Neuraxial Technique - E1

Question 1

What are the 6 reasons we should be set up to do a GETA w/ every neuraxial case?

Answer 1

1. Failed block
2. High Spinal - knock out resp. drive
3. LAST - cardiac arrest/seizures
4. Anaphylaxis
5. Severe CV collapse
6. Case exceeds duration of LA

Question 2

Spinal Block

Kit Contents Spinal

Answer 2

1. 3.5’’ styleted needle
2. Introducer
3. LA (skin, SAB)
4. Betadine Prep
5. Sterile drapes
6. needles (22g for skin, 18g)
7. filter needle - to draw up SA LA
8. gauze

• also need sterile gloves, hats, mask

Question 3

SAB

Why is the needle styleted?

Answer 3

To avoid microclots - the spinal needle is so small if it clots then you can’t push med in

Question 4

Why does the spinal kit have an introducer needle?

Answer 4

so the spinal needle does not bend

Question 5

SAB

What is the LA used for skin numbing?

Answer 5

1%

Question 6

SAB

What is the volume of med we inject w/ a spinal?

Answer 6

2 mL

Question 7

SAB

What are the cutting needles & when would we use them?

Answer 7

1. Quincke
2. Pitkin

• use if it is all we have - they cause PDPH

Question 8

SAB

What are the non-cutting needles?

Answer 8

1. Sprotte
2. Whitacre
3. Pencan
4. Green
5. Gertie Marx

Question 9

SAB

What are 3 advantages of using a pencil-point tip needle?

Answer 9

1. they drag fewer contaminants into subnormal tissue
2. click or pop can be sensed
3. less risk of PDPH

Question 10

How often should we take v/s w/ neuraxial blocks?

Answer 10

Q 3-5 min

Question 11

SAB

When will you see a swirl in your syringe?

Answer 11

If you are using a hyperbaric LA (mixed w/ dextrose) & you aspirate CSF

Question 12

SAB

When would we use a pelvic tilt?

Answer 12

1. in OB pts w/ a pillow to prevent HoTN caused by compression of the vena cava

Question 13

SAB

If the pt starts to tell you their hand is getting numb, what are we concerned for??

Answer 13

High migration of the LA

Question 14

SAB

Common Problems

Answer 14

1. lack of free flow CSF
2. resistance w/ injection
3. No swirl
4. Paresthesia - hard stop!
5. blood instead of CSF
6. No block - check expiration
7. Partial block - give pain meds

Question 15

Epidural

Epidural Kit Contents

Answer 15

1. sterile prep/drapes
2. LA
3. Tuohy needle - 17/18g
4. Needles (22g & 18g)
5. 3ml, 5ml, 20ml syringes
6. filter needle
7. line filter
8. LOR syringe
9. epidural cath

Question 16

Epidural

What LA is in the kits?

Answer 16

1. 1% Lido - skin
2. 1.5% Lido (15mg/kg) w/ 1:200,000 Epinephrine

Question 17

Epidural needles

Tuohy

Answer 17

1. most curvature (30 degrees)
2. blunt tip less likely to puncture SA space

Question 18

Epidural needles

Hustead Curvature

Answer 18

15 degrees

Question 19

Epidural needles

When do we use the Crawford needle?

Answer 19

1. catheter placement difficult
2. steep angle (thoracic)
   * has 0 degrees curvature

Question 20

Epidural Needles

Weiss Curvature

Answer 20

15 degree curve
* has wings

Question 21

Is the epidural needle styleted? What size is it?

Answer 21

• yes
• 17-18g

Question 22

What size should the epidural cath be compared to needle?

Answer 22

2 gauges smaller

Question 23

How many cm of the epidural cath should be in the epidural space?

Answer 23

3-5cm

Question 24

Epidural Catheter

Multi-orifice cath

Answer 24

mutliple holes down the catheter length
* lower incidence of inadequate anesthesia - better spread
* most common one used
* higher incidence of inadvertent intravascular placement

Question 25

# Epidural Block Determining Distance in cm

Answer 25

1. measure skin to epidural space - needle length is 9cm (subtract the visible cm from skin) - 9cm needle - 4cm visible = 5cm from skin to epidural space 2. Skin Marking - cath should be secured @ 10cm at the skin = 5cm from skin to epidural, 5cm in epidural space

Question 26

# Epidural Block What are potential concerns w/ lumbar tattoos? What is the recommendation?

Answer 26

1. ink could be carried into the spine - leading to chemical arachnoiditis 2. Paramedian approach

Question 27

# Epidural Block What direction should the epidural tip be?

Answer 27

Up - opening cephalad

Question 28

What is the test dose for an epidural catheter?

Answer 28

* 3 mL of 1.5% Lidocaine w/ epi (1:200,000) * 1.5% = 15mg/mL = 45mg * 1:200,000 = 5mcg/mL

Question 29

# Epidural Catheter What important #s do we need to record?

Answer 29

1. depth to epidural space (LOR) 2. Catheter marking @ skin - 10cm 3. Cath depth/length in epidural space (#cm in space)

Question 30

What are the 2 ways to identify the epidural space?

Answer 30

1. LOR syringe w/ saline (could do air or both) 2. Hanging drop method - don't use anymore

Question 31

# Epidural What are the symptoms of accidental IV placement?

Answer 31

1. HR increase by >20% 2. Tinnitus 3. metallic taste in mouth - first one usually 4. circumoral numbness * in pts on heart meds - BP increase of >20mmHg = IV placement

Question 32

# Epidural What are the symptoms of accidental spinal injection?

Answer 32

1. dense motor block w/i 5 min of test dose 2. pt says feet are numb

Question 33

When should we give the Epidural test dose in pregnant women?

Answer 33

After a contraction = clearer results

Question 34

# Epidural Dosing 1st dose

Answer 34

1-2mL/segment * Epidural placed L4/L5 - need T10 blocked = 6 segments * 6-12mL

Question 35

# Epidural Dosing Top-up Dose

Answer 35

* give before "two-segment regression" * give 1/2 - 3/4 of initial dose * could also start drip

Question 36

# Top-Up times Lidocaine

Answer 36

60 min from initial

Question 37

# Top-up Times 2-Chloroprocaine

Answer 37

45 min from initial dose

Question 38

# Top-up Times Mepivacaine

Answer 38

60 min from initial dose

Question 39

# Top-up Times Bupivacaine & Ropivacaine

Answer 39

120 min from initial dose

Question 40

# Epidural Common Problems

Answer 40

1. CSF "wet tap" (through dura) 2. Paresthesia 3. can't thread catheter (PLICA) 4. Aspirate blood 5. Positive Test dose 6. False positive test dose - OB contractions