spinals and epidurals

Question 1

what is the advantage of a pencil point needle?

Answer 1

better feel, less trauma

Question 2

the stylet prevents the introduction of dermal cells, but can lead to ____ ____ ____ ____

Answer 2

dermoid spinal cord tumor

Question 3

what are the absolute contraindications to spinal?

Answer 3

patient refusal, lack of cooperation, uncorrected coagulopathies, infection at the site of block, increased ICP, indeterminate neurological disease

Question 4

what three factors affect distribution?

Answer 4

barcity, position, dose

Question 5

what factors affect uptake and spread from subarachnoid space?

Answer 5

concentration of LA in CSF, surface area of nerve tissue exposed, lipid content of nerve tissue, blood flow to nerve tissue

Question 6

drugs in dextrose are hypo iso or hyperbaric?

Answer 6

hyper

Question 7

T/F Physiologic changes with a spinal include venodilation and arterial dilation

Answer 7

true

Question 8

sympathectomy is dependent on block ____

Answer 8

height

Question 9

physiologic changes related to a spinal and the GI system come from sympathetic innervation at what levels?

Answer 9

T6-L2

Question 10

GI effects of spinal = ____ secretions, sphincters ___ and bowel ____

Answer 10

increased secretions, sphincters relax, bowel constricts

Question 11

the iliac crest which spinal level?

Answer 11

L4-L5

Question 12

if you contact bone while doing a spinal what should you do

Answer 12

withdraw needle and stylet to skin and redirect. [moving introducer inside can cut and tough ligaments wont allow the needle to move well inside]

Question 13

which approach is good for calcified intraspinous ligament or difficult positioning

Answer 13

paramedian

Question 14

paramedian approach - angle the needle ___ and ____

Answer 14

medially and cephalad

Question 15

what are some causes of neurologic injury

Answer 15

needle introduction to nerve or cord, spinal cord ischemia, bacterial contamination, hematoma

Question 16

what causes caudal equina syndrome

Answer 16

microcatheters, 5% lido, repeated dosing

Question 17

what are causes of arachnoiditis?

Answer 17

infection, myelograms from oil based dyes, blood, neuro irritant, surgical interventions, intrathecal steroids, trauma

Question 18

what are the causes of meningitis?

Answer 18

bacterial or aseptic, use strict sterile technique

Question 19

PDPH has up to a ___% incidence

Answer 19

25

Question 20

PDPH is worse when head __, relief when ____

Answer 20

up, supine

Question 21

PDPH may take up to ___ weeks to resolve

Answer 21

1-6

Question 22

epidural blood patch is 1st effective in up to ___% OB and __% non-OB.

2nd effective up to ___%

Answer 22

90

Question 23

what are risk factors for spinal hematoma?

Answer 23

anticoagulation, increased age, female, hx of GI bleed, length of therapy

Question 24

epidurals - can use adult levels after age __

Answer 24

8

Question 25

vasomotor tone is controlled by __-___

Answer 25

T5-L1 | [decreased venous return, subsequent decreased CO]

Question 26

where are cardiac sympathetic fibers?

Answer 26

T1-T4 | [profound hypotension and bradycardia]

Question 27

respiratory arrest with an epidural is usually due to?

Answer 27

sympathectomy and brain and brainstem ischemia

Question 28

what is the key factor affecting spread for an epidural?

Answer 28

volume

Question 29

lumbar gets more spread ____ than ____

Answer 29

cephalad than caudal

Question 30

how to dose epidurals : <5'2 use? >5'2 use?

Answer 30

<5'2 use 1ml per level | >5'2 increase by 0.1ml for each 2 inches

Question 31

why do you decrease the dose for pregnancy and obesity?

Answer 31

epidural vein engorgement and increased adipose tissue

Question 32

the hanging drop technique is most commonly used for ____ epidurals

Answer 32

thoracic

Question 33

for a caudal block, the sacral ____ is ID'd by the sacral ___

Answer 33

hiatus, cornu

Question 34

for a caudal block, insert the needle at ___ degree angle, and a distinct pop or snap is felt when through _____

Answer 34

45 | sacrococcygeal membrane

Question 35

what is the test dose for an epidural

Answer 35

3ml of 1.5% lido with 15mcg epi

Question 36

what should you do if you have a unilateral block?

Answer 36

pull catheter back, unaffected side down, redose, replace

Question 37

what should you do if you have an inadequate block?

Answer 37

raise head and redose with higher concentration. add fentanyl or give 50mcg

Question 38

what should you do if the epidural is questionable and you need to go to the OR

Answer 38

in OR remove catheter, do CSE with new catheter placement

Question 39

what should you do with a dissipating block? (requires more or doesn't last)

Answer 39

check for intravascular placement, rebels with higher concentration and increase rate, add opiod.

