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Principles of Anesthesia > Spinal Anesthesia (Exam I) > Flashcards

Spinal Anesthesia (Exam I) Flashcards

1
Q

What type of neuraxial technique would exhibit a more rapid onset?

A

Spinal blocks

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2
Q

What type of neuraxial technique would exhibit a slower onset?

A

Epidural blocks

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3
Q

What type of block tends to extend cephalad?

A

Spinal blocks

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4
Q

The spread of epidural blocks can be controlled via the ______ of the local anesthetic.

A

volume

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5
Q

Which type of neuraxial block is more dense? Which is more segmental?

A

Spinal = Dense
Epidural = Segmental

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6
Q

Which type of neuraxial block will produce a dense neuromuscular blockade?

A

Spinal blocks

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7
Q

T/F. Epidural blocks tend to produce hypotension more than spinal blocks?

A

False. Spinal blocks tend to produce greater hypotension.

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8
Q

Spinal blocks are ____ based, whilst epidural blocks are _____ based.

A

dose; volume

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9
Q

Where should spinal blocks be placed? (especially if you’re a beginner)

A

L3 - L4

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10
Q

Differentiate the duration of action of spinal blocks vs epidural blocks.

A

Spinal blocks = limited and fixed duration
Epidural = variable duration due to catheter in place and infusion delivery.

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11
Q

Which neuraxial technique is more prone to local anesthetic toxicity?
Why?

A
  • Epidural blocks
  • Possibility for LA to infiltrate vasculature and flood the circulation.
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12
Q

Which neuraxial technique exhibits baracity?
What does this mean?

A
  • Spinal blocks
  • This means that the LA is influenced by gravity.
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13
Q

What factors affect the dermatome spread of a spinal block?

A
  • Position changes
  • Baricity
  • Dose
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14
Q

Epidural dermatome spread is incremental based on _______.

A

volume

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15
Q

Epidural spread is ____ mls per segment.

A

1 - 2

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16
Q

Which neuraxial technique is the preferred technique for Cesarean delivery?

A

Spinal block

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17
Q

What other names exist for spinal blocks?

A
  • Subarachnoid block
  • Intrathecal block
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18
Q

What types of surgical procedures indicate the use of spinal block?

A
  • Lower abdomen
  • Perineum
  • Lower extremities
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19
Q

What are absolute contraindications to spinal block?

A
  • Coagulopathy (ex. known disorder)
  • Sepsis
  • Patient refusal
  • Dermal site infection
  • Hypovolemia
  • Intraspinal mass
  • Severe Valvular disease
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20
Q

What are the relative contraindications to neuraxial anesthesia?

A
  • Spinal column deformities (ex. kyphosis)
  • Preexisting spinal cord disease (ex. MS)
  • Chronic Headache/backache
  • Inability to place block after 3 attempts
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21
Q

How many attempts does one have to place a neuraxial block?

A

Three attempts typically

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22
Q

The superior aspects of the iliac crests line up with what spinal segment?

A

L4

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23
Q

The inferior aspects of the scapula line up with what spinal segment?

A

T7

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24
Q

How many vertebrae are there?

A
  • 8 Cervical
  • 12 Thoracic
  • 5 Lumbar
  • 5 Sacral
  • 1 Coccyx
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25
Q

What type of neuraxial technique is used with a sacral approach?

A

Epidural

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26
Q

How is the sacral hiatus identified?

A

Via the sacral cornua on either side of the hiatus.

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27
Q

Which spinal nerves are our cardioaccelerators?

A

T1 - T4

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28
Q

What are the high points of the spine when the patient lays in the supine position?

A

High points = C3 and L3

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29
Q

What are the low points of the spine when the patient lays in the supine position?

A

Low points = T6 and S2

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30
Q

When blood is encountered during a neuraxial needle insertion, the most likely cause is that the needle is _________.

A

lateral

(needle should be dead center medial)

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31
Q

What ligament is indicated by “c” in the picture below?

A

Supraspinous ligament

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32
Q

What ligament is indicated by “b” in the picture below?

A

Interspinous ligament

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33
Q

What ligament is indicated by “a” in the picture below?

A

Ligamentum Flavum

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34
Q

What is the distance from the skin to the ligamentum flavum?

A

4 cm in 50% of patients
4-6 cm in 80% of patients

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35
Q

Where is the ligamentum flavum thinnest?

A

Cervical interlaminal spaces

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36
Q

Is the ligamentum flavum thickest near the rostral lamina or the caudad lamina?

