Neuraxal 6/2 Flashcards
Test 1 (92 cards)
1
Q
What happens to each type of LA when a pt lays down when in injected at L4-L5?
A
Hypobaric: floats – increased concentration at L3
Isobaric: Mostly stays in place but will spread – decreased concentrations at T6 & S2
Hyperbaric: Sinks – increased concentrations at T6 & S2
2
Q
What are your high points when pt is supine? low points?
A
High: C3 & L3
Low: T6 & S2
3
Q
Trough =
A
Lowest point
4
Q
What is the furthest up a hyperbaric solution can go while supine? What can you do to make it go higher?
A
T6
T-burg
5
Q
Which way does the LA spread when injected?
A
Both cephalad (towards head) and caudad (towards bum) simultaneously
6
Q
How are LA eliminated from the body?
A
Reuptake via vascular reabsorption in the pia mater
6
Q
T/F: metabolism occurs in CSF
A
F
LAs are eliminated by reuptake via vascular reabsorption in the pia mater
7
Q
LA are lipo_______ therefore they last last _____ in fat
A
philic
longer
8
Q
Bupivacaine has a ______ duration of action than Lidocaine
A
longer
9
Q
Spinal concentration, Dosages, Range: Bupivacaine
A
0.5 - 0.75%
T10: 10-15mg
T4: 12-20mg
Range: 130-220 mins
10
Q
Spinal concentration, Dosages, Range: Levobupivacaine
A
0.5%
T10: 10-15mg
T4: 12-20mg
Range: 140-220 mins
11
Q
Spinal concentration, Dosages, Range: Ropivacaine
A
0.5-1%
T10: 12-18%
T4: 18-25mg
Range: 80-210 mins
12
Q
Spinal concentration, Dosages, Range: 2-Chloroprocaine
A
3%
T10: 30-40mg
T4: 40-60mg
Range: 40-90 mins
13
Q
Spinal Concentration, Dosages, Range: Tetracaine
A
0.5-1%
T10: 6-10mg
T4: 12-16mg
Range: 90-120 mins
14
Q
The average onset for SAB is _____
A
5 mins
15
Q
Which Spinal LA has the shortest duration of action? Longest?
A
Shortest: Chloroprocaine
Longest: Levobupivacaine
16
Q
Which spinal LAs can you add epi to? How long does it extend the time by?
A
Bupivacaine & Tetracaine
20-50%
17
Q
Why do you put saline/air in epidural space after LOR?
A
Helps open up the space more –> prevents catheter from kinking.
18
Q
Epidural test doses have lidocaine & ______ in them. Why?
A
epi
If inject into vein –> tachy
19
Q
We always ________ before giving an incremental dose. Why?
A
Aspirate
Make sure there’s no blood –> not in vein on lateral side
20
Q
When do we want to give a top off dose?
A
Sensory segmental block decreases by 2 dermatome levels
Ex) want to be at T4 but now at T6
21
Q
What is the fastest epidural LA? Why?
A
Chloroprocaine
Dt higher concentration of 2&3%
22
Q
The fastest ester is _______ & amide is _______
A
Chloroprocaine
Lidocaine
23
Q
__________ speeds up the onset of LA. How is it done?
A
Alkalinization
Add 1cc of NaHCO3/bicarb (1meq/10ml)
This makes the LA MORE BASIC
24
For the initial epidural dose, it is ______ ml per segment
1-2 ml
Ex) If going from T10 to T4 = 6 segments
-lowest dose = 6mls
-highest dose = 12mls
25
How much is the top-up dose for epidurals?
50-75% of initial dose
**mostly use 50%**
26
The epidural space is _______ in the thoracic & ________ in the lumbar regions. How does this affect the spread?
smaller
larger
thoracic region has a larger spread
27
The concentration of the epidural LA determines the _______ of the block. We would give a walking epidural a _________ concentration. What would this do?
