae and the coccygeal nerve.
| slide 23
47
* Dural sac:
* where does it end in adults?
* where does it end in infants?
* Ends at S2 in adults.
* Ends at S3 in infants.
| slide 24
48
* The filum terminale is a continuation of the ___?
* It extends from the ___ to the ___.
* what is its main function?
* It is a continuation of the pia mater.
* It extends from the conus medullaris to the tailbone (coccyx).
* Its main function is to anchor the spinal cord to the coccyx.
| slide 24
49
Describe the internal filum terminale:
* Begins at the conus medullaris, extending to the dural sac.
* L1-S2
| slide 24
50
Describe the External Filum terminale:
* Starts from the dural sac and extends into the sacrum.
* S2-S5
51
how does the spinal cord receive blood supply?
* one anterior spinal artery
* two posterior spinal arteries
| slide 25
52
Anterior spinal artery
* origination?
* supplies what part of the cord?
* how much does it supply?
* Originates from the vertebral artery.
* Supplies the front (motor) portion of the spinal cord.
* Supplies the anterior 2/3 of the spinal cord
| slide 25
53
Two posterior spinal arteries
* Emerge from the ____.
* Originates from the ____ artery.
* Supply the ____ portion of the spinal cord.
* cranial vault
* vertebral
* posterior (sensory
| slide 25
54
what part of the cord has better protection from ischemia the posterior or anterior?
* The posterior spinal arteries are paired and have many connections from the **subclavian** and **intercostal arteries**.
* These connections help protect the **sensory** part of the spinal cord from ischemia.
| slide 25
55
what are symptoms of anterior spinal artery syndrome?
* Motor paralysis.
* Loss of pain and temperature sensation below the affected area.
| slide 26
56
what are causes of ischemia that can lead to anterior spinal artery syndrome?
* Low blood pressure (profound hypotension).
* Mechanical blockage.
* Blood vessel disease (vasculopathy).
* Bleeding (hemorrhage).
| slide 26
57
the anterior spinal artery receives additional blood slupply through what branches?
the **intercostal** and **iliac arteries**, though these are variable.
| slide 26
58
Artery of Adamkiewicz:
* what is it?
* where does it arise?
* damage to this can cause what?
* A crucial connection that supplies blood to the lower two-thirds of the spinal cord.
* It usually arises from the aorta between the T9and L2 regions
* Damage to this artery can also lead to anterior spinal artery syndrome.
| slide 26
59
what are the spinous ligaments posterior to anterior?
* Supraspinous Ligament
* Interspinous Ligament
* Ligamentum Flavum
* Posterior Longitudinal Ligament
* Anterior Longitudinal Ligament
| slide 27
60
Runs along the back, connecting the tips of the spinous processes from the upper back down to the lower back.
Supraspinous Ligament
| slide 27
61
Located between the spinous processes, providing stability by joining adjacent vertebrae.
interspinous ligament
| slide 27
62
* They are particularly thick in the lower back and form the sidewalls of the space outside the spinal cord (epidural space).
* Piercing this ligament indicates entry into the epidural space during procedures.
ligamentum flavum
| slide 27
63
Runs along the back side of the vertebral bodies inside the spinal column.
posterior longitudinal ligament
| slide 27
64
* Attached to the front of the vertebral bodies, running the length of the spinal column.
* Also connects to the outer fibers of the intervertebral discs, helping to bind the vertebrae together.
anterior longitudinal ligament
| slide 27
65
what layers are traversed during a midline spinal?
* Skin
* Subcutaneous fat
* Supraspinous ligament
* Interspinous ligament
* Ligamentum flavum
* Dura Mater **(POP)**
* Subdural space
* Arachnoid Mater
* Subarachnoid space
| slide 28
## Footnote
Silly Stupid SRNA, I Like Doing Spinal Anesthesia Swiftly
66
what layers are transvered during a paramedian approach?
* Skin
* Subcutaneous fat
* Ligamentum flavum
* Dura Mater
* Subdural space
* Arachnoid Mater
* Subarachnoid space
| slide 28
## Footnote
Stupid SRNA's Like Doing Spinal Anesthesia Supine
67
Why might we decide to use a paramedian approach?
What about patient Positioning?
* Use: When the interspinous ligament is calcified or the patient cannot flex their spine.
* Positioning: Can be performed while the patient is sitting, lying on their side, or face down.
| slide 28
68
Paramedian Approach Procedure:
* Insert the needle 15 degrees off the spine’s midline.
* Position the needle 1 cm to the side (lateral) and 1 cm below (inferior) the space between the vertebrae (interspace).
| slide 28
