Neuraxial Anesthesia Complications and Techniques Flashcards by Claire Edwards

Symptoms of postdural puncture headache (PDPH)

Feels Worse sitting down or standing compared to lying down
Occurs 2-3 days post puncture
Felt from forehead to back of head
Photosensitivity
Double vision
Tinnitus

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Patient risk factors of PDPH

-Younger
- Female
- Pregnant

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Practitioner risk factors of PDPH

Needle with cutting tip
Large diameter needle
Air for LOR
Positioning the needle perpendicular to the spine’s long axis

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What needle tips and gauges have the highest incidence of PDPH?

Quincke 22
Tuohy 16

*the bigger the needle the higher incidence

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Treatment for PDPH

Bed rest
NSAIDs
Caffeine (hoping the vasoconstriction will seal the hole)
Epidural blood patch
Sphenopalantine Ganglion block

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Epidural blood patch

Involves injecting patient’s own blood (10-20mL) into epidural space to clot the puncture.
*Not recommended within 24 hrs of dural puncture

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Sphenopalantine Ganglion Block (SPG)

Soak a cotton swab with LA (1-2% lidocaine or 0.5% bupivicaine) and insert through the nose to the back of the throat wall and leave it there for 5-10 minutes
*simpler and lower risk than blood patch

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Paresthesia

Nerve injury from needle and catheter
Higher incidence if it was experienced during insertion and with CSE techniques
Epidural has lower risk

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True or False: If paresthesia is illicited, keep going with insertion of the needle and catheter.

False. Stop and redirect needle

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What PPE is required when performing neuraxial anesthesia?

Sterile:
Gloves
Mask
Bonnet

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What is the best skin prep to prevent bacterial meningitis?

Alcohol and chlorhexadine

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What must be done when using iodine as a skin prep to prevent bacterial meningitis?

Allow it to dry and wipe off where needle will be placed

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True or False: If a patient has bacteremia, spinal procedures are contraindicated.

True. Absolute contraindication

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What is cauda equina syndrome?

Neurotoxicity of L1-S4 +coccygeal nerves from high levels of LA affecting nerve functions
*can be permanent

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Main S/S of cauda Equina Syndrome

Bowel and bladder dysfunction
Sensory deficits
Saddle anesthesia

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Risk Factors for Cauda Equina Syndrome

High concentration LA (5% lidocaine no longer used)
Microcatheters
Whiticare 25/26 needle
*Multipore catheters help prevent

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Cauda Equina Syndrome Treatment

Compression from disc, hematoma immediate laminectomy within 6 hours

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Transient Neurologic symptoms

Can be caused by patient position (lithotomy) or 5% lidocaine that stretch the nerves causing temporary symptoms of severe radicular pain in the back and buttocks that spread down both legs.
Usually resolve within a week.

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What surgeries have higher incidence of transient neurologic symptoms?

Outpatient surgeries and knee arthroscopy

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True or False: Early ambulation and LA concentration/baracity increase risk of transient neurologic symptoms.

False

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How do you prevent retained catheter fragments

Pull both the needle and catheter slow and gently together

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Risk factors for epidural vein cannulation

Multiple attempts
Pregnancy (bigger veins)
Stiffer catheters
Trauma to the vein during block procedure

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True or false: Blood in an epidural needle is normal

True: Yes from the skin UNLESS blood is continuing to come out

*blood is not normal in the catheter

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What are the 3 interventions for a unilateral epidural block?

Administer more anesthetic (50% top-up dose, don’t wait for segment regression)
Reposition the patient so the side that isn’t numb is facing down
Opioids

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CNS effects of the following lidocaine plasma concentrations (mcg/mL) 1-5 5-10 10-15 15-25 >25

1-5: Analgesia 5-10: Tinnitus, vertigo, restlessness, muscle twitching, numbness of lips and tongue, blurred vision 10-15: Seizures, loss of consciousness 15-25: Coma >25

Cardiopulmonary effects of the following lidocaine plasma concentrations (mcg/mL) 1-5 5-10 10-15 15-25 >25

1-5 5-10: hypotension, myocardial depression 10-15 15-25: respiratory arrest >25: CV collapse

Local Anesthetic Systemic Toxicity (LAST)

Most commonly caused by inadvertent injection and most commonly see a seizure, but bupivicaine may cause cardiac arrest

True or False: LAST is more common in peripheral nerve blocks than epidurals

True

What is the most lethal LA with regards to LAST and why?

