Neuraxial 5/27 Flashcards
Test 1 (110 cards)
1
Q
What are the 4 types of neuraxial anesthesia? 3 most commonly used? pediatric only?
A
- Spinal
- Epidural
- CSE
- Caudal -pediatrics only
The 1st 3 are the ones we will use the most.
2
Q
CSE =
A
Combined spinal & epidural
3
Q
What are the indications for neuraxial anesthesia? (4)
A
- Lower abd, perineum, LE (Lower abd & below)
- Orthopaedic Sx
- Vascular Sx on legs
- Thoracic Sx (adjunct to GETA)
4
Q
What are the most common Ortho Sx for neuraxial? What type of procedure is done?
A
Knee & Hip
Spinal
5
Q
Why do we use neuraxial in adjunct to GETA?
A
- Less movemenr during Sx
- Optimize postop pain management –> ambulate & do breathing exercises quicker dt less pain
6
Q
What are the benefits of neuraxial? (14)
A
Reduces risk of:
- Postop ileus
- Thromboembolic events
- PONV
- Respiratory complications
- Bleeding
- Narcotic use
- Itching
- Great mental alertness
- Less urinary retention
- Eat, void, ambulate faster
- Avoid overnight admission from complications of GA
- D/c from PACU faster
- Preemptive anesthesia
- Blunts stress response from Sx
7
Q
Gasses ______ risk of PONV
A
increases
8
Q
T/F: neuraxial anesthesia prevents urinary retention
A
F
Still have urinary retention, but it is LESS compared to GA
9
Q
What does relative contraindication mean? What are they for neuraxial? (4)
A
Weigh benefits vs risks
-can still do, but may be extra work
- Deformities of the spine
- Spinal cord disease
- Chronic HA/backache
- Failed insertion attempt 3x
10
Q
Deformities of the spinal cord include: ________ (4)
A
- Spinal stenosis
- Kyphoscoliosis
- Ankylosis spondylitis
-scoliosis
11
Q
Diseases of the spinal cord include: ________ (2)
A
- Multiple sclerosis (demyelination of spinal cord/brain)
- Post polio syndrome
12
Q
What causes spinal HA & chronic back pain from neuraxial? Can we give if a pt experiences these things beforehand? Why?
A
CSF leak = HA
needle trauma/inflammation = backache
Yes
Anesthesia Informed Consent
-Informs pt of possible complications & they can decide if they want to proceed
13
Q
Normal values: prothrombin time (PT)
A
12 - 14 seconds
14
Q
Normal values: international normalized ratio (INR)
A
0.8 - 1.1
15
Q
Normal values: activated partial thromboplastin time (aPTT)
A
25 - 32 seconds
16
Q
Normal values: bleeding time (BT)
A
3 - 7 mins
17
Q
Normal values: platelets (Plts)
A
150,000 - 300,000 mm3
18
Q
________ looks at platelet function
A
Bleeding time (BT)
19
Q
What does absolute contraindications mean? What are they for neuraxial? (8)
A
Cannot do at all
- Coagulopathy (includes disorders & anticoags)
- pt refusal
- Evidence of dermal site infection
- Severe/critical valvular heart disease
- HSS (idiopathic hypertrophic subaortic stenosis)
- Long duration of Sx
- Increased ICP
- Severe CHF
20
Q
Neuraxial absolute contraindications: INR greater than _______
A
1.5
21
Q
Neuraxial absolute contraindications: plts less than ________
A
100,000
22
Q
Neuraxial absolute contraindications: PT, aPTT, BT ______
A
2x
PT > 28 secs
aPTT > 64 secs
BT > 14 mins
23
Q
Which arm is the Extrinsic pathway? Associated factors? What medication is related to it? related labs?
A
R arm
3 –> 7
Warfarin/Coumadin
PT/INR
24
Q
Which arm is the Intrinsic pathway? associated factors? What medication is related to it? related labs?
