question

Spinal cord ends in _____ adult and ______ child

answer

L1; L3

question

The principal site of action for neuraxial blockade is believed to be the ______ _______

answer

nerve root

question

Differential blockade

answer

typically results in sympathetic blockade (judged by temperature sensitivity) that may be two segments or more cephalad than the sensory block (pain, light touch), which, in turn, is usually several segments more cephalad than the motor blockade; the concentration of local anesthetic decreases with increasing distance from the level of injection

question

sympathetic blockade

answer

Interruption of efferent autonomic transmission at the spinal nerve roots; typically judged by temperature sensitivity (alcohol prep pad)

question

Neuraxial blocks CV side effects

answer

decreased BP caused by vasodilation and venous pooling of blood in the viscera and lower extremities (decreased venous return and effective circulating volume) decreased heart rate caused by sympathetic blockage and unopposed vagal tone

question

Volume loading with 10-20ml/kg has been shown to _________

answer

repeatedly FAIL to prevent hypotension

question

Treatment of symptomatic bradycardia and hypotension

answer

atropine and vasopressors (ephedrine, phenylephrine, epinephrine)

question

loss of resistance

answer

encountered as the needle passes through the ligamentum flavum and enters the epidural space making it easier to push in saline or air

question

What levels can an epidural block can be performed at?

answer

1. cervical 2. thoracic 3. lumbar

question

Spinal anesthesia process

answer

the needle is advanced through the epidural space and penetrates the dura -subarachnoid membranes, as signaled by freely flowing cerebrospinal fluid

question

Epidural techniques are widely used in

answer

1. surgical anesthesia 2. obstetric analgesia 3. postoperative pain control 4. chronic pain management

question

Epidural anesthesia onset

answer

10-20min

question

The ___________ of local anesthetic needed for epidural anesthesia is________ than that needed for spinal anesthesia. _____________ is likely if a "full epidural dose" is injected intrathecally or intravascularly.

answer

quantity (volume and concentration); larger; toxicity

question

Some studies suggest that postoperative morbidity and possibly mortality may be _______ when neuraxial blockade is used either alone or in combination with general anesthesia.

answer

reduced

question

Neuraxial blocks may reduce

answer

1. venous thrombosis and pulmonary embolism 2. cardiac complications in high-risk patients 3. bleeding and transfusion requirements 4. vascular graft occlusion 5. pneumonia and respiratory depression following upper abdominal or thoracic surgery in patients with chronic lung disease 6. time until extubation and the need for mechanical ventilation

question

Neuraxial blocks may allow ______ return of gastrointestinal function following surgery.

answer

earlier

question

(T/F) Large population studies in Great Britain and the United States have shown that regional anesthesia for cesarean section is associated with reduced maternal morbidity and mortality than is general anesthesia.

answer

TRUE

question

spine

answer

provides structural support for the body and protection for the spinal cord and nerves and allows a degree of mobility in several spatial planes

question

Midline approach insertion of needle pathway

answer

1. skin 2. supraspinous ligament 3. interspinous ligament 4. ligamentum flavum 5. EPIDURAL space 6. dura mater 7. subDURAL space 8. arachnoid mater 9. subarachnoid space (SPINAL)

question

Atlas

answer

The first cervical vertebra lacks a body and has unique articulations with the base of the skull and the second vertebra; allows vertical head movement

question

Axis

answer

The second vertebra consequently has atypical articulating surfaces; allows horizontal head movement

question

sacral hiatus

answer

the laminae of S5 and all or part of S4 normally do not fuse, leaving a caudal opening to the spinal canal; is felt as a depression just above or between the gluteal clefts and above the coccyx, defining the point of entry for caudal blocks

question

Spinal segments that are CONVEX anteriorly

answer

cervical and lumbar

question

Spinal segments that are CONCAVE anteriorly

answer

thoracic and sacral

question

Spinal segments that are CONVEX posteriorly

answer

thoracic and sacral

question

Spinal segments that are CONCAVE posteriorly

answer

cervical and lumbar

question

Ventrally, the vertebral bodies and intervertebral disks are connected and supported by __________

answer

the anterior and posterior longitudinal ligaments

question

Dorsally, _________________________ provide additional stability

answer

the ligamentum flavum, interspinous ligament, and supraspinous ligament

question

meninges

answer

composed of three layers: the pia mater, the arachnoid mater, and the dura mater; all are contiguous with their cranial counterparts

question

subarachnoid space

answer

where cerebrospinal fluid (CSF) is contained between the pia and arachnoid maters

question

subdural space

answer

poorly demarcated, potential space that exists between the dura and arachnoid membranes.

