Spinal/epidural

Question 1

Where spinal cord ends

Answer 1

L1-L2, 2% in L3

Question 2

Subarachnoid space ends at __

Answer 2

S2

Question 3

Tuffier’s line

Answer 3

Body of L4 or L4-L5 interspace

find iliac crest horizontal line is L4 usually

Question 4

Which has a 7% higher success rate, L3-L4 or L4-L5?

Answer 4

L3-L4

Question 5

Vertebral Level (What level do we need?)

C7
T7-8
L2
L4
S2

Answer 5

Landmark

Bony knob at base of neck
Lower limits of scapulae
Terminal point of 12th ribs
Line across iliac crests
Posterior iliac spines

Question 6

Tell me the Dermatomal Level for Procedure

Upper abdominal surgery
Intestinal, gynecologic, and urologic surgery
Transurethral resection of the prostate
Vaginal delivery of a fetus, and hip surgery
Thigh surgery and lower leg amputations
Foot and ankle surgery
Perineal and anal surgery

Answer 6

Dermatomal Level 
T4
T6
Innervation from T10 - L2, and S2 - S4, 
T10
L1
L2
S2 to S5 (saddle block)

Question 7

Water intoxication is a s/e of what procedure

Answer 7

Transurethral resection of the prostate

Question 8

Specific gravity of CSF

Do we want to inject a hyperbaric or hypobaric?

Answer 8

1.003- 1.008

Question 9

Specific gravity of Bupivacaine 0.75% in D8.25%

Answer 9

1.0227- 1.0278 (hyperbaric) Most likely to be used

Question 10

Specific gravity of Lidocaine 5% in D7.5%

Answer 10

1.0262- 1.0333 (45m to 1 hour)

Question 11

Specific gravity of Tetracaine 1% in Water

Answer 11

0.9977- 0.9997 (Hypobaric so will float in csf) not very likely to be used) ( 3 hours)

Question 12

Specific gravity of Tetracaine 1% in D10%

Answer 12

Hyperbaric ( 3 hours)

Question 13

Epi wash & why?

Answer 13

local vasoconstriction in subarachnoid space decreasing removal of bupivacaine. so it’s .2 ccs

Question 14

sensory of spinal canal is ____ motor is on the ____ side

Answer 14

dorsal & ventral

Question 15

Shorter duration

Answer 15

Chloroprocaine & Lidocaine

Question 16

Longer Duration Spinal Procedures

Answer 16

Bupivacaine: similar dose and duration as Tetracaine (5-20 mg, 90-120 mins), slightly more intense sensory anesthesia (and less motor blockade) than Tetracaine.

Tetracaine: similar dose and duration as Bupivacaine (5-20 mg, 90-120 mins), slightly more motor blockade (and less sensory anesthesia) than Bupivacaine. Duration is more variable than Bupivacaine and more profoundly affected by vasoconstrictors.

Question 17

Spinal + opioids

Answer 17

Opiates can be added (usually 25 ug fentanyl) and affect the dorsal horn
Morphine (0.1 – 0.5 mg) can be used and provides 24 hours of relief, but unlike fentanyl, requires in-hospital monitoring for respiratory depression
Clonidine is sometimes added but is not as effective as the opiates [Eisenach et. al. Anesthesiology 85: 655, 1996]

Question 18

Which type of needle do we use for spinals

Answer 18

quincke, whitacre, sprotte dull ends so we dont cut

• More fibers cut = more headache
• use smaller like 25ish

Question 19

PDPH

Answer 19

post-dural puncture headache

Question 20

How to orient a spinal needle?

Answer 20

parallel insertion NOT horizontal

Question 21

When use nonquincke or special long needle for spinal?

Answer 21

when you have an obese pt and you must orient the needle

Question 22

Position for spinal

Answer 22

halloween cat

Question 23

Can you repeat a spinal?

