Master Deck Flashcards
(139 cards)
1
Q
What is the outermost layer surrounding the spinal cord?
A
Dura mater
2
Q
The dural sac terminates at what level?
A
S2
3
Q
What are the cardioaccelerator nerve fibers? (Select 4)
A
T1 - T4
4
Q
What is the absolute contraindication of spinal anesthesia?
A
Patient refusal
5
Q
Sensory blockade of which level is necessary for upper abdominal surgery?
A
T4
6
Q
For isobaric solution, what is the most important factor in determining the spread of the local anesthetic in subarachnoid block?
- Dose
- Concentration
- Volume
- Baricity
A
Dose
7
Q
Chloroprocaine is (Select 2)
- metabolized by the Liver
- (–) enantiomer of racemic procaine
- an ester local anesthetic
- short acting local anesthetic
A
- an ester local anesthetic
- short acting local anesthetic
8
Q
The blood in the venous sytem represents what amount of the total blood volume?
A
75%
9
Q
The effects of Bezold-Jarisch reflex are manifested as (Select 3)
- bradycardia.
- hypotension.
- coronary dilation.
- tachycardia.
- vasoconstriction.
- hyperventilation.
A
bradycardia.
hypotension.
coronary dilation.
10
Q
The diaphragm is innervated by?
A
C3 - C5
11
Q
The incidence of cauda equina syndrome is linked to high dose of which local anesthetic?
A
Lidocaine
12
Q
The patient allergic to para-aminobenzoic acid will most likely develop hypersensitivity to?
- Tetracaine
- Benzocaine
- Cocaine
- Bupivacaine
- Lidocaine
- Ropivacaine
A
Tetracaine
Benzocaine
Cocaine
13
Q
Which local anesthetic has high affinity to cardiac toxicity?
A
Bupivacaine
14
Q
Two mL of hyperbaric bupivacaine 0.75% concentration is equivalent to how many mg?
A
15mg
15
Q
What is the dermatome level for the umbilical area?
A
T10
16
Q
What needle offers the better control for an epidural
A
Winged Tuohy
17
Q
At what interval & how long are VS monitored after a spinal?
A
Q3mins for 15-20mins
18
Q
At what interval & how long are VS monitored after an epidural?
A
Q5mins for 20-30mins
19
Q
The spread of a spinal block is?
What about the spread of an epidural?
A
- Higher than expected
- As expected & can be controlled with LA volume
20
Q
The nature of a spinal block is ____ & it is ____ for an epidural?
A
- Dense
- Segmental
21
Q
Which neuraxial block is more likely to cause hypotension?
A
Spinal (SAB)
22
Q
What are the onset times for a spinal & epidural?
A
- Spinal= 5mins
- Epidural= 10-15mins
23
Q
What is the max dose for a spinal?
A
3cc
24
Q
What is the max dose for an epidural?
A
~20cc
25
What is the max dose for an epidural?
~20cc
26
The LA concentration for a spinal is what?
Fixed
27
Which neuraxial is influenced by gravity?
Spinal
28
Which neuraxial is more likely to cause LA toxicity?
Epidural d/t more veins
29
How many mL dose each segment hold in an epidural?
1-2mL
30
Spinal anesthesia is usually performed for procedures involving what?
- Lower abdomen
- perineum
- lower extremities
31
What is the preferred neuraxial for C-sections?
Spinal
32
What are the absolute contraindications for an SAB?
- Coagulopathy
- Sepsis
- Pt refusal
- Dermal site infection
- Hypovolemia
- Spinal cord disorders
- Valvular heart disease
33
With what aortic stenosis area (cm²) is a spinal contraindicated?
What about MS?
- AS= <1.0 cm²
- MS= <1.0 cm²
34
What neuraxial approach should be used with spinal column deformities?
Perimedian approach
35
At what dermatome level should one start for a thoracic epidural?
T7 & then can go up
36
How many spinal nerves are there?
