Spinal And Epidural Anesthesia Flashcards by Hailey Haas

How many total vertebra
Numbers:
Cervical
Thoracic
Lumbar
Sacral
Coccygeal

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High vertebral curves

C5 and L3

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Low vertebral curves

T5 and S2

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Purpose of ligaments

Where supraspinous ligament runs from

Stabilizing vertebral body

C5 to sacrum

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Where inter spinous ligament runs from

Entire length

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Outside to in ligaments (5)

Supraspinous 
Interspinous
Ligamentum flavum 
Posterior longitudinal ligament
Anterior longitudinal ligament

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Ligamentum flavum

Extends from where to where

Shaped like what and composed of what

Foramen magnum to sacral hiatus

Wedge shaped, elastin

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Ligamentum flavum

Thickest where

What color

Landmark for what

Tough and fibrous in who

Mid line 3-5 mm at L3

Yellow

Epidural placement

Young pregnant women

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Spinal meninges are continuous with what

Cranial meninges

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Dura mater

_____ meningeal tissue

Begins where and ends where in adults and where in infants

Abuts the what

Thickest

Foramen magnum, ends caudally at S2/Dural sac (PSIS) S3 in babies

Arachnoid mater/ subdural space

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Arachnoid mater

Principal physiologic ____ for ____ moving between epidural space and ___ ____

Abuts the ___ ___ giving rise to the subarachnoid space

Ends at ____.

It is ____ and ____

Barrier for drugs
Spinal cord

Pia mater

Delicate and nonvascular

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Subarachnoid space

Contains _____

Continuous with cranial ____ and provides vehicle for ___ in the spinal _____ to reach the ____

Houses what (2)

CSF

CSF, drugs, CSF, brain

Spinal nerve roots and rootlets

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Spinal cord

Runs from ___ ___ to ___ ____ ends at level ___-___

___ pairs of spinal nerves

Each with ___ root (motor) and ____root (sensory)

___ are composed of _____

Foramen magnum to conus medullaris, L1-L2

Anterior, posterior

Roots, rootlets

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Dural sac terminates at what level

What is role of filum terminale

Anchors everything down

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Dorsal/posterior (____) roots — _____

Ventral/anterior (_____/____) roots — _____

Sensory, dermatomes

Motor/autonomic, Myotome

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_____ is the skin area innervated by a spinal nerve and its segment

The portion of the spinal cord that gives rise to all the rootlets of a signal spinal nerve is called a _____

Dermatome

Segment

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Cutaneous distribution of spinal nerves

C6 \_\_\_
C7 \_\_\_ and \_\_\_ \_\_\_
C8 \_\_\_\_ and \_\_\_ \_\_\_
T4 \_\_\_\_
T6 \_\_\_\_
T8 \_\_\_\_ \_\_\_\_
T10 \_\_\_\_\_\_

Thumb 
2nd and 3rd finger
4th and 5th finger
Nippe
Xiphoid 
Last rib
Umbilicus

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CSF
_____ cc in subarachnoid space

Volume replaced ___-___x per day

Produced ___ml/hr by ___ ____

Specific gravity ____-____

150

3-4

21, choroid plexus

1.004-1.008

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Blood supply

Spinal cord supplied by ___ ___ spinal artery and __ ___ spinal arteries

___ branches come off of the ___ to supply these arteries

2 ____ arteries have better continuity of blood supply than the ___ spinal artery

1 anterior, 2 posterior

Radicular, aorta

Posterior, anterior

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Neural blockade

Local anesthetic bathes the ___ ___ in that space

\_\_\_\_ block (spinal anesthesia)
Local anesthetic is injected into \_\_\_ to directly bathe the nerve root, leads to rapid onset

Epidural anesthesia (outside of \_\_\_\_)
Local anesthesia is injected into \_\_\_ or \_\_\_ space and diffused through the \_\_\_\_ cuff before bathing the nerve root. Slower onset

Nerve roots

Subarachnoid, CSF

Meninges, epidural, caudal, Dural

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Physiology of neural blockade

Goal: blockade of ___ impulse, a stimulus that causes ___ or ___

Blocks all ___ regardless of fiber type

4 types:

__ and ___ function are also blocked

Nocioceptive, pain, injury

Impulses

Autonomic, sensory, proprioception, motor

Autonomic and motor

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Physiology of neural blockade

