Neuroaxial Blocks, Epidurals & Spinals Flashcards by Jaclyn Possin

What terms match up? 1. Epidural 2. Spinal block 3. SAB (subarachnoid block) 4. Peridural 5. Intrathecal 6. Extradural 7. Caudal

1, 4, 6, 7 2, 3, 5

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How many curvatures are there in the spine?

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Anterior or posterior curve? 1. Cervical 2. Thoracic 3. Lumbar 4. Sacral

Anterior 2. Posterior 3. Anterior 4. Posterior

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How many vertebrae are in each category? 1. Cervical 2. Thoracic 3. Lumbar 4. Sacral 5. Coccygeal

7 2. 12 3. 5 4. 5 5. 4

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What two types of vertebrae are fused in adults?

Sacral and coccygeal

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What level does the spinal cord stop from? And what emerges from there?

L1 and the cauda equina emerges from there

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What level is the line drawn from the lower borders of the scapula?

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What spinal level is the line is drawn between the iliac crests? And what is the name for this?

L4 - Tuffier’s Line

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What is the line between the posterior superior iliac spines?

S2 - distal extent of the dural sac

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What is the term for a baricity greater than the spinal fluid? Hyper or hypobaric?

Hyperbaric

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What are the 6 common parts of a vertebrae? And how many of each?

1 vertebral body 2 pedicles 2 transverse processes 2 laminae 1 spinous process 4 articular processes

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What is the function of the 2 pedicles on the vertebra?

Notched for nerve roots

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What is the function of the transverse processes on the vertebra?

Muscle attachments

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What is the function of the 4 articular processes on the vertebra?

Synovial joints or faucet joints. Enable the spine to bend, move and twist.

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What spinous process are more horizontal: Lumbar, cervical or throacic?

Lumbar & cervical

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What vertebrae laminae are more vertical in orientation?

The more caudal vertebra

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What vertebrae have shorter and broader spinous processes?

Lumbar

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What ligament joins the vertebral spines?

supraspinous ligament

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What ligament extends from the occipital protuberance to the coccyx?

supraspinous ligament

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What ligament is between the spinous processes?

Interspinous ligament

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What ligament extends from the foramen magnum to the sacral hiatus and is thickest in the lumbar area?

Ligamentum flavum

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What three ligaments do you transverse when you are placing an epidural?

Supraspinous ligament, transverse ligament, and ligmentum flavum.

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When will you know that you are in the epidural space?

When you loose resistance after crossing the ligmentum flavum

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The epidural space extends from what area to what area?

base of the skull to the sacrococcygeal membrane.

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The epidural space contains what?

epidural veins, fat, lymphatics, arteries, and nerve roots

What is the distance from the surface of the skin to the epidural space?

2.5cm to 8cm

What spinal level does the spinal cord extend to in adults and what level in children?

Adults: L1 Children: L3

What is the term for the tapered end of the spinal cord?

Conus medullaris

What structure anchors the spinal cord to the coccyx?

Flium Terminale

What are the nerve roots called that originate from the conus medullaris? And how does the spinal needle affect these nerve roots?

Cauda equina ("horses tail") The spinal needle pushes the nerve roots away

Label these 10 items

What are the three meninges from deep to superficial?

Pia mater, arachnoid mater, and dura mater

What meninges are thin?

Pia and arachnoid maters

What meninges are thick?

Dura mater

What meninge directly covers the spinal cord?

Pia mater

What meninge is spider web-like?

Arachnoid mater

What space contains the CSF?

Subarachonid space

What meninge is the outer layer that is the consistency of an egg membrane?

Dura mater

What area of the spinal cord is supplied by the anterior spinal artery? Is this artery single or paird? And where does this artery arise from?

Supplies the anterior 2/3 of the spinal cord. Single. Arises from the vertebral artery.

What does the posterior spinal artery supply blood to? Is this single or paired artery? What does this artery arise from?

posterior 1/3 of the cord Paired Arises from the cerebellar arteries

What is the artery in the spinal cord that aries from the aorta? What does it supply blood to? What level in the spine is this artery found?

Artery of Adamkiewicz Major blood supply to the anterior lower 2/3 of the cord Between T11 and L3

What is the term for the area between the radicular arteries on the spinal cord? What type of blood flow occurs in these areas? Why is this siginificant during low-flow states? Between which specific arteries does this occur?