A

Caudad Lamina

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37
Q

Where does the spinal cord typically end in adults?

A

L1 (60% of patients)

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38
Q

Where does the spinal cord typically end in kids?

A

L3

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39
Q

Where should a beginner SRNA stick for neuraxial access?

A

L3 - L4 interlaminar space

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40
Q

Where does the dural sac terminate?
What is in the dural sac after the termination of the spinal cord?

A
  • S2
  • Cauda Equina
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41
Q

List the spinal meninges from outermost to innermost.

A

Dura mater
Arachnoid mater
Pia mater

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42
Q

Which of the spinal meninges is avascular?

A

Arachnoid mater

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43
Q

Which of the spinal meninges is composed of a thin layer of connective tissue with interspersed collagen?

A

Pia mater

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44
Q

How much CSF do adults have?

A

100 - 160 mL

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45
Q

At what rate is CSF produced?

A

20 - 25 mL/hr

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46
Q

The entire CSF volume is replaced roughly every ____ hours.

A

6

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47
Q

What dermatome is at the level of the umbilicus?

A

T10

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48
Q

What dermatome is at the level of the nipples?

A

T4

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49
Q

What dermatome is associated with the thumb?
Why is this dermatome pertinent in the monitoring of neuraxial anesthesia?

A
  • C6
  • Thumb being numb could be indicative of impending C3-C6 involvement (diaphragmatic innervation)
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50
Q

What is Tuffier’s line?
What does it indicate?

A
  • Imaginary line between iliac crests.
  • Indicates L4 (or L4-L5 interlaminar space)
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51
Q

How much should the second dose of lidocaine 5% be in a spinal neuraxial technique?

A

Trick question. Spinal’s are one dose only.

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52
Q

What common dose of bupivacaine is used in spinal anesthesia?

A

Bupivacaine 0.75% in 8.5% dextrose

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53
Q

What common dose of Lidocaine is used in spinal anesthesia?

A

Lidocaine 5% in 7.5% dextrose

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54
Q

What common dose of Tetracaine is used in spinal anesthesia?

A

1% in 5% dextrose

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55
Q

What type of anesthetic is indicated below?

A

Ester

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56
Q

What type of anesthetic is indicated below?

A

Amide

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57
Q

What is the benefit of neuraxial pharmacologic adjuncts?

A
  • Postoperative analgesia
  • Extended duration
  • Improved block density
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58
Q

Which neuraxial adjunct only extends block duration?

A

Vasopressors (ie epinephrine)

59
Q

What neuraxial adjuncts are there?

A
  • Opioids
  • α2 agonists
  • Vasopressors
60
Q

What opioids (with respective doses) are often used in spinal anesthesia?

A
  • Morphine 100 - 400 mcg
  • Fentanyl 10 - 25 mcg
  • Sufentanil 2.5 - 10 mcg
61
Q

What opioids (with respective doses) are often used in epidural anesthesia?

A
  • Morphine 3 - 5 mg
  • Fentanyl 50 - 100 mcg
  • Sufentanil 10 - 25 mcg
62
Q

Why does post-op apnea and respiratory depression occur from neuraxial opioids?

A

Due to cephalad spread

63
Q

Higher doses of opioids are required with which neuraxial technique?

A

Epidural

64
Q

Which opioid has a slower cephalad spread? Why?

A

Morphine due to hydrophilicity

65
Q

Why is morphine not great for outpatient neuraxial anesthesia?

A
  • Delayed resp depression
  • Rostral spread to the brain
  • Slow spread to the intrathecal space
66
Q

Which opioids exhibit an earlier onset of respiratory depression? Why?

A

Fentanyl and Sufentanil due to their lipophilicity

67
Q

What troublesome (but not life-threatening) side effect occurs with neuraxial opioids?

A

Pruritis

68
Q

How is neuraxial pruritis treated?

A
  • Diphenhydramine 25 - 50 mg IV
  • Naloxone 0.1 mg IV (best but reverses pain control)
69
Q

How is neuraxial pruritis prevented?

A
  • Minimize morphine dose
  • Ondansetron 4 mg IV
  • Nalbuphine 2.5 - 5 mg IV
70
Q

How often does urinary retention occur with neuraxial opioid use?

A
  • 30 - 40 %
71
Q

Morphine doses of < 100mcg will have a lower incidence of _______.

A

PONV

72
Q

Adding fentanyl to morphine will decrease the PONV effects. T/F ?

A

False

73
Q

What is the epi wash dose?
Why is it used?