question

epidural space

answer

defined potential space within the spinal canal that is bounded by the dura and the ligamentum flavum

question

cauda equina (horse's tail)

answer

lower nerve roots course some distance before exiting the intervertebral foramina; these nerve roots float in the dural sac below L1 and tend to be pushed away (rather than pierced) by an advancing needle

question

dural sac

answer

S2 adults and S3 children

question

conus medullaris

answer

end of the spinal cord

question

filum terminale

answer

extension of the pia mater that attaches the spinal cord to the coccyx

question

spinal cord blood supply

answer

ONE anterior spinal artery TWO posterior spinal arteries

question

anterior spinal artery

answer

is formed from the vertebral artery at the base of the skull and courses down along the anterior surface of the cord providing 2/3 of the blood supply

question

posterior spinal arteries

answer

arise from the posterior inferior cerebellar arteries and course down along the dorsal surface of the cord medial to the dorsal nerve roots and providing 1/3 of the blood supply

question

the artery of Adamkiewicz (arteria radicularis magna)

answer

arising from the aorta, typically unilateral and nearly always arises on the left side, providing the major blood supply to the anterior, lower two-thirds of the spinal cord; injury to this artery can result in the anterior spinal artery syndrome

question

Blockade of neural transmission (conduction) in the _______________ interrupts somatic and visceral sensation.

answer

posterior nerve root fibers

question

Blockade of neural transmission (conduction) in the _______________ prevents efferent motor and autonomic outflow.

answer

anterior nerve root fibers

question

sensory blockade

answer

two or more segments below sympathetic blockade; typically measured by pain and light touch (pin-prick or sharp point distinction)

question

Vagus nerve (CN X)

answer

not blocked by neuraxial anesthesia; physiological responses of neuraxial blockade therefore result from decreased sympathetic tone and/ or unopposed parasympathetic tone; carries visceral afferent fibers

question

Vasomotor tone is primarily determined by sympathetic fibers arising from _____ , innervating arterial and venous smooth muscle.

answer

T5- L1

question

The sympathetic cardiac accelerator fibers arise at ________

answer

T1-T4

question

Treatment of hypotension during neuraxial anesthesia

answer

1. left uterine displacement in the 3rd trimester 2. auto transfusion with the head-down position 3. IVF bolus 5-10 mL/kg (only patient's that can "handle" extra fluid)

question

phenylephrine

answer

direct α-adrenergic agonists primarily produce arteriolar constriction and may reflexively increase bradycardia, increasing systemic vascular resistance

question

ephedrine

answer

direct and indirect β-adrenergic effects that increase heart rate and contractility and indirect effects that also produce vasoconstriction

question

Pulmonary considerations for neuraxial anesthesia

answer

severe chronic lung disease may rely upon accessory muscles of respiration (intercostal and abdominal muscles) to actively inspire or exhale; therefore decreasing effective coughing and clearing of secretions

question

Some evidence suggests that postoperative thoracic epidural analgesia in high-risk patients can improve pulmonary outcome by

answer

1. decreasing the incidence of pneumonia and respiratory failure 2. improving oxygenation 3. decreasing the duration of mechanical ventilatory support

question

GI/GU considerations for neuraxial anesthesia

answer

1. increased peristalsis due to sympathetic blockade, vagal tone dominance 2. loss of autonomic bladder control leading to increased risk for urinary retention

question

Endocrine considerations for neuraxial anesthesia

answer

can partially suppress or block stress response to surgery which leads to increased concentrations of adrenocorticotropic hormone, cortisol, epinephrine, norepinephrine, and vasopressin levels, as well as activation of the RASS

question

ABSOLUTE contraindications for neuraxial anesthesia

answer

1. patient refusal 2. bleeding diathesis 3. severe hypovolemia 4. elevated ICP 5. infection at site of injection 6. severe aortic or mitral stenosis

question

RELATIVE contraindications for neuraxial anesthesia

answer

1. sepsis 2. preexisting neurological deficits 3. uncooperative patient (dementia, psychosis, emotional) 4. demyelinating lesions 5. stenotic valvular heart lesions 6. LV outflow obstruction (hypertrophic obstructive cardiomyopathy) 7. severe spinal deformity

question

CONTROVERSIAL contraindications for neuraxial anesthesia

answer

1. prior back surgery at site of injection 2. complicated surgery 3. prolonged operation 4. major blood loss 5. maneuvers that compromise respiration

question

Incidence of epidural hematoma

answer

1:150,000

question

(T/F) Aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs) drugs do not increase the risk of spinal hematoma from neuraxial anesthesia procedures or epidural catheter removal.

answer

TRUE

question

(T/F) "Minidose" subcutaneous heparin prophylaxis is a contraindication to neuraxial anesthesia or epidural catheter removal.

answer

FALSE

question

Removal of an epidural catheter should occur ____ prior to, or _____ following, subsequent heparin dosing.

answer

1 hour; 4 hours

question

(T/F) Neuraxial anesthesia should be avoided in patients on therapeutic doses of heparin and with increased partial thromboplastin time.

answer

TRUE

question

If postoperative LMWH thromboprophylaxis will be utilized, epidural catheters should be removed _______ prior to the first LMWH dose. If already present, the catheter should be removed at least _____ after a dose of LMWH, and subsequent dosing should not occur for another 2 hr.