Question 40

what happens if you inject epidural into the SA space?

Answer 40

fast high spinal

Question 41

what happens if you give an epidural dose subdural?

Answer 41

delayed response 10-15min. get ready for high spinal

Question 42

what are the s/s for meningitis

Answer 42

non-positional headache, fever, lethargy, confusion, and classic nuchal rigidity

Question 43

what's the tx for meningitis?

Answer 43

emergent abx therapy, head CT, LP, neuro consult

Question 44

what condition is thought to be from adherence of tissue pulling?

Answer 44

arachnoiditis

Question 45

how far in advance do aspirin and NSAID's have to be d/c'd

Answer 45

they dont

Question 46

how far in advance does plavix need to be d/c'd?

Answer 46

7 days

Question 47

how far in advance does warfarin have to be d/c'd?

Answer 47

4-5 days | apex says 5

Question 48

you want the INR to be

Answer 48

1.5

Question 49

for IV heparin: delay until __h after block, remove catheter ___-___h after last dose

Answer 49

1, 2-4

Question 50

LMWH (ardeparin, dalteparin, enoxaparin, tinzaparin, danaparoid) PRE-OP guidelines?

Answer 50

block 10-12h after last dose; high dose delay 24h.

Question 51

LMWH post-op guidelines

Answer 51

twice daily dose: delay 1st dose for 24h, 2h delay after catheter removal. ---- once daily dose: 6-8h post op, remove catheter 10-12hr after last dose and wait 2h until next dose

Question 52

herbal drugs = d/c ___ days before surgery

Answer 52

5-7

Question 53

order the 5 ligaments form skin to sc

Answer 53

surpaspinous, interspinous, ligamentum falvum, posterior longitudinal, anterior longitudinal

Question 54

T/F With both the midline and paramedian approach, the needle should NEVER pass thru the anterior or posterior longitudinal ligaments

Answer 54

TRUE

Question 55

T/F Inadvertent injection of LA into the subdural space will cause a high spinal if using epidural dosing or a failed spinal if using spinal dosing.

Answer 55

TRUE

Question 56

(APEX) LA in the epidural space must first diffuse thru the ___ before they can block the nerve roots

Answer 56

dural cuff

Question 57

(APEX) in the subarachnoid space, the primary site of LA action is on the _____

Answer 57

myelinated pre-ganglionic fibers of the spinal nerve roots.

Question 58

(APEX) what are the factors that significantly affect spread for a spinal

Answer 58

baricity, patient position before/after, dose, site of injection, volume of CSF, density of CSF

Question 59

(APEX) T/F The factors that do not significantly affect spread of a spinal include barbotage, increased intrabdominal pressure, speed of injection, orientation of bevel, addition of vasoconstrictor, weight, gender.

Answer 59

TRUE

Question 60

(APEX) T/F Apnea after a spinal is usually the result of phrenic nerve paralysis or high concentrations of LA in the CSF?

Answer 60

FALSE. It is usually the result of cerebral hypo perfusion.

Question 61

(APEX) Spinal affect on GI system: inhibition of sympathetic outflow causes sphincters to ___ and ____ peristalsis

Answer 61

relax, peristalsis

Question 62

T/F in the setting of a spinal, as long as SBO is maintained, hepatic and renal blood flow and function are unchanged.

Answer 62

TRUE.

Question 63

(APEX) whats the deal with MS and neuraxials?

Answer 63

epidural anesthesia is safe but intrathecal technique may exacerbate symptoms

Question 64

a ____ solution will sink, a ____ solution will rise

Answer 64

hyperbaric sinks, hypobaric rises

Question 65

dextrose ___ baricity, water ___ baricity

Answer 65

increase, reduce

Question 66

(APEX) procaine 10% in water is an exception.. is it hyper, hypo, or isobaric?

Answer 66

hyperbaric

Question 67

which 2 needs are cutting tips

Answer 67

quincke and pitkin

Question 68

which 4 needles are non-cutting

Answer 68

pencil points = sprotte, whitacre, pencan. rounded bevel tips = greene

Question 69

T/F the pencil point tips require less force.

Answer 69

false they actually require more force.

Question 70

which needle type is more easily deflected/

Answer 70

cutting tip (quincke, pitkin)

Question 71

(APEX) what two things about the tuohy needle minimize the risk of dural puncture?

Answer 71

30 degree curvature and blunt tip

Question 72

T/F you should never withdraw the epidural catheter thru the needle

Answer 72

TRUE. this can shear the catheter leaving fragments inside the patient.

Question 73

(APEX) what factors increase the risk of caudal equina syndrome

Answer 73

5% lido and spinal micro catheters