Watershed zones Could be a lack of direct blood supply Could be areas of ischemia Between cervical radicular artery and thoracic radicular artery _or_ between thoracic radicular artery and radicularis magma

What is another name for radicularis magma? And what does this artery supply blood to?

Artery of Adamkiewicz The lower 2/3 of the spinal cord

Where is the CSF made?

Choroid plexus

Where is the CSF absorbed?

arachnoid villi

How much (mls) CSF is produced daily?

500cc

What is the total volume of the CSF?

120-150ml

How much of the CSF (mls) is in the spinal cord?

25-35mls

What is the pressure of the CSF when supine (horizontal)?

6-8mmHg

What is the specific gravity of the CSF?

1.004-1.009

What procedures (7) are neuroaxial blocks useful for?

lower abdominal, inguinal, urogenital, rectal and lower extremity, obstetric, acute/chronic pain

Can it be used in combination with general anesthesia?

Yes

Neuroaxial anesthesia (more or less): 1. nausea/vomiting 2. urinary retention 3. narcotic requirement 4. return to metal alertness 5. ability to eat, void and ambulate 6. patient safety 7. postop analgesia

1. less 2. less 3. less 4. quicker 5. quicker 6. improved 7. better

What are some debatable advantages of neuroaxial anesthesia?

safer decreased blood loss decreased thromboembolic events decreased post-op ileus increased cardiac stability increased respiratory stability

Absolute, relative or controversia contraindications? 1. uncooperative patient 2. patient refusal 3. prolonged operation 4. increased ICP 5. major blood loss 6. Mild or moderate stenotic valve lesions 7. maneuvers that compromise respiration 8. sepsis, elevated WBC, fever, 9. Severe hypovolemia 10. progressive or unstable neurologic disease 11. infection at the site of injection 12. severe arotic or mitral stenosis 13. demylinating lesions 14. Difficult to discern effects or complications of the block 15. acute upper respiratory infection 16. Chronic back pain, headache 17. Multiple back surgeries 18. significant coagulopathy (prolonged INR/PT, Plt \<80, severe hepatic dysfunction) 19. severe spinal deformity 20. heart blocks 21. full stomach 22. Patient age 23. HIV 24. difficult airway

1. relative 2. absolute 3. controversial 4. absolute 5. controversial 6. relative 7. controversial 8. relative 9. absolute 10. relative 11. absolute 12. absolute 13. relative 14. relative 15. controversial 16. relative 17. relative 18. absolute 19. relative 20. relative 21. controversial 22. relative 23. relative 24. controversial

Blockade physiology: 1. Level of motor neuron block compared to sensory 2. Level of autonomic nerve block compared to sensory

1. 2 levels below 2. 2 levels above

Blockade physiology: Heavy, light or no mylenation: 1. motor 2. sensory 3. autonomic

1. heavy 2. non-mylenated 3. light mylenated

Blockade physiology: Type of fiber: 1. Autonomic 2. Sensory 3. Motor

1. B 2. C 3. A

Blockade physiology: Onset (first, second, last) to effect: 1. Autonomic 2. Sensory 3. Motor

1. First 2. second 3. Last

Blockade physiology: Time to recovery (first, second, last): 1. Autonomic 2. Sensory 3. Motor

1. Last 2. Second 3. First

Spinal/Epidural Cardiovascular effects: The height of the block affects vasomotor tone how: Increase or decrease? 1. arterial vasodilation 2. SVR 3. Venous pooling 4. Venous return 5. Heart rate

1. increased 2. decreased 3. increased 4. decreased 5. decreased

Term for the autonomic blockade: unnoposed parasympathetic (vagal) tone (vs. sympathetic tone)

sympathectomy

Spinal/Epidural Cardiovascular effects: What level do the sympathetic fibers arise from?

T5-L1

Spinal/Epidural Cardiovascular effects: What levels do the cardio acceleratory fibers arise from?

