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Anesthesia Principles II > Regional Lecture I Part I > Flashcards

Regional Lecture I Part I Flashcards

1
Q

What was the first regional anesthetic?

A

Cocaine
(probably ice actually was first)

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2
Q

First documented application of a druge to produce localized anesthesia?

A

Karl Kollar, a college and friend of Freud demonstrated the use of local anesthesia allowing him to perform painless eye surgery in 1884.

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3
Q

Who started injecting cocaine into nerves?

A

William Halsted and Alfred Hall

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4
Q

What was the first percuntaneous block?

A

axillary by G. Hirschel in 1911

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5
Q

types of regional anesthesia?

A

topical
local infiltration
field block
intravenous regional - bier block
peripheral nerve block
neuraxial

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6
Q

advantages of topical anesthesia?

A

super easy
low skill
low risk
great for mucous membranes

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7
Q

disadvantages of topical anesthesia?

A

short DOA 1-4hrs
slow onset over skin (needs soak time)
doesn’t work well on inflamed or infected tissue

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8
Q

DOA of local infiltration?

A

short 1-6 hours

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9
Q

what is a field block?

A

infiltration of LA around an area you wish to anesthetize

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10
Q

Uses for field blocks?

A

carotid endarterectomy (superficial cervical plexus)

I&D of wounds

intercostobrachial and medial brachial cutaneous nerves

dentistry

plastic surgery

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11
Q

good option to supplement patchy peripheral or neuraxial blocks?

A

field block

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12
Q

good option to supplement patchy peripheral or neuraxial blocks?

A

field block

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13
Q

disadvantages of field blocks?

A

inconsistent coverage
only covers superficial structures
relatively short duration of action

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14
Q

what is the only medication that can be used for a bier block?

A

0.5% lidocaine

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15
Q

What is bier block best suited for?

A

short soft tissue upper extremity procedures

can be used for lower extremity procedures too, but doesn’t work as well and has more risk of systemic toxicity.

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16
Q

advantages of bier block?

A

relatively easy to perform
provides surgical anesthesia quickly

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17
Q

disadvantages of bier block?

A

tourniquet pain limits useful duration

tourniquet must be inflated for at least 20min

must be able to get IV access

pt habitus must be suitable for proper tourniquet fit

failed tourniquets risk large volume of LA immediately entering central circulation > actue LA toxicity

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18
Q

how soon does tourniquet pain start?

A

within 30min

by 1 hour will have significant tourniquet pain

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19
Q

Procedure steps for Bier Block

A

place IV

double lumen tourniquet to upper arm (pad arm with cotton)

arm exanguination with esmarch bandage

inflate distal cuff, inflate proximal cuff, deflate distal cuff (always inflated to 50-100mmHg above SBP)

inject LA

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20
Q

LA dosing for bier block?

A

30-50ml of 0.5% lidocaine.

3mg/kg MAX!

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21
Q

how quickly does bier block work?

A

less than 5 min

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22
Q

what do you do once tourniquet pain starts?

A

inflate distal cufff, then deflate proximal cuff

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23
Q

how do you end a bier block?

A

use two stage tourniquet deflation

(deflate for 10sec, inflate for 1 min) x3

results in more gradual LA washout

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24
Q

indications for peripheral nerve blocks?