Answer 23

NO NO NO bc if you had some of cord

Question 24

Steps

Answer 24

Check expiration date & lot #, save wrapper to record on chart

2. Open kit away from yourself-take out tray and remove tape
3. Initial inspection and palpation
4. Pt palpation- Tuffier’s Line
   a. If feel spinous process, go up 1 interspace
   b. If feel interspace go up to next interspace
   c. Want L3-L4 interspace
5. Sterile gloves
6. Open kit rest of the way w/ sterile technique
7. Drop butt drape under patient’s butt
8. Prep w/ betadine
   a. 3x-each time prep circle with smaller radius than previous
   b. Move in circle outwards-careful not to swipe over area already cleaned
9. Draw up drugs
   a. Skin wheal: 1% Lido-3 mL syringe
   b. Test dose: 1.5% Lido w/ Epi 1:200,0000-in glass syringe
   i. Wet plunger of glass syringe to make it slick, frost disappears
   ii. Careful not to get glove powder onto it
10. Open drape-away from you-drape patient
11. Palpate T3-T4 interspace-keep thumb on lower spinous process
12. “Going to feel a pinch”-inject Lido w/ short needle (25 GA) for skin wheal
13. Change needle head to 18 GA-inject Lido deeper-sweep side to side
14. Advance slightly cephalad (150) until feel resistance (Ligamentum flavum)
    a. Skin Subcutaneous tissue Supraspinus ligament Intraspinus ligament Ligamentum flavum  Epidural space

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b. Position: back of hand against pt.’s back, fingers on needle hub
c. Caution w/ pt leaning over too far-might not have to go as cephalad
15. Fill glass syringe with3-4 mL preservative free NS & small (1cc) air bubble
16. Remove stylet-attach glass syringe- apply pressure to compress air bubble
17. With non-dominate hand, advance needle slowly with continuous pressure on the
plunger to compress air bubble until LOR (in epidural space)
a. Take note of how deep you advance- Read 1cm stripes
18. Perform air test only if the LOR didn’t feel right or catheter won’t advance past end of needle
a. Rapidly inject 2CCs of air from glass syringe and quickly remove thumb from plunger, plunger should not pop back out
19. If “air test “ fails, advance needle, with stylet, 1-2 mm further to ensure tip of needle is not in a soft spot in the ligament or not completely in epidural space (caution not to puncture dura)
20. Perform air test again and LOR if necessary
21. Insert striped catheter to about 15cm mark (3 hash marks)
22. If catheter advances beyond tip of needle but not far enough to insure successful block,
DO NOT WITHDRAW, try injecting though catheter while advancing 23. If not successful, remove needle and try again
24. Remove needle while holding catheter-“follow needle”
25. Add adapter onto end of catheter-pop it down
26. Hookup test dose syringe-aspirate-inject test dose thru catheter
a. Done to identify inadvertent venous cannulation or subarachnoid placement
b. 1.5% Lido (45 mg=3cc) w/ 1:200,000 Epi (15 mcg=3cc)= 3cc total
c. Will be hard to inject-inject over 4 secs
27. Watch for tachycardia 45 seconds after injection, hTN-hit BP cuff 28. Ask patient if they feel and change in sensation
29. Apply foam sticker @ 450 angle to catheter
30. Apply Tegaderm
31. Tape “window” around Tegaderm with 3-4” tape 32. Drape Cath up & over pt.’s shoulder-tape
33. Charting
a. Continuous epidural-L3/4
b. Prepped & draped
c. 17 GA Tuohy
d. LOR x1 (how many tries it took you to get into epidural space)
Negative for CSF, heme with aspiration
e. Epidural space enter @ X cm
f. Catheter placed to X cm
g. Test dose given: 45 mg Lido + 15 mg Epi-negative results

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h. Catheter taped
34. Removal of epidural catheter
a. Catheter should simple pull out with little to no resistance
b. If resistance encountered, place patient in position they were in when block administered
c. DO NOT FORCE, CALL ATTENDING

Question 25

Spinal/Epidural Indications:

Answer 25

``` Spinal/Epidural Indications: 1. Hernia repairs 2 Gynecological surgeries (manual removal of a retained placenta) 3. Urological repairs 4. Operations in the genital region 5. Operations in perineum 6. Post op pain management (epidural) ```

Question 26

Spinal/Epidural Contra-indications:

Answer 26

8. Inadequate resuscitation measures 9. Hypovolemia 10. Clotting and Bleeding disorders 11. Sepsis and septicemia 12. Neurological diseases 13. Unwilling Patient 14. Non suitable Operating Room environment where the team is not accustomed to operating with patient wide awake.

Question 27

Assessment of the block (performed on lateral abdominal and chest wall):

Answer 27

1st. Feel for cold sensations after administration of aerosol spray or cold alcohol swab. 2nd Ask for sensation of pain after pin prick. 3rd Ask the patient to lift legs.