density
low
manages pain but allows some motor function
28
Epidural Concentration, Sx concentration, Range: 2-Chloroprocaine
Concentration: 3%
Sx: 3%
Range: 30-90 mins
29
Epidural Concentration, Sx concentration, Range: lidocaine
Concentration: 2%
Sx: 2%
Range: 60-120 min
30
Epidural Concentration, Sx concentration, Range: Ropivacaine
Concentration: 0.1-0.75%
Sx: 0.75%
Range: 140-220 min
31
Epidural Concentration, Sx concentration, Range: Bupivacaine
Concentration: 0.0625-0.5%
Sx: 0.5%
Range: 160-220 mins
32
Epidural Concentration, Sx concentration, Range: Levobupivacaine
Concentration: 0.0625-0.5%
Sx: 0.5%
Range: 150-225 mins
33
How do opioids as adjunct affect neuraxials? (2) Meds? (3)
-Analgesia
-Density
-Morphine
-Fentanyl
-Sufentanil
34
How do Alpha-2 agonists as adjunct affect neuraxials? (3) Meds? (2) Dose?
-Density
-Duration (1hr)
-Analgesia
-Dexmedetomidine/Precedex 3mcg
-Clonidine 15-45mcg
(Precedex not FDA approved IT)
35
How do vasopressors as adjunct affect neuraxials? Meds? (2) Dose?
-duration
-Epi 0.2-0.3mg (epi wash)
-Phenylephrine 2-5mg
36
What are some investigative agents for neuraxial adjuncts? (4)
Neostigmine
Magnesium
Ketamine
Versed
37
What do neuraxial opioids target?
Substantia gelantinosa of the dorsal horn = lamina 2
38
What opioids are hydrophilic? (3) what are the properties of them?
-morphine
-hydromorphone
-meperidine (Demerol)
-longer onset
-last longer
**-respiratory depression occurs late**
39
What opioids are lipophilic? (2) what are the properties of them?
-fentanyl
-sufentanil
-stays in CSF shorter
-works quickly
-short duration of action
**-respiratory depression occurs early on (usually in recovery room vs on the floor)**
40
What considerations should we have with hydrophilic opioids?
**-Respiratory depression occurs late** --> need to communicate with recovery RN --> need pulse ox & close to nurses station
41
Neuraxail opioid dose: Sufentanil
IT: 5-10mcg
Epidural: 25-50mcg
Epidural Infusion: 10-20mcg/hr
42
Neuraxail opioid dose: Fentanyl
IT: 10-20mcg
Epidural: 50-100mcg
Epidural Infusion: 25-100mcg/hr
43
Neuraxail opioid dose: Hydromorphone
IT:
Epidural: 0.5-1mg
Epidural Infusion: 0.1-1.2mg/hr
44
Neuraxail opioid dose: Meperidine
IT: 10mg
Epidural: 25-50mg
Epidural Infusion: 10-60 mg/hr
45
Neuraxail opioid dose: Morphine
IT: 0.25-0.35mg
Epidural: 2-5mg
Epidural Infusion: 0.1-1mg/hr
46
For neuraxial opioid adjunct, what considerations should we have if the patient is going home the same day?
Use the lower dose
47
T/F: With epidural neuraxial opioid adjunct, some of the druf enters the bloodstream
T
48
What are the most common SE from neuraxial opioid adjuncts? (4)
1. Pruitis (Incidence 30-100%)
2. Respiratory depression
3. Nausea
4. Urinary Retention (Incidence 30-40%)
49
What is the Tx for pruritis for opioids giving as adjuncts neuraxially? (3) Prophylaxis? (3)
Tx:
1. Benadryl 25-50mg
2. Naloxone 0.1mg IV (best - BUT will anatagonize pain as well, use as last resort of if itching is really bad)
3. Buprenex (agonist/anatagonist)
Prophylaxis:
1. use min dose (<300 mcg morphine)
2.Ondansetron 4mg IV
3.Nubain 2.5-5.0mg IV
50
There is a higher incidence for respiratory depression with morphine and other ________ opioids
Hydrophilic
51
What is required for neuraxial morphine and other hydrophilic opioids? (3)
1. Capnography
2. Pulse ox
3. Alarms
52
Respiratory depression from opioid adjuncts is reversed with what?
Naloxone 0.1-0.2mg
53
Nausea w/ neuraxial opioids is dependent on the _______. Describe this. What is the Tx for this? (3)
Dose
low doses decreases incidence
<300mcg morphine
**<100mcg morphine almost absent**
Tx: Ondansetron
Naloxone 0.1mg
Phenergen 12.5-25mg
54
Which LA has a profound increase when a vasopressor is added? Variable?
tetracaine
Bupivacaine & lidocaine
55
Pts on anticoagulants or w/ bleeding pathologies are at risk of ________ w/ neuraxial anesthesia. What is the optimal Tx & timeframe?