A

surgical anesthesia
post-op pain control
vascular dilation
chronic pain

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25
contraindications to RA?
contralateral paralyzed diaphragm severe aortic stenosis preexisting peripheral neuropathy
26
4 blocks we should all know?
interscalene axillary femoral popliteal these will cover 90% of cases
27
Example of when SAB can be sole anesthetic?
C- section
28
Example of when wrist block can be sole anesthetic?
carpal tunnel surgery
29
Example of when infraclavicular block can be sole anesthetic?
AV fistula
30
Example of when intra-articular block can be sole anesthetic?
knee arthroscopy
31
Example of when topical lidocaine can be sole anesthetic?
cataracts
32
Which LAs have fast onset, short duration, and dense block?
lidocaine mepivicaine
33
LA that has slower onset, long duration, and provides a dense block?
bupivicaine exparel (liposomal bupivicaine) with very long action and ver slow onset
34
LA with sloer onset, long duration, but not as profound of a block?
Ropivicaine
35
What does epi do when added to LAs?
work as intravascular marker decrease uptake > longer DOA
36
what does phenylephrine do when added to LAs?
decrase uptake > longer DOA
37
what does dexamethasone do when added to LA?
prolong duration
38
what does clonidine do when added to LAs?
prolong duration
39
what does bicarb do when added to LAs?
speed onset
40
Complications/risks of peripheral nerve blocks?
infection (very rare, still keep sterile though) hematoma indidental blockade pneumothorax nerve injury intravascular injection LA toxicity total spinal anesthesia
41
What to know about infection risk with PNBs?
Risk is < 1% cPNB ^ risk compared to single shot femoral and axillary sites have ^ risk localized infection more frequent than full sepsis
42
how to lower risk of infection with PNBs?
avoid puncture of infected tissue ensure goo aseptic technique skin prep, sterile technique, catheter dressed well (biopatch etc) judicous pt selection reduce trauma with block placement
43
What about PNBs in pt that are already septic or infected?
no clear data some say no ^ risk for SS Eddie would not place continuous catheter
44
what factors increase risk of infection with PNB?
recent trauma recent ICU admission compromised immunity (including DM) catheter in place for > 48hrs absence of ABX use
45
What increase risk of hematoma with PNBs?
prolonged needling larger size needle trans-arterial technique pt with coagulopathy
46
what are the coagulopathy guidelines for PNBs?
same as neuraxial Caveat - common and well accepted to judiciously practice outside of these guidelines different blocks have different risks
47
how to decrease risk of hematoma with PNBs?
consciously avoid vascular structures (both deep and superficial, veins collapse easily with minimal pressure from needle or US, so you may pierce vein and not see it, or get bloody aspiration) hold pressure after inadvertent vascular puncture (5min for arterial)
48
what is the risk of hematoma from PNB?
can put pressure on the nerve > nerve injury
49
risk of incidental blockade of what nerve with ISB/supraclavicular/superficial cervical blocks?
phrenic nerve recurrent laryngeal nerve sympathetic cervical ganglion
50
what happens with incidental blockade of phrenic nerve?
diaphragm paralysis > decreased ventilation this is VERY common, approaching 100% usually not clinically significant in healthy patients.
51
what happens with incidental blockade of recurrent laryngeal nerve?
Ipsilatetal vocal cord paralysis > hoarseness
52
what happens with incidental blockade of sympathetic cervical ganglion?
horner's syndrome
53
what incidental blockade can occur with a paravertebral block?
costal or epidural spread
54
why could intrarterial injection of LA be less dangerous than venous?
because most flow to periphery and allow time for LA to be absorbed by other tissues. most veins flow directly to the heart
55
which arteries flow directly to the brain?
vertebral and carotid
56
What LA volume can cause almost immediate seizure and neurological LA toxicity?
even 1-3ml
57
What is LAST?
local anesthetic systemic toxicity
58
are neurological s/s always visible in LAST?
no, maybe be delayed or absent
59
what might be the first sign of LAST?
CV instability
60
why is it easy to not notice intravenous injection?
compression of vessels during US/needling can hide it with no aspiration of blood.
61
Methods to prevent LAST?
monitors: ECG, BP, Sat communication with pt frequent gentle aspiration every 3-5 ml slow injection of LA avoid traumatic needling judicious dosing of LA epi marker in blocks with ^ volume be prepared to treat
62
how long is continuous monitoring required after high dose blocks?
30min of ECG, BP, and Sat
63
what symptoms of LAST should pt be aware of and be told to communicate
metallic taste, ears ringing, circumoral numbness, anxiety, double vision, dizziness, etc.
64
when to decrease LA dose in PNBs?
advanced age poor cardiac function preexisting conduction abnormalities decreased plasma proteins
65
