Spinals ppt (josh) Flashcards by Diana Hathaway

Other names for spinal anesthesia? (4)

SAB
Neuraxial block
Conduction block
intrathecal block

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What factors make up the decison to use spinal or not to use spinal

Case selection
Surgeon
Pt selection
Spinal vs General
Spinal vs Epidural
Combined CSE

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What cases are good for spinal anesthesia (this is off pabalate’s slides so not all inclusive)

OB, GYN
Urological
Orthopedics Upper/lower
Lower Abd
Vascular
Post op pain management

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Condtraindications to Spinals

ABSOLUTE

PT REFUSAL (thats for you jake)
Sepsis or infection at injection site
Coagulopathy or anticoagulation
Elevated ICP or Cerebral edema

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Condtraindications to Spinals

RELATIVE

Pt appropriateness
Local infection near site
Hypovolemia
CNS Disease
Chronic Back pain
Prior Lami
Prior SAB with difficulty

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Pt selection:

use spinals cautiously in pt’s with what?

Mabitz type I, or II
3rd degree HB w/o pacemaker
Fixed volume cardiac states (IHSS, Severe Aortic Stenosis)

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have studies shown any difference b/t morbidity or mortality b/t GA and Regional in HEALTHY patients

Nope

(when i wrote this i had dr. monaghan in my ear saying “ hmm (with his right index finger and head both pointing to the right) now that sounds like a great reasearch idea, if anyone is interested see me after class”

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does regional have a lower risk of thrombophelbitis compared to general?

Yep

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your probally saying why? why is there a lower incidence of thrombophlebitis? well answer it… why is there a lower incidence??

postulated to be due to a lower incidence of venous stasis and a higher blood flow r/t vasodilation of the lower extremities!!!!

BAAAAAAMMMM!!!

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Does data support one anesthestic over another? ex spinal vs Epidural vs GA

Negativo

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but… why is there speculation that spinal anesthesia better?

b/c they say spinal anesthesia is much less styressfull to a pt’s physiology than GA

( this s not an accurate speculation don;t be that provder)

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Spinal vs Epidural vs General:

as a result of that last speculation that spinal anesthesia is much less stressful to a pt’s physiology than GA what usually occurs? or what pt’s usually get spinals?

there is an increase in spinals with patients with SIGNIFICANT co-existing diseases, especially the elderly

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Spinal vs Epidural vs General:

so as stated in the last to sides the overall assumption is that sick pt’s tolerate Spinals better than GA!!! don’t always beleive that.

(this is just for info)

per his slide it states

comfort factor- pt is too sick for GA but will tolerate a Spinal w/o significant problems (be careful with this assumption)

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Spinal vs Epidural vs General:

what pt’s may benefit most from spinal anesthesia? (5)

Asthma/COPD/ long pulm hx/ heavy smokers
Fear of GA
OB C-section
Hx of thrombophelbitis ot incresed risk
Any pt with obviously diff airway (undergoing a sx that is suitable for spinal)

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SPINALS vs EPIDURALS

Advantages of SPINAL

Quicker to perform
less painful to pt
fast onset

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SPINALS vs EPIDURALS

disadvantages of SPINAL

fixed duration
PDPH

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SPINALS vs EPIDURALS

Advantages of Epidural

Continuous Infusion
postoperative pain management

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SPINALS vs EPIDURALS

EPIDURAL disadvantages

More painful
Longer to perform
slower onset

(exact opposite of spinals advantages)

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SPINAL A&P

give me the basic 6 Anatomy parts when doing a spinal

Spinal cord
Vertebral body
Ligaments (supraspinous, interspinous, ligamentum flavum)
Spinal cord (L1-L2)
Subarachnpid Space
CSF fluid

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SPINAL A&P

The ___________ of the Parietal lobe, is primarily responsible for receiving painful stimuli

Postcentral Gyrus

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SPINAL A&P

the ________ of the parietal lobe is responsible for motor function and mavement away from painful stimuli

Precentral gyrus

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just to see locations

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SPINAL A&P:Awesome facts

CSF total volume?

150 mL

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SPINAL A&P:Awesome facts

total of 150 mL total CSF fluid how much is in the spinal cord at any given time?

30-50 mL

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SPINAL A&P:Awesome facts CSF pH?

approximately 7.32

SPINAL A&P:Awesome facts CSF is secreted at a rate of what?