Epidural hematoma
Surgical decompression within 8 hours -- to optimize recovery chances
56
Where can we find the guideline regulations regarding anticoags, anti platelets and neuraxial anesthesia?
American Society for regional anesthesia and pain medicine
57
What type of drug is aspirin?
COX inhibitor
Antiplatelet
58
What are the low risk Sx? (5) How long do we hold ASA/NSAIDs?
-endoscopic procedures
-cataract sx
-superficial sx
-breast sx
-ambulatory sx
Do not need to - defer to hospital policy
59
What are intermediate sx? (5) How long do we hold ASA/NSAIDs?
-carotid endarterectomy (CE)
-Head/neck sx
-intrathoracic or intra-abdominal sx
-orthopedic sx
-prostate sx
consider holding for cervical ESI (epidural spinal injection) & stellate ganglion block
60
what are high risk sx? (4) How long do we hold ASA/NSAIDs?
-emergencies sx (esp in elderly)
-open aortic sx
-peripheral vascular sx
-long surgeries with significant volume shifts/ blood loss
**Hold for 5 half-lives**
61
Tirofiban, Eptifibatide, & abciximab are ____________. How long do we need hold drug before neuraxial?
Glycoprotein IIb/IIIa antagonists
Tirofiban, Eptifibatide: 4-8hrs
Abciximab: 24-48 hrs
62
Clopidogrel, Prasugrel, Ticlopidine are ___________. How long do we need to hold drug before neuraxial?
Thienopyridine derivatives (block ADP transferase)
Clopidogrel: 5-7 days
Prasugrel: 7-10 days
Ticlopidine: 10 days
63
What is considered unfractioned heparin? What factors does it inhibit? How long do we need to hold drug before neuraxial? What considerations should we have?
SQ/IV heparin
2, 9, 10, 11, 12
Low dose (<5000): 4-6hrs
Medium (<20,000): 12 hrs
Therapeutic (>20,000 or pregnant): 24 hrs
If on UFH for greater than 4days -- get plt count
64
What is considered low molecular wt heparin? What factors does it inhibit? How long do we need to hold drug before neuraxial? What considerations should we have?
Enoxaparin (lovenox)
Dalteparin (Fragmin)
Tinzaparin (INNOHEP)
10a
12hrs before prophylatic dose
24hrs before therapeutic dose
Need to ensure coagulation status appears normal -- PTT, ACT, Plts, anti factor 10a (& renal both in elderly)
65
The antidote to heparin in _________, to warfarin is __________ & to benzos is _________.
protamine sulfate
vitamin K
Flumazenil
66
What is the other name for warfarin? What factors does it inhibit? How long do we need to hold drug before neuraxial? What considerations should we have?
Coumadin
Vitamin K dependent factors
2, 7, 9, 10
5 days
Verify normal INR <1.5
67
Thrombolytic agents activate ________. What medications are these? (4) What considerations should we have w/ neuraxial?
Plasminogen
TPA
Streptokinase
Alteplase
Urokinase
THIS IS AN ABSOLUTE CONTRAINDICATION!!!!
DONT DO IT GIRL!!!
68
What meds are considered Direct all anticoagulant? (3) What factors does it inhibit? How long do we need to hold drug before neuraxial?
Apixaban (eliquis)
-Rivaroxaban (Xarelto)
-Dabigatran (Pradaxa)
-ban
10a
72 hrs
69
What is considered herbals? How does it work? What considerations should we have?
All the G-herbs
-garlic
-ginkgo
-ginseng
Activate plasminogen
Can proceed IF PT IS NOT ON OTHER BLOOF THINNERS
70
What causes a Postdural puncture headache?