A
L arm
12 –> 11 –> 9 –> 8
heparin
PTT
ACT (activated clotting time)
25
What are the factors in the common pathway?
5 & 10 --> 2 --> 1 --> 13
26
Neuraxial absolute contraindications: What are the valve diseases associated w this? What are the relevent values?
AS & MS
Valve area:
=/< 1.0 cm2 in AS
< 1.0 cm2 in MS
27
What is the difference between severe & critical AS?
severe:
-Velocity: 4-4.5 m/sec
-Pressure gradient: 40-50 mmHg
**-Valve area: 0.7-1.0 cm2**
Critical:
-Velocity: >4.5 m/sec
-Pressure gradient: >50 mmHg
**-Valve area: < 0.7 cm2**
28
What are the clinical manifestations associated w/ AS? (3) What are the survival yrs after occurance of these s/s?
1. Angina - 5 yrs
2, syncope - 3 yrs
3. Failure - 2 yrs
29
SAB =
subarachnoid block
30
Neuraxial absolute contraindications: EF less than _____
30-40%
Really just < 30%
31
_______ is not good with AS
Hypotension
32
What are your cardiac accelerators?
T1 - T4
33
Neuraxial characteristics: Spinal- Onset; Spread; Nature of block; Motor block; Hypotension?
Onset: Rapid (5 mins)
Spread: Higher than expected
Nature of block: Dense
Motor block: Dense (cant move)
Hypotension: Likely
34
Neuraxial characteristics: Epidural- Onset; Spread; Nature of block; Motor block; Hypotension?
Onset: slow (10-15 mins)
Spread: as expected
Nature of block: segmental
Motor block: minimal
Hypotension: less than spinal
35
T/F: SAB can go as high as the head
T
may extend extracranially
36
Once we have confirmed the SAB is in the right place & we administer medications, what do we do?
Lay pt down IMMEDIATELY --> LA will go cephlad (up) & onset is RAPID
37
What causes the hypotension in SABs? Why is this less of a problem with epidurals?
Spread upward to cardiac accelerators
Epidural = segmental
38
Your HR would _____ with SABs. What are these responses called?
Decrease
Sympathectomy -- reduces sympathetic tone
39
The spread with an epidural is controlled by the ______ of LA used. How does this work?
volume
more volume = higher spread
40
T/F: Walking epidurals are common in the US
F
opens you to litagation
common in Europe tho
41
What is a wet tap? Who is this more common in?
Needle went directly thru dura mater
Skinny pts
42
Baricity is based on having _______. What area is baricity relevant?
CSF/fluid
Subarachnoid space
43
SA space =
Subarachnoid space
44
What is in the epidural space?
Nerves
Fatty tissue
Lymphatic
**Blood vessles/Veins**
45
F/T: Epidural space has baricity
F
46
The onset for spinal is ____ minutes and for epidural is _____ minutes
5
10-15
47
Describe the duration of a spinal vs epidural
spinal: limited & fixed --> **1 time injection** & depends on dose/concentration/medication
epidural: unlimited --> **catheter stays in place** & can add medication
48
Which type of neuraxial is more difficult to do? Why?
Epidural
Easy to accidentally go thru the epidural space and do wet tap --> spinal
49
The spinal is place between _______ (3) & and the epidural is placed _______. Why?
L3-L4
L4-L5
L5-S1
Anywhere in the spinal column
Spinal: Has to be given BELOW the spinal cord bc LA given in the same region = SA space
Epidural: Not in the same area as spinal cord so can give in any location
50
Dosing of spinal is based on _______ and epidural is based on ________
dose
volume
51
Which type of neuraxial exposes the pt to Local Anesthetic Toxicity (LAST)? Why? What do we do to try & prevent this?
Epidural
Epidural space has lots of veins (& big veins)
-There are not alot of veins in the SA space
We aspirate to make sure that we are not getting CONTINUOUS blood flow & do a TEST DOSE
52
Which type of neuraxial is influenced in by gravity/baricity? Why?