A
  • 0.2 - 0.3 mg
  • Used to prolong duration of neuraxial medication.
74
Q

What is the neo wash dose?

A

2 - 5 mcg

75
Q

What drug exhibits a much more profound increase in duration when vasopressors are used with it?

A

Tetracaine

76
Q

What do the α-2 agonists contribute as neuraxial adjuncts?

A
  • Intensification and prolongation of motor and sensory block.
77
Q

What is the neuraxial dose of clonidine?

A

15 - 45 mcg

78
Q

What is the neuraxial dose of dexmedetomidine?

A

3 mcg

79
Q

What factors effect the uptake of medication into the neural space?

A
  • LA concentration in CSF
  • Nerve surface area
  • Lipid content of nerve
  • Blood flow to the nerve
80
Q

What is the reason for differential block?

A

Differing neurons reacting to anesthetic due to their characteristics.

ex. smaller diameter neurons more susceptible

81
Q

In what order are nerves affected by neuraxial anesthetics?

A

1st: B-Fibers (SNS)
2ⁿᵈ: C- Fibers (pain & temp)
3rd: A-delta Fibers (pain & temp)
4th: Aα, Aβ, Aγ (Motor)

82
Q

What nerve type (if blocked) would recover the quickest?

A

Aα (motor function)

83
Q

What nerve type (if blocked) would recover the slowest?

A

B-Fibers (SNS)

84
Q

What nerve type would have the slowest onset of block?

A

Aα

85
Q

The sensory block is assessed to be at the T8 level, where would you expect SNS blockade and motor blockade to be?

A

SNS blockade: T6 (T6 - T2)
Motor blockade: T10

86
Q

What metabolizes anesthetic in the CSF?

A

Trick question. No metabolism occurs in CSF, all anesthetics are eliminated by reuptake

87
Q

What is the most important factor affecting epidural block height and distribution?

A

Volume

88
Q

What drug factors greatly influence neuraxial drug distribution and block height?

A
  • Dose
  • Baricity
  • Patient position
89
Q

For spinal anesthesia, _____ is the most reliable determinant of local anesthetic spread (and block height).

A

Dose

90
Q

What makes a hyperbaric solution?

A

Dextrose

91
Q

What makes a Hypobaric solution?

A

LA + water in 3x the amount of LA.

Ex. 1mL of Lido + 3mL of H₂O

92
Q

What makes an isobaric solution?

A

Plain LA or LA/CSF mix

93
Q

What solution would be best for hip and knee surgeries?

A

Isobaric

94
Q

What type of solution was used in each of the scenarios below?

A
  1. Hypobaric
  2. Isobaric
  3. Hyperbaric
95
Q

How much hyperbaric SAB would be used in a non-obstetric patient?

A

2mL

96
Q

Swirl will be present with ______ solutions.

A

hyperbaric

97
Q

Compare and contrast dosing for isobaric and hypobaric neuraxial anesthetics.

A
98
Q

How much CSF do adult humans have?

A

100 - 160mL

99
Q

How does elderly age affect neuraxial anesthesia?

A

Everything is exaggerated (↑ duration, faster onset, etc.)

100
Q

How does pregnancy affect CSF volume?

A

↓CSF volume via ↑abd pressure

101
Q

Is local anesthetic spread enhanced or diminished in pregnant patients??

A

Enhanced

102
Q

L3 and higher injection sites can result in what?

A

Neural damage

Inject at L4-L5

103
Q

What is barbotage?

A

Aspiration of CSF before LA injection

104
Q

How does bradycardia occur with autonomic blockade from local anesthetic injection?

A
  • Bainbridge reflex inhibition
  • SA node atrial stretch
  • Bezold-Jarisch reflex
  • T1-T4 cardioaccelerator block
105
Q

What is the Bezold-Jarisch reflex?

A

Cardioinhibitory reflex defined as bradycardia, vasodilation, and hypotension resulting from stimulation of cardiac receptors.

Credit: LITFL.com

106
Q

What is the Bainbridge reflex?

A

Compensatory reflex of increased heart rate in response to increases in intravascular volume.

107
Q

If a patient is hypotensive but normovolemic what is the first drug that should be tried? (usually)

A

Ephedrine

108
Q

What GI occurrence results from neuraxial anesthesia?

A

Sympathectomy → increased peristalsis → N/V

109
Q

Sympathetic blockade above _____ will result in losses to bladder control.

A

T10

110
Q

How can neuraxial anesthesia result in hypothermia?

A

Sympathectomy results in widespread vasodilation and heat dissipation peripherally.