Failure of dura puncture site to seal over --> continuous CSF leak = decrease volume --> decreased pressure in brain area --> brain sags/stretch membranes --> HA
71
PDPH =
Postdural puncture HA
72
What are the symptoms of PDPH? (6)
1. Worse sitting/standing
2. occurs 2-3 days after
3. HA from front-back (frontal-occipital)
4. Sensitivity to light
5. Double vision
6. Ringing in ears
73
What are risk factors of PDPH? (3) Practitioner factors? (4)
-Young
-female
-pregnant
-needle with cutting tip
-large diameter needle
-air for LOR
-needle perpendicular to the spines long axis
74
_______ needles reduce risk of PDPH.
Penpoint needles
75
What is the Tx for PDPH? (5)
1. Lay down - bedrest
2. NSAIDs
3. Caffeine
4. Epidural blood patch
5. Sphenopalatine Ganglion Block
76
Describe an epidural blood patch
Primary Tx PDPH
Inject 10-20 cc total of pts blood into epidural space
Give 1-2 cc at a time --> after 2 cc pt will experience alot of pain from HA (thats how you know its working) --> continue giving in incremental doses
90% effective
**Do not do within 24 hours of dural puncture** -- Standard is 48 hrs
77
Describe a Sphenopalatine Ganglion Block
Secondary Tx PDPH
1. Soak cotton swab in LA
-1-2% lidocaine or 0.5% bupivacaine
2. tilt pt head back --> insert swab up nose towards back of throat
3. Put swab on Sphenopalatine Ganglion for 5-10 mins
(This reduces HA symptoms)
78
Describe Paresthesia
Complication from neuraxial
Needle injury from needle & catheter
-Deficit the same area paresthesia occured
**Redirection of needle indictated**
79
Describe a failed spinal
Complication from neuraxial
Considered --> Tx.
-no effect: redo
-Patchy block: TIVA/GA
-unilateral block: TIVA/GA
80
Describe Post-Spinal Bacterial Meningitis
Complication from neuraxial
Causes: Aseptic technique failure
-Bacteria in blood
-Leaving wet betadine on the skin
81
What is the recommended skin prep to use for neuraxial?
Combo alcohol & chlorhexidine
82
T/F: We need to make sure we inject the needle for neuraxial before the betaine drys & wears off
F
It actually needs to be fully dry & excess needs to be scraped of dapped off w sterile gauze -- dont want fluid/betadine in SA space with spine = meningitis
83
Describe Cauda Equina Syndrome
Complication from neuraxial
**Nerves effected: Cauda = L2-S5 + coccygeal nerve**
Causes: High levels of LA
-5% lidocaine
-Microcatheters
Symptoms:
-serious neurological complications that can be permanent
-bowel/bladder dysfunction
-sensory deficits: loss of feeling in legs/feet
-saddle anesthesia
-sexual dysfunction
-paralysis/weakness
-back pain
Tx:
Supportive care
**If compression/hematoma --> laminectomy <6hrs**
84
Describe Transient Neurologic Symptoms
Complication from neuraxial
Causes: improper positioning during procedures --> stretch nerves --> causes temporary symptoms
Risk factors: 5% lidocaine
Tx: Pain relief, NSAIDs, opioids, trigger point injections
85
How do you know if you've left the epidural catheter tip inside? How can you prevent this? What do you do is this does happen?
If the small blue tip isnt on the end when you pull it out
Pull the catheter out very slowly
Inforn the pt --> monitor the pt for s/s --> if none, they are ok
If s/s --> Sx to remove broken piece
86
Describe Blood in epidural needle/catheter
Complication from neuraxial
Too far lateral --> adjust needle or pull back catheter
Risk factors: Multiple attempts
-Pregnancy
-Stiff cathether
-Trauma to epidural vein
87
Describe Unilateral Epidural Block
Causes: Catheter inserted too far to 1 side & only diffusing that 1 side
-plica
Tx: Adjust catheter
-reposition the pt: Lay down on side that still have feeling
-administer more LA
-use opioid
88
Describe Local Anesthetic Systemic Toxicity
Causes: Inadvertent injection of LA into systemic circulation
Symptoms associated with Lidocaine (or any LA):
1-5: analgesia
5-10: tinnitus, skeletal muscle twitching, numbness of lips/tongue, restlessness, vertigo, blurred vision – hypotension, myocardial depression
10-15: seizure, loss of consciousness
15-25: coma - respiratory arrest
>25: cardiovascular collapse
89
LAST is more common in __________ than in epidurals
Peripheral nerve blocks
90
What is the most important step with LAST Tx?
Lipid emulsion
91
T/F: With Bupivacaine, cardiac arrest may come before seizures with LAST
T