Different nerve types have different ___ to local anesthetic

___ nerves highly sensitive with rapid onset of blockade

___ nerve intermediate sensitivity

__ nerves more resistant to LA and have slower onset

Sensitivities

Autonomic

Sensory

Motor

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Physiology of neural blockade

Spinal blockade

autonomic blockade ___-___ levels ___ sensory blockade
motor blockade ___ ___ sensory blockade

Epidural blockade

autonomic blockade __ level as sensory blockade
motor blockade ___-___ levels ___ sensory blockade

2-6, above
2 below

Same
2-4 below

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Benefits of neuroaxial anesthesia

decreased incidence of ___, cardiac ___, and ____
decreased lower extremity vascular ___ ___ due to vasodilation and increased blood flow ___ blockade
decreased incidence of ____

DVT, morbidity, death

Graft occlusion, below

Pneumonia

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Benefits of neuroaxial anesthesia - decreased ___ response - avoids ____ manipulation - decreased incidence of ____ - intra and postop ___ relief

Stress Airway PONV Pain

Disadvantages of neuroaxial anesthesia - ___ - delayed ____ start - failure rate depends on _____ - not a ____ anesthetic

Hypotension Case Experience Benign

7 considerations for choosing a technique

``` Anatomy Age Pregnancy Patho/comorbidities Sensory level required vs adverse physiologic effects Length of procedure Post op analgesic needs ```

Indications for SAB/Epidural Anesthesia - sole ___ - combined ____-___ blockade - combined _____/____ used in major ____ procedures and lower ___ ____ cases

Anesthetic Spinal-epidural GA/regional Abdominal, extremity vascular

Indications for SAB/epidural Analgesia ____ and in ___ and ____

Postop and in labor and delivery

Contraindications One absolute: Semi absolute ____ ____ at injection site ___ defects/____ therapy

Patient refusal Increased ICP Infection Clotting, anticoagulant

Contraindications Severe _____ or ____ CNS ___/____ Inability to remain ____ for block _____ ______

Hemorrhage or hypovolemia Disease/meningitis Still Bacteremia Septicemia

Contraindications ____ lesions with fixed __ ___ (severe ___/___ and ___ cardiomyopathy) Difficult _____ Full ____ ______ neuropathies

Valvular, stroke volume, AS/MS, hypertrophic Airway Stomach Peripheral

Cardiovascular changes Loss of ____ activity results in vasodilation ___ blockade, decreasing SVR ___-___%, decreased ___, therefore CO ___-___% ___ dilation greater than ___ dilation

Sympathetic, below, 15-20, preload, 10-15 Venous, arterial

Cardiovascular changes If blocked is at or cephalad to __-__ level the cardiac accelerators are blocked resulting in ___ Results in profound ____ Treatment includes: 3

T1-T4, bradycardia Hypotension Vasopressors, volume load (15 ml/kg), vagolytics to treat bradycardia

Pulmonary changes Low levels of blocked- minimal effect of ___/___/___/___ space As block ascends, _____ muscle paralysis occurs, a perception of ineffective breathing and decrease ability to ___ develops No direct ___ effects except those related to positioning unless high block (___-___, ___ nerve) With profound hypotension, may see ___ of central respiratory centers which causes respiratory ___

MV, TV, RR, Dead Accessory, protect Respiratory, C3-5, phrenic Ischemia, arrest

GI/Renal effects Nausea vomiting effects ___% _____ due to unopposed ___ activity Flow to liver ___ dependent, maintenance of MAP-___untoward liver effects Renal blood flow has ____ effect _____ dysfunction, urinary ____. Avoid excessive ____ if no foley

20 Hyperperistalsis, parasympathetic BP, no Minimal Bladder, retention, IVF

Metabolic/endocrine effects Blocks ___ response to surgery ____ release may be blocked from the ___ ___ ____ secretion is delayed ____ due to altered ____ with vasodilation

Stress Catecholamine, adrenal medulla Cortisol Shivering, thermoregulation

Neuro effects ___ maintained unless MAP less than ___ Manifested by ___/___ and if sufficiently decreased, ___ and ___ Decreased signals to ____ ___ system leads to ___

CBF, 60 N/V, apnea and hypoxia Reticular activating system, drowsiness

Lateral decubitus ___ to the ___. ___ flexed to the ___ Sitting Low ___ ____ block Improved ___ anatomy

Forehead to the knees, thighs flexed to abdomen Lumbar, sacral, midline

Pre-procedure set up Monitors: 3 ____ ___ delivery Fluids ____-___ ml Equipment for ___ management and resuscitation available Emergency ___ drawn Consider___ prior to procedure, identify ____

Pulse ox, ekg, BP Suction Oxygen 500-1000 Airway Meds Sedation, landmarks

Median approach Most ___, needle placed ___, ___ to spinous processes, aiming slightly ____

Common, midline, perpendicular, cephalad

Paramedian approach Indicated in patients who can't ___ Spinal needle placed ____ cm ____ and slightly ___ to the center of the selected interspace

Flex 1.5, laterally, caudal

Midline approach ``` Layers transversed ____ _____ ____ ____ ____ ____ ____ ____ ____ (____ ___) ___ ___ ___ ___ (____ ___) ___ ___ ___ ___ If reached last 2, too far ```