30 mL/hr

SPINAL A&P:Awesome facts CSF is secreted at a rate if 30 mL/hr by ______ Cells of the ____ \_\_\_\_

* Epindymal * Choroid plexus

SPINAL A&P:Awesome facts CSF is replaced once ever \_\_-\_\_\_ hours

3-4 hrs

SPINAL A&P:Awesome facts th _spinal cord_ starts and ends where?

* starts- FORAMEN MAGNUM * ends L1

SPINAL A&P:Awesome facts the _spinal Canal_ starts and ends where?

* Starts- FORAMEN MAGNUM * Ends- SACRAL HIATUS

SPINAL A&P:Awesome facts what is beyond L1

the cauda equina

SPINAL A&P:Awesome facts how many vertebral bodies are there?

33 (24 separated by intervetebral disk) 7 cervical 12 thoracic 5 lumbar 5 sacrum 4 coccxygeal

SPINAL A&P:Awesome facts how many spinal nerves are there?

31 (pairs) cervical-8 thoracic-12 lumbar-5 Sacral-5 coccygeal-1

SPINAL A&P:Awesome facts the 31 pairs of spinal nerves carry what?

motor and sensory information

SPINAL A&P:Awesome facts the spinal cord is composed of what 2 types of matter

gray white

SPINAL A&P:Awesome facts Gray matter is composed of what 2 things?

neuronal cells unmylinated fibers

SPINAL A&P:Awesome facts a large number of ________ are found in the GRay Matter

interneurons

SPINAL A&P:Awesome facts what is contained in the white matter?

various tracts

SPINAL A&P:Awesome facts what are the 2 tracts contained in the white matter?

Ascending descending

SPINAL A&P:Awesome facts what is the Ascending tract contained in the white matter of the spinal cord made up of?

* dorsal white matter

SPINAL A&P:Awesome facts what does the Ascending tract contained in the white matter of the spinal cord made contain (it's purpose)?

Ascending SENSORY tracts

SPINAL A&P:Awesome facts what is the Descending tract contained in the white matter of the spinal cord made up of?

* Lateral and Ventral white matter

SPINAL A&P:Awesome facts what does the Descending tract contained in the white matter of the spinal cord contain?

* Descending MOTOR tracts

Label this

1. Posterior Longitudinal ligament 2. Dura Matter 3. Ligamentum Flavum 4. Supraspinous ligament 5. Interspinous ligament 6. Subdural spaace 7. Arachnoid mater 8. Pia mater 9. Cord 10. Subarachnoid Space

Lable this

1. Dural sac 2. Epidural vein 3. interlaminar space 4. Lamina 5. Ligamentum Flavum 6. Supraspinous Ligament 7. Intraspinous ligament 8. Spinous Process 9. Transverse process

SPINAL A&P: Spinal Cord Roots What Carries all AFFERENT signals heading INTO the spinal cord and brain

DORSAL ROOT

SPINAL A&P: Spinal Cord Roots What carries all EFFERENT signals heading out to the periphery

VENTRAL ROOT

SPINAL A&P: Spinal Cord Roots the doral root and ventral root fuse together to form what?

the main nerve root the exits the spinal cord at the particular level

Lable this

1. Ganglion of sympathetic trunk 2. Dorsal root and Ganglion 3. Spinal Cord 4. Ventral root 5. Preganglionic fibers 6. post gangliionic fibers 7. Gray ramus 8. White ramus

SPINAL A&P: Spinal Cord Roots The _______ is the primary site of action of the LA, both with spinal and epidurals. the only doifference is WHERE the root is being anesthetized, either subarachnoid or in the epidural space

NERVE ROOT

SPINAL A&P: Nerves Nerve type and fiber determine the order of block\> the order of block is what?

1. Sypathetic/Parasympathetic 2. Sensory 3. Motor

SPINAL A&P: Nerves Sympathetic/parasympathetic nerves * what size fibers? * what are the 3 fibers? * what are their pathways?

* Small * C, B, preganlionic * Afferent and efferent

SPINAL A&P: Nerves Sensory fibers * what size fibers? * what are the 3 fiber? * what are the pathways?

* Small and middle intermediate * C, A-delta, A-beta * Afferent and Efferent

SPINAL A&P: Nerves Motor nerves * What size fibers? * what are the 3 fibers? * what are the pathways?

* large thick * A-alpha, A-Beta, A-gamma * Efferent and afferent

2 division of the peripheral nervous system?