SAB
There's Baricity is based on fluid
-there's CSF in the SA space & none in the epidural space
53
The Epidural space is a _______ space
"Potential space"
54
Are you able to manipulate where the LA go after injection? What is it called? Describe this
Yes
Manipulation of dermatome spread
SAB: w/i 1st 5 mins w/ position changes
Epidural: incremental based on volume --> 1-2 cc per segment
55
Hyperbaric _______ & hypobaric _______
sinks
floats
56
We need to _______ before giving an incremental dose for epidural. Why?
aspirate
To make sure you are not in a vein (LAST) on the lateral side of the epidural space.
57
When trendelenburg your head is ______
down
58
What is the order that loss with neuraxial?
1. Sympathectomy
2. Sensory loss
3. Motor loss
59
There are _____ segments between L4 -T4. How much LA would I give for an epidural?
12
12 cc
60
There are ____ vertebrae in the spine. How are the split?
33
Cervical = 7
Thoracic = 12
Lumbar = 5
Sacral = 5 (fused)
Coccyx = 4 (fused)
61
Kyphosis is in the _________ & Lordosis is in the _______
Thorax
Lumbar
62
What is your center landmark in the spine? Where is the needle insertion done with neuraxial? Which side of the vertebrae is this?
Spinous process
Midline between 2 (upper & lower) spinous processes
Posterior
63
The spinal cord goes in the _______ which is on the ______ side of the vertebrae. What else is located here?
vertebral foramen
posterior
-spinal cord nerve roots
-epidural space
64
______ isn't divided into 2 parts. What doesn't it have?
C1
Vertebral body
65
The anterior vertebrae is called the _______ & the anterior is called ______
body
vertebral arch
66
The ___________ (2) link the anterior & posterior segments of the vertebrae. What part of the vertebrae is this on?
laminate (more posterior)
Pedicle (more anterior)
Posterior
67
_________ is lateral to the spinous process
transverse process
68
How are the spinous process of cervical & thoracic different from lumbar? What considerations do we need to have?
Cervical & thoracic: They angle downward (caudal)
-Requires needle approach from above (cephalad)
Lumbar: sticks out directly backwards (posteriorly/horizontally)
-easier approach; horizontal approach
69
__________ is usually placed at ____ for thoracic Sx
Epidural
T10
70
Degeneration of the ____________ can decrease the space inbetween spinous processes and the _________. Where are these located? What considerations should we have with this?
intervertebral disc
Intervertebral foramen
Between the 2 vertebral bodies of vertebraes
Degeneration --> smaller intervertebral foramen --> press on spinal nerves --> pain, numbness, weakness --> problems bending/curving back dt pain --> harder for access
71
What is the purpose of the spinous and transverse processes?
Muscles/ligaments attach to them to help stabilize & support the spine
72
The _______ is the opening between vertebrae. What exits here?
Intervertebral Foramina
Where spinal nerves exit the spine
73
The osterior side of the intravertebral foramen it's formed by _______
facet joints
74
What are the two parts of the facet joints? What do they do? What is the function?
Inferior articular process
superior articular process
They connect with the vertebrae above/below it
-Ex) L3 inferior articular process connects with L4 superior articular process
Guide and limit the spine movement
-control the back motions
75
_________ is the hip, which is equivalent to _____ on the spine. What are the 2 names for this line here?
Superior aspect of iliac crest
L4
Intercristal Line
Tuffier's Line
76
____ is the safest place for insertion for SAB
L4
77
Posterior superior iliac spine is at _____
S2
78
In adults, above Intercristal Line is _______ and below is _______
L3 - L4
L4 - L5
79
An infant up to 1 yo, Intercristal Line corresponds w/ _____
L5 - S1
80
Rib 10 =
L1
81
Inferior angle of scapula =
T 7
82
Root of spine of scapula =
T3
83
Vertebra prominens =
C7
84
The landmark for caudal anesthesia is the ________ which is only in _______ patients. The needle/LA is inserted into the _______ that is covered by the __________
Sacral cornu
pediatric
Sacral Hiatus
Sacrococcygeal ligament
85
laminate _____ in the sacrum is incomplete and is bridged by the _________
Incomplete
Sacrococcygeal ligament
86
Caudal anesthesia is considered an ______. Why?