``` Skin SQ tissue Supraspinous ligament Interspinous ligament Ligamentum flavum Epidural space Dura mater Arachnoid mater Subarachnoid space Pia mater Spinal cord ```

Paramedian approach Misses the ___ and ___ ligaments Unable to use ___ ___ as guide Useful in ___ epidurals or pts with narrow ___ openings

Supraspinous and inter spinous Spinous process Thoracic, vertebral

Pencil point needle (___/___) - designed to spread fibers and reduce ___ ___ ___ - yield a distinct ___ as pencil point penetrates the ___ - offers increased ___ strength to minimize bending or breakage

Sprotte, Whitacre Post Dural headache Pop, dura Tip

Cutting needle (_____) Dural ___ less likely to be noticed due to ___ tip Increased risk of __ ___ ___ Introducer may not be ___ Bevel must be facing ___/___ in sitting position and ___/___ in lateral position to reduce headache risk

Quincke Pop, sharper Postdural puncture headache Necessary Left/right, up/down

SAB 1. An atomic landmark is identified, ___ ___ ___ palpated and ___ is identified 2. A __ ___ is established and a prep solution applied with ___ basic sponges, applied in what fashion 3. A drape is applied, using a ___ ___ wipe the ___ from the injection site 3. A skin wheel is raised with ___ml of ___ ___ with a ___G needle

Superior iliac crest, L4 Sterile field, 3 Sterile gauze, iodine 2, 1% lidocaine, 25

SAB 4. A ___G introducer is passed through skin ___, angled cephalad, stopping in the ___ ___ 5. A ___G needle is inserted into introducer, stopping at ___ space where presence of ____ determined Layers further than epidural:

17, wheal Ligamentum flavum 25, arachnoid, CSF Dura, arachnoid, subarachnoid space

SAB 7. CSF is ___ and ___ ___ are identified as a change in ___ and ____ as the local anesthetic and CSF mix 8. The dose is slowly injected, ___ after installation 9. All needles are removed and patient is ___

Aspirated, mixing lines, baricity, temperature Aspirating Positioned

Midline approach Palpated ___ ___ of upper vertebra to make sure midline Increased resistance as pass through the ___ ___ then loss of resistance as pass through ___ to ___ ___ Remove ___ and confirm free flow of CSF (rotate ___ degrees ___times) Aspirate CSF ___ and ___ med admin

Transverse processes Ligamentum flavum, dura, subarachnoid space Stylet, 90, 4 Before and after

Paramedian approach Identify ___ edge of ___ ___ process Skin wheel ___ cm ___ and ___ cm ___ to that point Needle aimed __-__ degrees __ and slightly ___ If lamina contacted needle and walked off in a __ and __ direction After ___ obtained ___ technique as midline

Caudad, superior spinous 1, lateral, 1 caudad 10-15, medial, cephalad Medial and cephalad CSF, same

Density Specific gravity

The weight in grams of 1 cc of solution at a certain temp The ratio of the density of a solution to the density of water at a constant temperature

Baricity What substances are referring to in SAB CSF specific gravity

The density of a solution to the density of another substance CSF and LA 1.004- 1.008 (heavier than water)

Specific gravity of LA can be altered by adding ___, ___ or ___ _baric and ___baric produce reliable blocks

Dextrose, water, CSF Isobaric and hyperbaric

Hyperbaric solution Specific gravity: Mix the local anesthetic with ___ and allows LA to ___ into ___ areas

Greater than 1.11 Dextrose, settle, dependent

Hypobaric solution Specific gravity: Mix LA with what Will go where

Isobaric solution Specific gravity How you mix it

Factors affecting spread of LA Top 3 affecting spinal and not epidural 3 others that affect both