Somatic and autonomic

SPINAL A&P: Somatic contains sensory neurons for control of what?

skin, muscle, and joint movement

SPINAL A&P: Somatic the motor fibers arise from the motor neurons in the ____ horn, their axons exiting the spinal cord via the Ventral root

Ventral

SPINAL A&P: Somatic contains what pathway(s)?

afferent (incoming) Efferent (outgoing)

SPINAL A&P: Somatic which pathway is sensory neurons for pain, proprioception, pressure, touch, etc?

afferent

SPINAL A&P: Somatic which pathway is motor neurons for skeletal muscle movement, both reflexive and purposeful?

efferent

SPINAL A&P: AUTONOMIC 2 divisions

sympathetic (stimulating) Parasympathetic (relaxing)

SPINAL A&P: AUTONOMIC the sympathetic nerves originate in the intermediolateral gray matter of \_\_-\_\_ spinal cord segments

T1-L2

SPINAL A&P: AUTONOMIC the parasympathetic nerves only originate in the ____ nerves or the _____ nerve?

Cranial nerves Sacral nerves

SPINAL A&P: AUTONOMIC in the sympathetic system the preganglionic nerve fibers end where?

in the sympathetic chain in one of the many sympathetic ganglia

SPINAL A&P: AUTONOMIC in the parasympathetic system the preganglionic fibers actually end where?

IN the organ that they innervate

SPINAL A&P: AUTONOMIC another name for parasympathetic another name for sympathetic

* cranioscral * Thoracolumbar

Just a pic to reference the last few slides

enjoy

SPINAL A&P: AUTONOMIC the SNS is composed of what 3 receptors?

Alpha Beta Dopamine

SPINAL A&P: AUTONOMIC What are the primary NT of the SNS?

Norepinephrine Dopamine

SPINAL A&P: AUTONOMIC what are the 2 receptors of the PNS

nicotinic Muscarinic

SPINAL A&P: AUTONOMIC what is the primary NT of the PNS

acetylcholine

SPINAL A&P: Nerves spinal anesthesia interupts \_\_\_\_\_\_, \_\_\_\_\_, and _______ nervous system innervation

Sensory Motor Sympathetic

SPINAL A&P: Nerves the LA blocks the small C fibers of the sympathetic system first and gradually diffuses into the interior of the nerve where the large fibers are for _______ block followed by ____ block

* sensory * Motor

What is the goal of a spinal?

Anesthesia to a region of the body | (i hope ypou got that)

levels of a block ? ? ? (fill in motor, sympathetic, motor)

* sympathetic * Sensory * motor

if i give a spinal at T-6 tell me where the levels are: for ex motor, sensory, sympathetic

T-4--sympathetic T-6--- Sensory T-8---- Motor

Segmental level of block required: what sx are good with a T-4 to T-6 block

Intraabdominal

Segmental level of block required: what sx are good with a T-6 to T-8 block

GU, low abdominal

Segmental level of block required: what sx are good for a T-8 to T-10 block

GU, A/R, Legs

Pic for reference

pic for reference

get ready for pure awesomeness know these next few slides for sure

drop your socks grab your cocks lets go

tell me the cutaneous level and significance of each segmental level (basically if you block is here where on the body are you assessing and what does it mean) C8

* Fifth digit * All cardiaaccelerators fibers blocked (T1-T4) (their fucked)

tell me the cutaneous level and significance of each segmental level T1-T2

* Inner aspect of arm and forearm * some degree of cardioaccelerator blockade

tell me the cutaneous level and significance of each segmental level T3

* Apex of axilla * Easily determined landmark

tell me the cutaneous level and significance of each segmental level T4-T5

* Nipple * possibility of carioaccelerator blockade

tell me the cutaneous level and significance of each segmental level T7

* tip of xiphoid * Splanchnics may be blocked (T5-L1)

tell me the cutaneous level and significance of each segmental level T10

* Umbilicus * Sympathetic nervous sytem blockade to legs

**tell me the cutaneous level and significance of each segmental level** T12

* inguinal ligament * ***_No_*** sympathetic nervous system blockade

tell me the cutaneous level and significance of each segmental level S1

* outer aspect of foot * Confirms block of the most difficult nerve root to anesthetize

How to remember those last slides

* Start with C8 (highest level) end with S1 (lowest landmark) * (since u started with C8 there are 8 landmarks) * C8= thumb S1 equals foot * travel up from thumb to groin with corrosponding points * ex C8 thumb/ Thoracic strts forarms- axillia-nipple- xiphoid- umbilicus- inguinal liament I dunno may not help but I see it

chart I used from his ppt

Spinals: Systemic Effects CV- hypotension is directly proportional to degree of what?

sympathetic blockade

Spinals: Systemic Effects think of what level when worring about CV effects

T4 (nipple line)

Spinals: Systemic Effects what occurs above T-4 level?

brady decreased CO Decreased B/P

Spinals: Systemic Effects what occurs below T4 level

* Dilate * Decreased SVR * Decreased VR

where are the carioaccelerator fibers located?