31 pairs
- 8 cervical
- 12 thoracic
- 5 lumbar
- 5 sacral
- 1 coccyx
37
How many cervical spinal nerve pairs are there?
8 pairs
38
What helps locate the sacral hiatus?
The sacral cornu to either side
39
What is the needle approach with thoracic neuraxial?
Cephalad
40
Where are adipose tissue & blood vessels located in the epidural space?
Laterally
41
What is the average lumbar distance from skin to ligamentum Flavum?
4-6cm
42
In most adults the spinal cord ends at ____ & at ____ for children?
- L1
- L3
43
The dural sac terminates at what location?
S2
44
What conditions cause low CSF?
- Obesity
- Pregnancy
- ascites
- increased abdominal pressure
45
LA anesthetic selection depends on?
- Type of surgery
- Length of surgery
- Surgeon
46
Which LA is not mixed with Epinephrine?
Ropivicaine
47
What class of medications are used as neuraxial adjuncts?
- Opioids
- Alpha-2 agonists
- Vasopressors
48
How do vasopressors affect neuraxial anesthesia?
The extend the duration only
49
How do alpha-2 agonists affect neuraxial anesthesia?
Improve density, duration & analgesia
50
How do opioid adjuncts affect neuraxial anesthesia?
Intensify the block/density
- Do not extend the duration
51
What are the spinal doses for
- Morphine
- Fentanyl
- Sufentanil
- Morphine: 100 - 400 mcg
- Fentanyl: 10 - 25 mcg
- Sufentanil: 2.5 - 10 mcg
52
What are the epidural doses for
- Morphine
- Fentanyl
- Sufentanil
- Morphine: 3 - 5 mg
- Fentanyl: 50 - 100 mcg
- Sufentanil: 10 - 25 mcg
53
Fentanyl & Sufentanil cause early respiratory depression due to being?
Lipophilic
54
What is a very common side effect of neuraxial anesthesia?
Pruritis
55
Neuraxial pruritis can be?
- Treated with:
- Prophylaxis:
- Treat: benadryl 25-50 mg IV, Naloxone 0.1 mg IV, Buprenex
- Prophylaxis: Minimize morphine dose <300mcg, Zofran 4 - 8 mg, Nubain 2.5 - 5 mg
56
What med can help prevent neuraxial hypotension?
Zofran 4 - 8 mg
57
What happenz to a SAB when Tetrcaine is mixed with a vasoconstrictor?
Profound increase in length of block
58
What med is given to prevent the 5 & Dime reflex?
Robenol (Glycopyrrolate)
59
What is the neuraxial adjunct dose for precedex?
3 mcg
60
What is the neuraxial adjunct dose for Clonidine?
15 - 45 mcg
61
What is the neuraxial adjunct dose for epinephrine?
0.2 - 0.3 mg
62
What is the neuraxial adjunct dose for phenylephrine?
2 - 5 mg
63
What factors affect LA uptake into neural space?
- LA concentration in CSF
- Surface area of neural tissue
- Lipid content of the nerve
- Blood flow to the nerve
64
List the affected nerves for a SAB in order first to last?
1) B-fibers
2) C-fibers
3) A-delta fibers
4) A-alpha, A-beta & A-gamma
65
C-fibers transmit ____ information & B-fibers transmit ____information?
- Sensory
- Sympathetic
66
Blocking C & A-delta fibers will result in the loss of?
Pain & temperature senses
67
What fibers are used for motor tone?
A-gamma
68
Proprioception & motor function is controlled by what fibers?
A-alpha
69
The sympathetic level is ____ levels higher/lower than the sensory?
- 2 - 6 levels
- higher
70
The sensory level is ___ levels higher/lower than the motor level?
- 2 levels
- higher
71
How are LA's eliminated from the SAB?
Via vascular reabsorption
72
What drug factors are the most important affecting LA distribution & block height?
Dose & Baracity
73
What patient factors are the most important affecting LA distribution & block height?
