Neuraxial Lecture 1 (Exam 1) Flashcards by Jourdan Treece

What are clinical indications for neuraxial anesthesia?

Surgery in: Lower abdomen, perineum, lower extremities
Orthopedic surgery
Vascular Leg surgery
Thoracic Surgery

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Why would neuraxial anesthesia be used for thoracic surgery?

As an adjunct to GETA (coughing, deep breathing, ambulation, post-op pain management)

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Neuraxial anesthesia (increases/decreases): Post-op ileus, narcotic usage, thromboembolic events, PONV, bleeding, respiratory complications

Decreases complications

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Neuraxial anesthesia offers
Great _________
_____ Urinary retention
_____ to eat, void, and ambulate
Avoids unexpected admission from GA complications
_____ PACU discharge times*
Preemptive anesthesia

Great mental alertness
Less urinary retention
Quicker to eat, void and ambulate
Quicker PACU discharge times

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A benefit of neuraxial anesthesia is that it _____ the stress response from surgery

Blunts stress response

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What are relative contraindications to neuraxial anesthesia? (4)

Deformities of the spinal column
Preexisting disease of the spinal cord (MS, Post-polio)
Chronic HA/Backache
Inability to perform SAB/Epidural after 3 attempts (Per provider)

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What are pre-existing diseases of the spinal cord? (Relative C/I to neuraxial anesthesia)

MS or Post-polio syndrome

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What are absolute contraindications to neuraxial anesthesia? (6)

Coagulopathy (risk of epidural hematoma)
INR > ____
Platelets < ____
PT, aPTT, BT ____x normal
*Patient refusal
*Evidence of dermal site infection

Coagulopathy (risk of epidural hematoma)
INR > 1.5
PLT < 100,000 (consider trends)
PT,aPTT, BT 2x normal
Known coagulation disorder OR on anticoagulants
*Patient refusal
*Evidence of dermal site infection

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Normal PT 12

12-14 seconds

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Normal INR

0.8-1.1

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Normal aPTT

25-32 seconds

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Normal Bleeding Time? What does bleeding time tell you?

3-7 minutes
BT tells you platelet function

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Normal Platelet?

150,000-300,000 mm3

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INR levels assess _____ activity
aPTT levels assess _____ activity

INR - Coumadin
aPTT - Heparin

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What heart valve disease is an absolute CI to neuraxial anesthesia?

Severe or critical Aortic or mitral stenosis

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Severe aortic stenosis valve area

0.7-1 cm2

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severe mitral stenosis valve area

< 1 cm2

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Is idiopathic hypertrophic subaortic stenosis (HSS) a relative or absolute CI to neuraxial?

Absolute CI

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When the ______ is longer than the duration of the LA, that is an absolute CI to neuraxial

Operation length > DOA of LA

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Is increased ICP a relative or absolute CI to neuraxial?

Absolute CI

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Severe CHF is an absolute CI to neuraxial when EF < ____% because they are ______ dependent

30-40%; Preload dependent

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Mild AS valve area _____
Moderate AS valve area _____
Severe AS valve area _____
Critical AS valve area ______

Mild ≥ 1.5 cm2
Moderate 1-1.5 cm2
Severe 0.7-1 cm2
Critical < 0.7 cm2

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What is the death spiral in neuraxial anesthesia?

Hypotension causes MI
Leading to ischemic contractile dysfunction
Leading to decreased CO
Leading to worsening Hypotension
Leading to increased ischemia

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If you have aortic stenosis and have angina, what is your LE?
Syncope?
HF?

Angina - 5 years
Syncope - 3 years
HF - 2 years

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Onset of: Spinal: Epidural:

Spinal: Rapid (5 min) Epidural: Slow (10-15 min)

This type of anesthesia spreads higher than expected; and may extend extracranially

Spinal

This type of anesthesia spreads as expected and can be controlled with the volume of LA

Epidural

What is the nature (dense/segmental) Spinal Epidural

Spinal: Dense Epidural: Segmental

This anesthesia has dense motor blockade

Spinal

This anesthesia has minimal motor blockade

Epidural

is spinal or epidural more likely to cause hypotension?

Spinal is more likely for hypotension d/t cardiac accelerators (T1-T4) - Epidural also causes hypotension but less than a spinal

Which is limited and fixed in duration? Which is unlimited in duration?