T1-T4

Spinals: Systemic Effects Hypotension if more pronounced in what pt?

Dehydrated elderly Decreased VR

Spinals: Systemic Effects respiratory Increasing hight of block may block what muscles

intercostals

Spinals: Systemic Effects respiratory what resp diseases are most effected by spinals

ones with * SOB * high CO2 * low O2

Spinals: Systemic Effects to prevent resp complications keep block below what level?

Spinals: Systemic Effects the phrenic nerve is resistant to what?

A alpha | (?????)

Spinals: Systemic Effects respiratory what other muscles besides intercostals my be affected that can compromise respirations?

abdominals

Spinals: Systemic Effects Visceral S2-4 causes what? T5-L1 causes what?

* atonic bladder * (blocks) sphinter tone

Spinals: Systemic Effects renal effects?

none autoregulated

Spinals: Systemic Effects neuroendocrine what level blocks adrenals

Spinals: Systemic Effects what affects thermoregulation? (why do they get cold?)

vasodilation=hypotension

Spinals: Drug and spinal levels Distribution of LA in CSF is dependent on what 5 factors? (4 main)

1. Baracity 2. Contour of spinal cord 3. Position of pt during and first few min post 4. Dosage of LA 5. Other

Spinals: Drug and spinal levels how do the following affect blockade 1. DOSE 2. VOLUME 3. TURBULENCE 4. BARICITY

1. level (directly r/t dose) 2. spread (r/t volume) 3. increases spread 4. density ratio

Spinals: Drug and spinal levels what are other factors that affect level of spinal anesthesia

1. age 2. CSF 3. Curvature 4. Drug volume 5. IntraAbdominal pressure 6. Needle direction 7. Pt height 8. Pregnancy

Spinals: Drug and spinal levels how do the following affect blockade 1. intraAbdominal pressure

* Î IVC pressure, î epid plexus, Low CSF volume = INCREASED spread

Spinals: Drug and spinal levels: BARICITY 3 types of baricity?

hyperbaric Solutions Hypobaric Solution Isobaric Solution

another name for baricity?

specific gravity

Spinals: Drug and spinal levels: BARICITY CSF has a baricity of what at normal body temp?

1.003-1.008

Spinals: Drug and spinal levels: BARICITY Hyperbaric are prepared by adding ______ in amounts sufficient to increase the density of the LA above that of CSF

Glucose (Dextrose)

Spinals: Drug and spinal levels: BARICITY Hyperbaric. \_\_\_\_\_\_ \_\_% and ________ \_\_% are usually premixed with dextrose and come in a hyperbaric solution in your tray?

Lidocaine 5%( I wonder if that is supose to be 0.5??) bupivacaine 0.75%

Spinals: Drug and spinal levels: BARICITY hyperbaric being heavier than CSF allows the solution to do what?

settle in the most dependent aspects of SA space

Spinals: Drug and spinal levels: BARICITY hyperbaric the level is usually determined by what?

position of pt

Spinals: Drug and spinal levels: BARICITY hyperbaric when supine the solution tends to gravitate to where? and what level?

thoracic kyphosis T6

Spinals: Drug and spinal levels: BARICITY hyperbaric what does a sitting position produce

a low sensory level of anesthesia

Spinals: Drug and spinal levels: BARICITY Hyperbaric what does a "saddle block" do?

numbs the area that would normally by in contact with a saddle when riding a horse

Spinals: Drug and spinal levels: BARICITY Hypobaric is prepared how

by adding 6-8 mL of sterile H2O to the LA

Spinals: Drug and spinal levels: BARICITY with hypobaric solutions after injection the LA "\_\_\_\_" since it is now lighter than the CSF

Floats up

Spinals: Drug and spinal levels: BARICITY Hypobaric when is it used

rarely used other than in academic settings to demonstrate the tech

Spinals: Drug and spinal levels: BARICITY Isobaric solutions are created how?