How should you be prepared to treat LAST?
have 20% lipid emulsion in area where blocks are performed have a plan: ASRA/NYSORA checklists
66
What epi dose is used in PNBs?
1:200,000
67
when do you not add epi to blocks?
fingers, nose, PP, and toes. (also ears)
68
Epi ammount in normal (emergency) epi syringe?
1mg/10ml or 100mcg/ml or 1:10,000
69
CNS symptoms of LAST?
first: excitation: agitation, confusion, twitching, seizure later: depression: drowsy, obtunded, coma, apnea neuro symptoms may be subtle/absent also, benzos can hide the seizures
70
CV signs of LAST
excitation followed by depression ^BP ^HR, ventricular ectopy, multiform VT, VF > decrease in BP, bradycardia > asystole
71
hallmark sign of cardiac toxicity of LA?
Ventricular ectopy, multiform VT, VF
72
hallmark of severe LA toxicity?
progressive decrease in BP, bradycardia>asystole
73
how does LAST progress?
maybe slow or fast, and some S/S may be subtle or absent
74
when should you be vigilant in monitoring RA?
always during and after RA!!!
75
LAST treatment
1. call for help/lipid emulsion therapy 2. ASRA/NYSORA checklists 3. alert cardiopulmonary bypass team/nearest facility that has it 4. Airway mgmt (100% FIO2 mask or vent) 5. abolish seizure, versed or propofol but avoid propofol if CV is unstable 6. manage cardiac arrhythmias ACLS
76
what meds to avoid during LAST?
Ca++ chanel blockers beta blockers lidocaine phenytoin vasopressin (contraversial)
77
Lipid emulsion dosing for LAST?
Bolus 1.5ml/kg about 100ml (based on lean body weight) infusion of 0.25ml/kg about 18ml repeat bolus Q 5 min if persistent CV collapse infusion doubled to 0.5ml/kg if hypotension continues continue infusion for at least 10min after CV is stable this is with all other ACLS meds as well
78
what is upper limit for lipid emulsion therapy?
10ml/kg over first 30min.
79
what is a rare but profound complication of PNB?
pneumothorax
80
which PNBs have the higest risk of pneumothorax?
Brachial plexus blocks supraclavicular highest ISB, ICB, and suprascapular lower Thoracic blocks paravertebral PEC blocks intercostal blocks
81
Do you get JVD with pneumothorax?
yes
82
late sign of pneumothorax?
tracheal shift away from pneumothorax
83
gold standard for diagnosing a pnemothorax?
CT scan
84
are chest X-rays sensitive to finding pneumos?
no
85
What is likely best way to diagnose pneumo and also has 100% negative predictive value?
ultra sound
86
what kind of probe should you use for lung ultrasound?
linear trasnducer - best image phased array - gets deeper for obese pts or large breasts, but image quality goes down
87
where to start with probe during lung ultrasound?
midclavicular line and 2nd-4th interspace, probe oriented parasagittally move from midclavicular line to ant axillary line
88
what are you looking for with lung ultrasound?
pleural sliding during respiration acoustic artifacts seen with pleural layers are touching lung edge - where lung stops touching chest wall d/t air pocket
89
What does it mean if you don't see pleural sliding?
air is present = pneumothorax sliding looks like shimmering line
90
in what mode do you see pleural sliding?
2D
91
what is M-mode?
shows motion over time
92
what does normal lung look like in m-mode?
sea shore pattern
93
what does pneumothorax look like in M bode?
bar code pattern no motion seen, so same appearance above/below pleural line
94
When are B-lines and comet tails present?
normal lung tissue
95
What are B-lines?
acoustic differences of air/water in lung tissue
96
what are comet tails?
US waves bouncing off interface of the pleural layers. they move synchronously with respiration
97
What does it mean if B-lines and comet tails are not present?
pneumothorax
98
regarding B-lines and comet tails, even if you only have 1 what does that mean?
no pneumo
99
what are A lines?
horizontal lines equally spaced emanating from the pleural lines. Just an echo of the sound waves back to prove because there is nothing for them to bounce off of. a lines equal pneumothorax
100
what is the most specific sign for a pneumothorax?
lung point assessment. it is also the most difficult to find, even for experienced operators.
101
what is lung point assessment?
shows location on chest where lung stops touching the chest wall. by finding edges of air pockets allows for calculation to estimate size of the pnemo
102
can pneumos resolve spontaneously over time?
yes, sometimes
103
how often do transient nerve injuries occur with PNBs?
Up to 10% usually resolve in days to weeks, rarely weeks to months for resolution
104
are nerve injuries from PNB common?
no, they are an infrequent complication
105
how often to permanent nerve injuries occur from PNB?
1.5/10,000
106
what are the effects of a permanent nerve injury from PNB?
range from localized numbness to paralysis
107
how does risk of nerve injury varry throughout the body?
risk decreases distally
108
pre-existing diseases the increase risk of nerve injury?
DM, PVD, atherosclerosis

Anesthesia Principles II (14 decks)

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