Spinal - limited Epidural - Unlimited

What levels can you safely place a spinal? What levels can you place an epidural?

L3-L4 L4-L5 L5-S1 Epidural - any level!

Which placement is more advanced (requires more skill)

Epidural placement

Which is dose-based (mg)? Which is volume-based? (concentrations are lower)

Dose - Spinal Volume - Epidural

Which method is at risk for LAST?

Epidural (many veins in the epidural space)

Gravity influences both spinals and epidurals. Spinals are effected by _____ Epidurals are effected by ______

Spinals - Baracity Epidurals - Pt. Positions

Within the first ____ minutes, you can manipulate the dermatome spread after dosing of SPINALS via what 3 things?

First 5 minutes: 1. Position changes 2. Baracity of solution 3. Dose

Dermatome spread after epidural placement is based on what

Volume: 1-2 mL per segment (12 segments = 12 cc)

How many vertebrae are there TOTAL? Cervical Thoracic Lumbar Sacral Coccyx

33 Total C = 7 T = 12 L = 5 S = 5 C = 4

Kyphosis is ______ curvature in the _____ spine Lordosis is ______ curvature in the ____ spine

Kyphosis -Concave Thoracic Lordosis -Convex Lumbar

Which 2 segments of vertebrae are fused?

Sacral and Coccyx are fused

What is the only vertebrae that is not divided into 2 main parts?

What 2 structures link the anterior (body) and posterior (vert. arch) segments of a vertebra to form the vertebral forament?

Pedicle (more anterior) and Lamina (more posterior)

Space that houses the spinal cord, nerve roots, and epidural space

Vertebral foramen

What is a protective cushioning area around the spinal cord?

Epidural Space

Landmark to find the midline of the back?

Spinous process

what differentiates the lumbar from the cervical & thoracic vertebrae?

Spinous processes in cervical and thoracic are angled CAUDAD, requiring a needle approach from above (CEPHALAD approach)

Soft pads between vertebrae that act as shock absorbers

Intervertebral discs

Openings between the vertebrae where the spinal nerves exit the spine

Intervertebral foramen

The anterior side of the intervertebral foramen is formed by the _______ and _______ The posterior side of the intervertebral foramen is formed by the ______

Anterior: Vertebral body & intervertebral disc Posterior: Facet joints

Disc Degeneration happens when the intervertebral discs wear down, making the ______ smaller and pinching the spinal nerves causing pain, weakness and numbness

Intervertebral foramina

These structures guide and limit the spine's movement, and keep the back's motions controlled

Facet Joints

Injured facet joints can press on nearby _______and produce pain and muscle spasms i the dermatome

spinal nerves

an area of skin served by a spinal nerve

Dermatome

The superior aspect of the iliac crest is at what vertebrae level? This "line" is also called _______ or _______

L4 Tuffier's Line or Intercristal Line

Posterior superior iliac spine is at which level?

The space above Tuffier's line is:

L3-L4

The space below Tuffier's line is:

L4-L5

Tuffier's line is useful for placing ____

Spinal needles

In infants < 1 year, Tuffier's line corresponds with _______ intervertebral space

L5-S1

The lamina of _____ is incomplete and bridged only with _____

S5; Ligaments (it is unfused)

Located at the base of the sacrum and aligns with _____ vertebra. Used as an access point to caudal anesthesia

Sacral hiatus

The sacral hiatus is covered by what ligament?

Sacrococcygeal ligament

The landmark for caudal anesthesia - Projections of articular processes/bony protuberances that guard the area of the sacral hiatus

Sacral Cornua

Landmark for caudal anesthesia Access point for caudal anesthesia

Landmark - sacral cornua Accesss - sacral hiatus

What is the rostral origin of the spinal cord?

Medulla oblongata

Tapering of the spinal cord at the end

Conus Medullaris

Where does the conus Medullaris end in adults? In infants?