Epidural
No CSF
87
There are _____ pair of spinal nerves & ___ total
31
62
88
The spinal cord starts at the _______ & ends at the ________. Where is the conus medullaris in adults? Infants?
Medulla oblongata
Conus medullaris
Adults: L1 - L2
Infants: L3
89
What is the cauda equina? What is the relevance of it?
"Horse tail"
Bundle of spinal nerves
-extends from conus medullaris to dural sac
-consist of nerve roots from **L2 - S5 & coccygeal nerve**
L & R nerves are separated until the cauda equina --> nerves are now bundled together --> Anesthetic bathes both sides’ nerves --> bilateral sensory/motor blockade for lower body procedure
90
The SA space ends at the _______. Where is this in adults/infants?
dural sac
Adult: S2
Infants: S3
91
Is the dural sac inside or outside of thee SA space?
CSF is in the SA space which is inside Dural Sac
92
Describe the Filum Terminale
Anchors spinal cord to coccyx (prevents it from floating up)
2 parts:
-Internal filum terminale: conus medullaris to dural sac
-External filum terminale: dural sac to sacrum
93
There is _____ anterior spinal artery and it supplies blood to the anterior _____ of the spinal cord and is associated with _____
1
2/3
motor
94
There is ____ posterior spinal arteries that are associated with ______
2
Sensory
95
Which spinal artery is more prone to ischemia? Why?
Anterior
There is only one --no collateral
96
The ______ supplies blood to the lower 2/3 of a spinal cord. Arises from the aorta between _______. Damage to this can cause what?
Artery of Adamkiewicz
T7-9 & L2
Anterior spinal artery syndrome
97
_______ ligament connects to tips of the spinous processes
Supraspinous ligament
98
________ is located between the spinous processes
Interspinous ligament
99
_________ forms the side of the space outside the spinal cord/epidural space
Ligamentum flavus
100
the ______ ligament runs along the anterior vertebral body and the _________ ligament runs along the posterior
Anterior longitudinal ligament
Posterior longitudinal ligament
101
What is the layers of transverse during midline neuraxial?
"some say school is like doing squats and sharting"
Skin --> SQ fat --> supraspinous ligament --> interspinous ligament --> ligamentum flavum --> dura mater --> subdural space --> arachnoid mater --> SA space
(Epidurals: ligamentum flavum --> Epidural space)
102
What is the layers of transverse during paramedian neuraxial?
Skin --> SQ fat --> ligamentum flavum --> dura mater --> subdural space --> arachnoid mater --> SA space
(Epidurals: ligamentum flavum --> Epidural space)
103
What are the indications for paramedian approach for neuraxial? How is it done?
interspinous ligament is calcified
-pt cannot flex spine
-scoliosis
1. Insert needle 15° off spine midline
2. Position needle 1cm lateral & 1cm inferior to the space in between the vertebrae
104
Epidurals don't pierce the ______
Dura mater
105
How will you know you're in the epidural space?
Will have a loss of resistance
106
T/F: you should always have GA set up when giving neuraxial LA
T
107
If you put LA in the _______ it will not work. This is also a __________ space
Subdural space
Potential space
108
another name for spinal anesthesia is __________ anesthesia
intrathecal
109
While doing an epidural, if you aspirate and see continuous blood, what does this mean?
On the lateral side of epidural space
Need to adjust needle and go midline
110
What is Baton's Plexus?
Epidural vein
Valveless informs a plexus draining blood from the cord and it's linings
Engorged with obesity and pregnancy --> increasing the risk during needle procedures