T1-T4

Spinal/Epidural Cardiovascular effects: What is the effect of blocking the cardioaccelerator fibers? What is this reflex called?

unopposed vagal tone and slowing of the heart rate Bainbridge reflex

What are some pulmonary effects of spinal anesthesia? 1. accessory muscle 2. intercostal nerve 3. perception of breathing 4. vital capacity 5. effect of phrenic nerve 6. cough

1. loss of 2. paralysis 3. loss - can be scary 4. small decrease 5. Rarely paralyzed - apnea may result from brainstem hypoperfusion 6. Impaired - problem with pts with COPD

Effects of spinal anesthesia: GI: 1. vagal tone 2. peristalsis 3. sphincters

1. unopposed 2. increased 3. relaxed

Effects fo spinal anesthesia: 1. thermoregulation 2. CNS 3. stress response

1. decreased 2. depression (some) 3. decreased (some)

Immediate complications of spinal anesthesia: Total spinal How does this happen?

inadvertent dural injections with epidural placement

Immediate complications of spinal anesthesia: Total spinal Onset fast or slow?

Fast

Immediate complications of spinal anesthesia: Total spinal What levels does it get to?

cervical levels

Immediate complications of spinal anesthesia: Total spinal What are symptoms? (2 neuro, 2 cardiac, 1 GI, 2 resp)

agitation, unconsciousness, nausea, hypotension, bradycardia, respiratory insufficiency, apnea

Immediate complications of spinal anesthesia: Total spinal What is treatment? (Actions and meds)

ABC's Ephedrine, phenylepherine, fluids, move rapidly to epinephrine (300-500mcg)

Immediate complications of spinal anesthesia: Cardiac arrest What is an early symptom?

profound bradycardia

Immediate complications of spinal anesthesia: Cardiac arrest What patient population is most at risk?

young, healthy people

Immediate complications of spinal anesthesia: Cardiac arrest What type of block does it arise from?

high sympathetic block

Immediate complications of spinal anesthesia: Cardiac arrest Why does it occur?

vagal responses to decreased preload

Immediate complications of spinal anesthesia: Cardiac arrest What type of treatment is necessary?

Rapid, agressive treatment of bradycardia and hypotension (epinepherine 300-500mcg)

Immediate complications of spinal anesthesia: GI complications Incidence of nausea and vomiting

25% about 100% for c-section

Immediate complications of spinal anesthesia: GI complications

unopposed vagal tone, increased peristalsis, relaxed sphincters

Immediate complications of spinal anesthesia: GI complications What is a good antiemetic that is not usually used for an antiemetic?

atropine

Immediate complications of spinal anesthesia: intravenous injection/local toxicity What should you do prior to injection?

Aspirate

Immediate complications of spinal anesthesia: intravenous injection/local toxicity What should you do prior to giving the entire epidural injection?

Give a test dose

Immediate complications of spinal anesthesia: intravenous injection/local toxicity Lidocaine toxicity will manifest how?

CNS toxiticy (tingling, strange taste - copper pennies/metalic, visual disturbances, ringing in the ears)

Immediate complications of spinal anesthesia: intravenous injection/local toxicity Marcaine (bupivicaine) toxicity will manifest how? How do you treat?

Cardiac toxicity (ventricular arrhythmias) Treat with lipid rescue - because lipid soluable

Immediate complications of spinal anesthesia: intravenous injection/local toxicity What is the med dose and % for lipid rescue? what is the bolus rate? How often do you repeat the boluses? Until what dose is reached? What is the infusion rate? Continue until when? When would you increase the infusion? What would you increase the infusion to? What is the maximum dose?

intralipid 20% **Bolus:** 1.5ml/kg over 1 min Repeat boluses every 3-5 minutes until 3ml/kg **Infusion:** 0.25ml/kg/min continue until hemodynamic stability has been restored Increase rate if BP drops - to 0.5ml/kg/min **Maximum dose:** 8ml/kg

Delayed complications of spinal anesthesia: What is the most common complication of SAB?

Post dural puncture headache (PDPH)

Delayed complications of spinal anesthesia: What is the cause of PDPH?

Leakage of CSF through dural hole - CSF pressure falls and brainstem drops into the foramen magnum

Delayed complications of spinal anesthesia: PDPH What needle gauge do you want to use?

high gauge - small needle 17g touhy - 80% 29g sprotte - 1%

Delayed complications of spinal anesthesia: PDPH What direction do you want the bevel?