Adults: L1-L2 (L1 in most Txtbooks) Infants: L3

A bundle of spinal nerves extending from the conus medullaris to the dural sac

Cauda Equina

The cauda equina consists of nerve roots from levels _____ vertebrae and the ______ nerve

L2-L5 nerve roots and coccygeal nerve

The dural sac ends @ ____ in adults ____ in infants

S2 adults S3 infants

The subarachnoid space ends at the

Dural sac

Structure that is a continuation of the pia mater and extends downward from the conus medullaris to the coccyx (tailbone)

Filum Terminale

The main function of the filum terminale is to anchor the _____ to the _____

spinal cord; coccyx

Internal filum terminale ranges _______ External Filum Terminale ranges ______

Internal: Conus medullaris to dural sac External: Dural Sac to the sacrum

The ASA is responsible for what type of function?

Motor

The 2 Posterior Spinal Arteries originate from the _____ artery and are responsible for what function?

Vertebral artery Sensory FunctionT

The posterior spinal arteries are paired and have many connections from the ______ and _____ intercostal arteries. These connections protect the _____ part of the spinal cord from ischemia

Subclavian and Intercostal arteries Sensory protection from ischemia

Motor paralysis & loss of pain and temperature sensations below the affected area

Anterior spinal artery syndrome

The ASA might receive additional branches from _____ and ____ arteries

Intercostal & Iliac arteries

A crucial connection that supplies the blood to the lower 2/3 of the spinal cord Damage to this artery also leads to ASA syndrome

Artery of Adamkiewicz

Artery of adamkiewicz arises from the aorta between: ______ and ____ regions

T7-9 and L2 regions

Ligament running along the back connecting the tips of the spinous processes together (most superficial)

Supraspinous Ligament

Ligament located between the spinous processes, joins adjacent vertebrae and provides stability.

Interspinous Ligament

Ligament that feels "gritty" and form the sidewalls of the space outside the spinal cord (epidural space) Piercing this ligament indicates entry into the epidural space

Ligamentum Flavum

Runs along the backside of the vertebral bodies

Posterior Longitudinal Ligament

Attached to the front of the vertebral bodies & intervertebral discs , running the length of the spinal column

Anterior longitudinal ligament

Name the layers to traverse during a midline approach for spinal.

Skin SubQ Fat Supraspinous Ligament Interspinous Ligament Ligamentum Flavum Dura Mater Subdural space Arachnoid mater Subarachnoid space

Name the orders of meningeal layers from outer to inner

Dura Mater Arachnoid Mater Pia Mater - Directly covers the spinal cord

Located outside the dura mater, containing fat, nerves, lymphatics, and small blood vessels (veins)

Epidural space

Potential space between the dura and arachnoid mater

Subdural space

Between the arachnoid and pia mater which is filled with CSF that cushions and protects the spinal cord

Subarachnoid space

The ligamentum flavum attatch superior and inferior ____ to each other

Laminae

Name the layers that you traverse via paramedian approach for spinal

Skin SubQ Fat Ligamentum Flavum Epidural Space Dura Mater Subdural space Arachnoid mater Subarachnoid Space

What are 2 reasons to use a paramedian approach?

1. Calcified interspinous ligaments 2. Patient cannot flex spine

What 3 positions can a patient be in for a paramedian approach

1. Sitting 2. Lying down 3. Face down

During paramedian approach, insert the needle ____ degrees off the patient's midline

15 degrees

Paramedian approach: position needle ___ cm to the side and ___ cm inferior to the space between the vertebrae

1 cm lateral and 1 cm inferior

Name the borders of the epidural space: Cranial, Caudal, Anterior, Lateral, Posterior

Cranial: Foramen magnum Caudal: Sacrococcygeal Ligament Anterior: Posterior longitudinal ligament Lateral: Vertebral Pedicles Posterior: Ligamentum Flavum and lamina

Fatty tissue in the epidural space increases or decreases the availability of certain drugs?

Fatty tissue decreases the availability of drugs

Compared to lidocaine, fentanyl, and morphine, Bupivicaine is absorbed ______ in the epidural space

bupivicaine is absorbed more d/t fatty tissue

The epidural veins are known as ____ plexus and are _____; they drain blood from the spinal cord and its linings

Batson's Plexus; Valveless

The density of veins in Batson's plexus increases ______

Increases laterally

What conditions (2) cause the veins in Batson's plexus (epidural space) to become engorged, leading to increased risk during needle procedures

1. Obesity 2. Pregnancy

How do you know if you're in the vein in the epidural space?

Blood is continuously coming out

Neuraxial Lecture 1 (Exam 1) Flashcards

(107 cards)