Baricity of LA, position of patient, concentration and volume injected Level of injection, rate of injection (barbotage), direction of needle and bevel

Which solution used in hip surgery

Hypobaric

4 decisions to consider when dosing SAB

Surgical site Length of procedure Body size (height and width) Physiology

Duration of spinal block ___ of local anesthetic ___ determines duration Done by ___ absorption via ___ and ___ blood vessels Metabolized in ___ ___ can prolong length of block

Rate, elimination Vascular, subarachnoid, epidural Vasoconstrictors

Epidural placement ___ ___ technique with __ needle, ___ facing opening ___ of ___ technique, __ or ___ filled glass syringe

Continuous catheter, touhy, laterally Loss, resistance, air, saline

Epidural insertion sites: 3

Thoracic, lumbar, caudal

Epidural space Widest point is ___, ___ mm Contains ___ and __ ___ Closed space Medication and catheter deposited into ___ space

L2, 5 Fat and blood vessels Potential

Epidural Ligamentum flavum depth from skin is __ cm, 80% of pts between __-__ cm ___-__mm thick at midline in lumbar region

4 3.5-6 5-6

Epidural placement LOR technique Steady ___ on ___ compress __ __ while advancing needle, when epidural space entered __ is gone and fluid is easily injected Note needle __ when this happens Advance __-__ cm, ___-__ is pregnant

Pressure, plunger, air bubble Resistance Depth 2-3 4-6

Caudal block Involved delivery into __ space via injection through ___ ___ Acces via ___ ligament and __ ___ __ or __g needle and syringe

Epidural, sacral hiatus Sacrococcygeal ligament and sacral hiatus 22 or 23

Landmarks in caudal anesthesia: 3

Sacral Cornu Posterior illiac spines S2 Sacral hiatus

Caudal anesthesia Identify __ __ and __ Needle is introduced in a slightly ___ direction through __ at a __ degree angle The needle advanced until a __ felt as going through __ membrane Needle is then __ to a __ degree angle and advanced __-__ __ to make sure bevel is in caudal epidural space

Sacral hiatus and PSIS Cranial, 60 Pop, sacrococcygeal Drop, 20, 2-3 mm

Caudal anesthesia ___ to confirm absence of ___ and __ Make sure no ___ injection with other hand There should be very little ___ to injection

Aspirate, blood and CSF SQ Resistance

Caudal anesthesia uses: 4

Peds post op pain control Hypospadias Inguinal hernia repair Perineal and sacral area procedures

Limitations to caudal anesthesia Variable anatomy in ___, best in pts in what age group High risk of injection into a ___ ___ Difficulty maintaining ___ should a catheter be used

Adults, less than 7 years old Venous plexus Sterility

Spread of epidural While injecting test dose will notice what if in vascular space or what in subarachnoid space The quality and extent of epidural dependent on ___ and __ of LA For induction use ___-___ ml per segment

Rise in heart rate from epi, can't feel legs if in subarachnoid Volume and concentration 1.25-1.6

Post dural puncture headache __-__% incidence Due to decrease in ___ pressure with compensatory cerebral ___. Causes brain stem to ___ which stretches __ and pulls on ___ Fronts-occipital postural headache occurs within what range of anesthesia Treatment: 7

1-4 Intracranial, vasodilation, sag, meninges, tentorium One day to one week Bed rest, hydration, NSAIDS, abdominal binder, epidural saline injection, caffeine, epidural blood patch

PDPH Increased incidence in ``` ___ __ patients ___ needle size ___ population ___ for LOR ___ tip needles __ to meninges ___ attempts ```

``` Young female Larger Pregnant Air Cutting, perpendicular Multiple ```

Procedure for epidural blood patch __-__ ml Aseptic epidural injection of autologous blood into ___ level, at same level or more ___ __% effective If more than __ attempts than other causes need to be ruled out Side effects: 2

10-20 Epidural, caudad Greater than 90 2 Backache and radicular pain (pain radiating to lower extremity)

Epidural hematoma Primary cause is what Presents with __ or __ ___ weakness Consult ___ right away if suspected, __-__ hours before permanent injury Greater than __ hours makes odds of decompression less successful Hold LMWH __-__ hours before placement and hold __-__ hours after. Heparin can be given __-__ post.

Coagulation defect Numbness or lower extremity weakness Neurosurgery, 6-8 8 10-12, 10-12 1-2

Spinal And Epidural Anesthesia Flashcards

(77 cards)