Keep parallel to fibers to avoid cutting - bevel to the side

Delayed complications of spinal anesthesia: PDPH What patient population has the highest incidence? What patient population has the lowest incidence?

pregnant, young females - 20% elderly males - \<5%

Delayed complications of spinal anesthesia: PDPH What is the hallmark symptom? What are the characterisitics? What is the onset time?

POSITIONAL HEADACHE headache behind the eyes moving posteriorly to occiput and extending to the neck and shoulders. Throbbing or constant and associated with photophobia and nausea Onset: 12-72 hours following the procedure

Delayed complications of spinal anesthesia: PDPH What are the 5 interventions to treat a PDPH?

Recumbant positioning analgesics fluid caffeine blood patch

Delayed complications of spinal anesthesia: PDPH How much blood is needed for a blood patch?

15-20 mLs

Delayed complications of spinal anesthesia: PDPH What level do you put the blood patch?

One level below the leak

Delayed complications of spinal anesthesia: PDPH How long does relief take with a blood patch?

Immediate

Delayed complications of spinal anesthesia: GI Is there increased or decreased peristalsis with a sympathetic blockade? What if the patient has a bowel obstruction?

Increased peristalsis Contraindicated in a bowel obstruction

Delayed complications of spinal anesthesia: Urinary What complication can happen in the urinary tract?

Urinary retention

Delayed complications of spinal anesthesia: Endocrine What happens with the stress response?

Blunted

Delayed complications of spinal anesthesia: Bachache What causes backache? How can you treat this?

Profound skeletal muscle relaxation with SAB, positioning in litotomy may cause ligament strain Treat with reassurance, rest - (or resume reasonable activities of daily leaving), heat, and mild analgesics.

Delayed complications of spinal anesthesia: paralysis What is the incidence of paralysis - frequent or rare? What is the etiology (three categories)?

Rare Direct: needle trauma, surgical positioning Toxic: chemical (betadine/chlorahexidine), virus, bacteria Ischemic: hematoma (in watershed zones)

Transient neurological symptoms: What are some transient neurological symptoms of spinal anesthesia? What is the etiology? How long do symptoms last? What are risk factors?

pain or dysthesia in the buttocks, thighs, or lower limbs radicular irritation Symptoms usually resolve in 1 week Risk factors: lidocaine, lithotomy, obesity

What is cauda equina syndrome?

Neurotoxicity

Cauda Equina Syndrome: What are possible factors?

Multiple attempts, parathesia, microcatheters, 5% lidocaine

Cauda Equina Syndrome: What are symptoms?

Bowel and bladder dysfunction, paresis fo the legs, patchy sensory deficits

Menningitis and arachnoiditis: How does this occur? List 4

1. Contamination of equipment - virtually elimated with disposables 2. insertion technique, 3. catheter (coring of epidermis - use stylet in needles), 4. glass particles (use filtered needle)

Epidural hematoma: What increases the risk of epidural hematoma?

use of LMWH

Epidural hematoma: What happens to the spinal cord with an epidural hematoma?

Mass effect - direct pressure and ischemia of the spinal cord

Epidural hematoma: What are symptoms of an epidural hematoma?

Sharp back and leg pain - progression of numbness and motor weakness. With or without sphincter dysfunction

Epidural hematoma: What diagnostic technique needs to be done immediately?

CT or MRI

Epidural hematoma: What is the treatment of an epidural hematoma? and how soon does it need to be done?

Evacuation within 6 hours?

Epidural abscess: What are the symptoms of an epidural abscess?

back pain with fever following epidural anesthesia

Epidural abscess: What is the treatment for an epidural abscess?

Antibiotics and surgical decompression

Epidural abscess: What can you do to prevent an epidural abscess?

Sterile technique and remove the catheter after 96 hours

What is the invisible line called that goes above the iliac crests? What vertebrae does this intersect?

Tuffier's line L4

When inserting a neuroaxial block, what does the dominant hand do? What does the nondominant hand do?

Dominant: drives the needle Non-dominant: braces against the back

When do you aspiriate when injecting for a spinal? What are you looking for when you aspiriate?

Aspirate at the beginning, mid and post (personal preference) "swirl" of the CSF - to make sure it got into the CSF

What is the paramedian technique?

Approaching the spinal column 1 inch from midline

Neuroaxial Blocks, Epidurals & Spinals Flashcards

(118 cards)