111
Q

What drug (not meperidine) did Dr. Tubog mention that will treat post-op shivering?

A

Ondansetron

112
Q

What is the dose for lipid rescue?

A

1.5 mL/kg bolus
0.25 mL/kg gtt

113
Q

Why must the CRNA be prepared to convert to general anesthesia with all neuraxial cases?

A
  • Failed block
  • High spinal
  • LAST
  • Anaphylaxis
  • CV collapse
  • Prolonged case
114
Q

What dermatomal level would be necessary for a C-section or upper abdominal case?

A

T4

115
Q

What dermatomal level would be necessary for vaginal delivery, uterine surgeries, hip procedures, or TURPs?

A

T10

116
Q

What types of needles are cutting needles and thus not a great choice for spinal anesthetics?

A
  • Quincke
  • Pitkin
117
Q

What is the typical onset of spinal anesthesia?

A

5 min

118
Q

What needle approach is recommended for patients with scoliosis or other spinal abnormalities?

A

Paramedian

119
Q

Name the tissues from superficial to deep in a spinal anesthetic.

A

Skin
Subcutaneous
Supraspinous ligament
Interspinous ligament
Ligamentum flavum
Epidural space
Dura mater
Subdural space
Arachnoid mater
Subarachnoid space

120
Q

What degree of approach is used for a paramedian approach for a spinal anesthetic?

A

10-15°

121
Q

What ligaments are not felt during a paramedian spinal approach?

A

Supraspinous and interspinous ligaments

122
Q

What is an early symptom of a high spinal?

A

Inability to phonate

123
Q

What are symptoms of a high spinal?

A
  • Apnea (C3-C5 involvement)
  • Inability to phonate
  • Sympathectomy
  • Unconsciousness
  • Upper extremity block
124
Q

Rapid injection of LA in the subarachnoid space will result in…

A

A high spinal

125
Q

If the patient can phonate, the block likely isnt high enough to require ______.

A

intubation

126
Q

Canceling a case due to a high spinal is indicated if what conditions are occurring?

A

Inability to maintain CV and respiratory status

127
Q

What type of needle tip is preferred to prevent post-dural puncture headache (PDPH) ?

A

Pencil point

128
Q

Do the elderly have a higher risk of PDPH from spinals?

A

No, they have a lower risk.

129
Q

What is the mechanism of PDPH?

A

Loss of CSF → CN traction → CN VI adduction & CN VIII tinnitus.

130
Q

What are the treatments for PDPH?

A
  • Bedrest
  • NSAIDs & narcotics
  • Caffeine
  • Blood patch
131
Q

What dose of caffeine is given for PDPH?

A

300 - 500mg PO or IV

132
Q

A blood patch is determined to be necessary for a PDPH. The patient was stuck at L1-L2. Where would the blood patch be placed?

A

L2-L3

133
Q

How does a blood patch work?

A

20mL of blood is injected into the interlaminar space below site of injury. The blood clots and prevents further CSF leak.

134
Q

What is the hallmark sign of Transient Neurological Symptoms (TNS) ?
What medication increases the incidence of TNS?

A
  • Severe radicular back pain
  • Lidocaine 5%
135
Q

What is Cauda Equina Syndrome?

A
  • Occurs when cauda equina nerve roots are compressed and leads to possible permanent paraplegia.
136
Q

What are s/s of possible cauda equina syndrome?

A
  • Bowel/bladder dysfunction
  • Paraplegia
  • Back pain
  • Saddle anesthesia
  • Sexual dysfunction
137
Q

If compression (disc, hematoma, etc.) is a factor in cauda equida syndrome, what is indicated?

A

Immediate laminectomy within < 6 hours

138
Q

What can cause transient hearing loss with neuraxial anesthesia?

A

CSF pressure changes.

139
Q

What is horners syndrome? What causes it?

A
  • Ptosis, anhydrosis, & miosis
  • High sympathectomy
140
Q

What ester is great for nasal intubations?

A

Cocaine

141
Q

What CN are blocked for awake intubations?

A

CN V, IX, and X

142
Q

What is arachnoiditis?
What causes it?

A

Meningeal inflammation from:

  • Wrong med in epidural space
  • non-preservative free solutions
  • Betadine contamination
143
Q

What are the three most often causes of epidural/spinal hematoma?

A
  • Clotting disorders
  • Traumatic needle placement
  • Indwelling or long-term catheters
144
Q

What neuraxial complication has large jury awards?

A

Epidural/spinal hematoma

Principles of Anesthesia (24 decks)

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