- CSF Volume
- Advanced age
- Pregnancy
74
What procedure factors are the most important affecting LA distribution & block height?
- Pt position
- Epidural injection post spinal (EVE)
75
What type of LA is best suited for C-sections or hysterectomy?
Hyperbaric LA
76
What is the best LA type for prone cases?
Hypobaric
77
What are the doses of Hyperbaric SAB in Non-Obstetric patients?
- @ T4
- @ T10
- @ sacral
- T4= 2 mL
- T10= 1.5 mL
- Sacral= 1 mL
78
What is barbotage?
Aspirating CSF & seeing the "swirl" mixing into the LA
79
What is the Bezoid-Jarisch reflex?
The body tries to normalize cardiac function --> bradycardia
80
What can be given to inhibit the Bezoid-Jarisch reflex?
Zofran 4 - 8 mg IV
81
What fibers maintain arterial & venous tone?
Preganglionic B-fibers
82
What fluids are the best option for preloading?
Warmed Isotonic solutions
83
Why are glucose containing solutions avoided in neuraxial anesthesia?
Glucose leads to increased u/o, which can lead to more hypotension
84
What is the best option for normovolemic hypotension?
Ephedrine
85
GI sympathetic outflow originates at what dermatomes?
T6 - L1
86
A Pt complains of nausea after neuraxial anesthesia, what is most likely going to happen & how can it be averted?
- Hypotension
- Treat with ~ 1cc Neo
87
What VS monitoring is definitely needed for a spinal?
BP & SpO2
88
What is the dose for intralipid rescue?
1.5 mL/kg bolus --> 0.25 mL/kg drip
89
What dermatome correlates with the testicles?
S2
90
Vaginal delivery or a TURP require a block up to which dermatomes?
T10
91
What two needles increase the chances of a spinal headache?
Quincke & Pitkin (they are cutting needles)
92
What is the quickest way to determine if the fluid coming out of the spinal needle is CSF?
The fluid will be warm
93
How is a Pt positioned while performing a lateral spinal?
- Legs flexed up to abdomen
- Forehead flexed down towards knees
94
What solution will result in a swirl?
Hyperbaric solutions
95
When is a paramedian approach needed?
For a Pt with scoliosis or someone with rods.
96
What will be bypassed in a spinal with a paramedian approach?
- The supraspinous ligament &
- The interspinous ligament
97
The spinal needle is in the right place but you get no CSF, what do you do?
- rotate needle 90° & wait 10-15 sec
- insert stylet & remove it
- try aspirating
- withdraw needle & try again
98
There is blood in your spinal needle, what do you do?
- check if it clears up after a few drops of CSF
- reposition the needle if blood continues to drip
99
During a spinal the Pt complains of pain in the leg, what do you do?
- Ask the Pt where the pain is
- Do not inject anything
- Withdraw the needle and direct more medially
100
During a spinal you continue to hit bone, what do you do?
- Reposition Pt
- Change needle if damaged
- Try a different interspace or paramedian approach
- Stop after 3 attempts
101
You hit a bony prominence early during a spinal, how do you direct your needle?
Direct it caudal
102
You hit a bony prominence late during a spinal, how do you direct your needle?
Direct it cephalad
103
What is an early symptom of a high spinal?
Inability to phonate
104
What are the causes of a high spinal?
- Excessive dose
- Failure to reduce dose in elderly, obese, & short ppl)
- Rapid injection
- Improper position after SAB
- unrecognized intrathecal placement of epidural catheter
105
Where would a PDPH headache located & what exacerbates it?
- Located in frontal & occipital lobes
- Upright position makes it worse
106
What possible S/S are associated with PDPH?
- Photophobia
- Diplopia (CN 5v1)
- Tinnitus (CN 8)
- seizures
107
What are the treatments for PDPH?
- Supine position
- NSAIDs, narcotics (fentanyl)
- Methylxanthine (caffeine) (caution in elderly sensitive to caffeine)
- Blood patch
108
What is the dose for caffeine PO or IV?