by diluting the LA with CSF

Spinals: Drug and spinal levels: BARICITY when is Isobaric solutions usefull?

when you don't need your block to go much higher than L1 (hip/knee sx)

Spinals: Drug and spinal levels: BARICITY When is isobaric solutions usually used?

rarely except in academic settings to demonstrate the tech

Spinals: Drug and spinal levels: BARICITY chart memorize if you want? I would just know which are hyper/hypo/and iso baric

normal Baricity of CSF 1.003-1.008

Spinals: Drug and spinal levels: tell me the volume/ onset/ duration w and w/o epi 1. Lido 5% 2. tetricaine 0.5% 3. Bupivacaine 0.5-0.75% 4. Ropivacaine 0.5-0.75%

Volume onset w/o epi w/epi 1. 1-2mL 2-4 min 45-60 60-90 2. 1-3 mL 4-6 60-90 120-180 3. 1-2 4-6 90 140 4. 1-2 4-6 90 140

chart for reference

\*\*\*\*\*\*\*\*\*\*\*\*\*\*\* Spinal level is determined by what???????

Dose

Spinals: Drug and spinal levels: Position Supine with head slightly down will push your level up to where?

T4-5

Spinals: Drug and spinal levels: Position supine and level will usually give you ehat level

T6-7

Spinals: Drug and spinal levels: Position Supine with head slightly up will give you what level?

T10-11

Spinals: Drug and spinal levels: what besides position can effect level of blockade

1. scoliosis (alters low point) 2. Hyphosis/Kyphoscoliosis (alter low point) 3. Previous back sx (post surgical anatomic changes can effect level either higher or lower than expected) 4. Any condition that lowers amt of CSF (can puch level up higher) (preg, ascites, large abd/pelvis tumors) 5. Age related decreeases in CSF

Spinals:procedures and tech Name the anatomical structures from skin

1. Supraspinous ligament 2. Interspinous ligament 3. Ligamentum flavum 4. epidural space 5. dura 6. Arachnoid 7. Aubarachnoid space (our target space) 8. pia matter)

Spinals: LA what are the 4 most commonly used LA in regional anesthesia

1. Lidocaine 2. tetricaine 3. Bupivacaine 4. Ropivacaine

Spinals: LA LA MOA

* Produce conduction blockade of neural impulses * prevent passage of Na+ ions through ion selective Na+ channels in nerve membranes * they bond to the Na+ channel itself and keep it in the active or open position

Spinals: LA what is commonly added to LA to prolong their duration

* Epi * Phenylephrine

Spinals: LA what is the dose of EPi

0.1-0.2 mg 100mcg-200mcg

Spinals: LA phenylephrine dose

2-5 mg 2000-5000 mcg

Spinals: LA Epi and Phenylephrine can prolong spinal anesthesia by up to how much?

50%

Spinals: TECHNIQUES 3 main approaches

1. midline 2. Paramedian (lateral) 3. Lumbosacral (taylor)

Spinals: TECHNIQUES what are the 2 mainanatomical landmarks you want to identify?

1. spinous process 2. iliac crest

Spinals: TECHNIQUES in 95% of pts the illiac crest corrasponds to what spinal level

just a pic

Spinals: TECHNIQUES Give me the whole process of doing a spinal step by step

* Open tray-needles-drugs * Check baseline VS * Glove and prep * Draw up drugs (sterile tray) * Localize skin * decide approach * Needle and Stylet advanced until "pop" * remove stylet- clear CSF flow x 4 * ask about parasthesia * check swirl inject * asprate inject repeat repeat * remove needles and syringe together * assess pt

Spinals: TECHNIQUES how do u assess levels? sympathetic sensory motor

* temp * pain (sharp) * movement

Spinals: stategies for sucess?

* pr cooperation * Positioning * Knowing landmarks * Localize well * sticking with it * Tell your pt it may not work * attemot to insert spinal w/o introducer if difficult * change position if not working * Make sure drug gets to pt

Spinals: how do u treat hypotension

* IV fluids pressors *

Spinals: how to treat high spinals

* treat symptoms

Spinals: what causes N/V

b/p vs Vagal

Spinals: Postop complications

Urinary backpain PDPH

Spinals: what to document

* position an dmonitors * Skin prep * Landmarks * Skin localization * Needle (type, guage, length, introducer * SAB punctur #, CSF, Blood, Paresthesia * Drug- concentration, dose, lot #