Bupivicaine because of its affinity for the Na channels in the heart and slower dissociation from the receptor during diastole

Risk factors for LAST CNS toxicity

Hypercarbia Hyperkalemia Metabolic Acidosis

List the LA in order of most to least difficulty of cardiac resuscitation

Bupivicaine Levobupivicaine Ropivicaine Lidocaine

True or false: CNS depressants decrease the risk of CNS toxicity from LAST

True by raising the seizure threshold

What do you use to treat seizures caused by LAST and what should you avoid?

Benzos Avoid propofol

How does ACLS differ when it is caused by LAST?

Epi can make the resuscitation more difficult and lower lipid therapy so use < 1mcg/kg and amio for ventricular arrhythmias

Lipid Therapy Dosage

>70kg: 100mL bolus over 2-3 min followed by 250mL over 15-20 min <70kg: 1.5 mL/kg bolus over 2-3 min followed by 0.25 mL/kg/min Continue infusion 15 min after stability Max dose: 12mL/kg

What other medications should be avoided with LAST?

LA Beta-blockers CCBs Vasopressin

Test dose

Give 1.5% lidocaine with epi 1:200,000 to observe for CV effects (tachycardia >20%) or SAB effects (ringing in ears, metallic taste, numbness of mouth or motor block) in case you're in the subarachnoid space

What is a spinal or epidural hematoma most commonly associated with?

Anticoagulation

What is a major symptom of epidural/spinal hematoma?

Pain

Can cord ischemia from epidural/spinal hematoma be reversed?

Yes if laminectomy is performed within 8 hours

Arachnoiditis

Inflammation of meninges that leads to extensive sclerosisof arachnoid membranes and constriction of vascular supply *Associated with: -**non FDA meds injected (med error/patient harm) -Betadine contamination -Use of non preservative free solutions

True or False: Always stabilize your needle

True

True or False: You don't need to have your GA setup ready when performing neuraxial anesthesia

False: ALWAYS prepare you GA set up

What are the 3 most common causes for failure of a spinal procedure?

1. Wrong dose 2. Wrong location 3. Wrong position

True or False: Always scrub 3 times with skin prep and hold the sponge upside down

True

What are non cutting (pencil) spinal needles and what are their advantages?

Sprotte Whitacre Pencan Greene Gertie Marx *better at preventing PDPH, drag fewer contaminants into subnormal tissue, "click or pop" can be sensed

What are the 2 cutting spinal needles?

Quincke Pitkin

What is included in timeout?

ID Consent Allergies Site

True or False: We get a swirl of CSF with all LA

False. Only observed when using a hyperbaric LA

True or False: Always check your expiration of LA because they may not work if they are expired

True

Tuohy Needle

Epidural needle with most curvature (30 degrees) and blunt tip so least likely to puncture Subarachnoid space

What degree curve does a Hustead epidural needle have?

When is a Crawford epidural needle preferred?

Difficult cath placement or a steep angle (thoracic epidural) *it has no curvature

What degree curvature does a Weiss have? How to differentiate?

15 and it has wings

How much does each mark of a Tuohy needle measure? How long is the needle?

1 cm 9 cm to the hub and 10 cm to the window

What is the optimal epidural space/length for a catheter?

3-5 cm

What are advantages of a plastic epidural catheter?

Stiffer Less expensive

How old does a tattoo need to be before placing an epidural?

5 months

What are the 2 ways of identifying the epidural space and what is the performed method?

1. LOR (preferred) 2. Hanging drop

Consideration for pregnant women and an epidural test dose

Give after the contraction for more clear results

Consideration for patients on heart medications and an epidural test dose

a large increase of BP (>20mmHg) could also mean the needle is in a blood vessel

What are the recommended top-up times for the following medications? 2-chlorprocaine Lidocaine Mepivicaine Bupivicaine and ropivicaine

2-chlorprocaine: 45 Lidocaine: 60 Mepivicaine: 60 Bupivicaine and ropivicaine: 120

What med should you use if you are doing a CSE?

The same med in both spaces

Neuraxial Anesthesia Complications and Techniques Flashcards

(63 cards)