300 - 500 mg daily or BID
109
Describe a blood patch?
- The patch will be 1 level lower than the tap
- Need a fresh IV
- Pre-medicate Pt as injection of blood can be painful
- Place Pt in lateral position (for comfort)
- Once in epidural space get 20cc of blood from new IV
- Inject 20cc into epidural space
110
When do transient neurologic symptoms start after a spinal?
What are the S/S?
When does it resolve?
What med has a higher incidence?
- Develops after block resolves
- Severe radicular back pain
- 90% resolve within a week
- Higher incidence with 5% lidocaine
111
What are the S/S of cauda equina syndrome?
- Bowel/bladder dysfunction
- paraplegia (late sign)
- back pain
- saddle anesthesia
- sexual dysfunction
112
What are the S/S of Honer's syndrome?
Ptosis, anhydrosis & Miosis
113
What 3 nerves are blocked during an awake intubation?
- Trigeminal (5₂)
- Glossopharyngeal (IX)
- Vagus (X)
114
How is CN 5₂ blocked?
With cocaine on a Q-tip into the nostrils for 5mins
115
How is CN 9 blocked
With a tongue depressor wrapped in 4x4 coated with lidocaine & have Pt suck on it for 5mins
116
How is the vagus nerve blocked for an awake intubation?
Inject lidocaine anteriorly and have Pt cough to spread the lidocaine.
117
What 3 things can cause arachnoiditis?
- nonapproved drugs into the intrathecal or epidural space
- using non-preservative free solutions
- betadine contamination
118
What are the S/S of spinal/epidural hematomas?
- Pain is a major sign
- Numbness/weakness
119
Which procedure has a higher incidence of systematic toxicity, spinal or epidural?
Epidural, hence the test dose
120
What's the antibiotic of choice for prophylaxis?
- Cephalosporins
121
What would one change to decrease to the chances of a spinal/epidural abscess occuring?
Use CHG + alcohol instead of povidine-iodine
122
To maintain the ability to walk, where does an epidural have to be?
Has to be above T10
123
What are the disadvantage of epidurals?
- slower onset
- longer time to perform
- less dense block
124
For thoracic epidurals, one should adjust their needle approximately how many degrees cephalad?
35° - 55°
125
How does an increased pH affect epidurals?
The diffusion is increased
126
What are the 2 determinants of epidural block spread?
- Site of injection
- volume & dose of LA
127
What is the segmental dose for epidurals?
1-2 mL per segment
128
What can one ask the Pt during an epidural test dose to ensure placement?
- Do you have any ringing sensation?
- Do you have a metallic taste?
- Any oral numbness
129
What does adding Epi to an epidural result in?
Increased duration of the block
130
What is the phenylephrine dose for epidurals?
2 - 5 mg
131
Adding bicarb to an epidural will help with?
- Increases the rate of diffusion of the drug
- increases the speed of onset of the block
132
What is the downside of 2-chloroprocaine in epidurals?
What about the benefit?
- Downside is decreased efficacy of subsequent epidural opioids
- Must be re-dosed every 45mins
- Benefit of rapid onset
133
Which LA has the greatest motor function depression in epidurals?
What about the least?
- greatest: Lidocaine
- least: Ropivacaine
134
When is the Crawford needle preferred?
- In thoracic epidurals.
- Or difficult or steep angle placements
135
What is the downside to single opening epidural catheters?
Can cause spotty blocks
136
What is the test dose for epidurals?
3cc of 1.5% Lidocaine with Epi 1:200,000
137
What indicates a positive epidural test dose?
- 20% increase in HR
- Tinnitus, metallic taste, circumoral numbness
138
An epidural Pt complains of severe depressed motor function 5mins after the epidural, what is the cause?
The procedure resulted in a spinal block rather than an epidural
139
How much Bicarb is added to the LA for an epidural?
1 meq per 10 mL of LA