answer

2 hours; 10 hours

question

The major arguments for having the patient asleep are that

answer

1. most patients, if given a choice, would prefer to be asleep 2. the possibility of sudden patient movement causing injury is markedly diminished.

question

The major argument for neuraxial blockade while the patient is still awake

answer

patient can alert the clinician to paresthesias and pain on injection

question

(T/F) There is greater consensus that thoracic and cervical punctures should, except under unusual circumstances, only be performed in asleep patients because of the risk of sudden movement

answer

FALSE

question

Minimum requirement monitoring for labor analgesia

answer

1. BP 2. pulse ox

question

(T/F) Epidural steroid injections for management of pain (when little or no local anesthetic is injected) do not require continuous monitoring.

answer

TRUE

question

The spinous processes of the cervical and lumbar spine are nearly__________ , whereas those in the thoracic spine are almost ________ and can overlap significantly.

answer

horizontal; vertical

question

In the cervical area, the first palpable spinous process is _______

answer

C2

question

The most prominent spinous process is on vertebrae _____

answer

C7

question

With the arms at the side, the spinous process of ____ is usually at the same level as the inferior angle of the scapulae.

answer

T7

question

A line drawn between the highest points of both iliac crests (Tuffier's line) usually crosses the body of ______

answer

L4

question

A line connecting the posterior superior iliac spine crosses the _____ posterior foramina.

answer

S2

question

_______ of the spine (arching the back "like a mad cat" maximizes the "target" area between adjacent spinous processes and brings the spine closer to the skin surface

answer

flexion

question

Positions for neuraxial anesthesia

answer

1. sitting 2. lateral decubitis 3. Buie's position (jack-knife)

question

paramedian approach

answer

used for patients who cannot be positioned easily (eg, severe arthritis, kyphoscoliosis, or prior spine surgery); typically used for thoracic epidural puncture;

question

Paramedian approach insertion of needle pathway

answer

1. skin 2. paraspinous muscles 3. ligamentum flavum 4. EPIDURAL space 5. dura mater 6. subDURAL space 7. arachnoid mater 8. subarachnoid space (SPINAL)

question

Quinke needle

answer

is a cutting needle with end injection; higher risk for PDPH

question

Whitacre

answer

blunt tip / round tip (pencil-point) needles; decreased risk for PDPH

question

Sprotte

answer

is a side-injection needle with a long opening; more vigorous flow of CSF, however increased incidence of a failed block if the distal part of the opening is subarachnoid (with free flow CSF), the proximal part is not past the dura, and the full dose of medication is not delivered.

question

MAJOR factors influencing level of spinal block

answer

1. baricity of the local anesthetic solute 2. position of the patient during and immediately after injection 3. drug dosage 4. site of injection

question

CSF has a specific gravity of

answer

1.003- 1.008 at 37 ° C.

question

hyperbaric solution

answer

denser and heavier compared to CSF; tends to accumulate caudally; added glucose in solution

question

hypobaric solution

answer

less dense and lighter compared to CSF; tends to accumulate cephalic; added sterile water or fentanyl in solution

question

isobaric solution

answer

equal density as CSF; tends to stay near site of injection; mixed with CSF (1:1)

question

Other factors influencing level of spinal block

answer

1. patient height 2. vertebral column anatomy 3. direction of needle bevel or injection port 4. age 5. CSF 6. drug volume 7. intra-abdominal pressure 8. pregnancy

question

the apex of the thoracolumbar curvature is _____

answer

T4

question

Hyperbaric solutions tend to move to the most dependent area of the spine normally _______ in the supine position

answer

T4-T8

question

Taylor approach

answer

a variant of the standard paramedian approach, the needle enters 1 cm medial and 1 cm inferior to the posterior superior iliac spine and is directed cephalad and toward the midline.

question

The lowest point is usually ______, where a hyperbaric solution tends to settle once the patient is placed supine.

answer

T6

question

Lumbar CSF volume ________ correlates with the dermatomal spread of spinal anesthesia.

answer

inversely

question

Conditions associated with greater dermatomal spread for a given volume of injectate due to decreased volume of CSF

answer

1. increased abdominal pressure 2. engorgement of epidural veins 3. pregnancy 4. ascites 5. large ABD tumors

question

Spinal anesthetic agents

answer

ONLY preservative free

question

Addition of vasoconstrictors to spinal anesthetic agents

answer

α-adrenergic agonists, epinephrine (0.1- 0.2 mg enhance the quality and/ or prolong the duration of spinal anesthesia; seem to delay the uptake of local anesthetics from CSF and may have weak spinal analgesic properties

question

Addition of opioids to spinal anesthetic agents

answer

improve both the quality and duration of the subarachnoid block.

question

The most commonly used agents for spinal anesthesia.

answer

Hyperbaric bupivacaine and tetracaine

question

Hyperbaric bupivacaine and tetracaine for spinal anesthesia

answer

Both have a slow onset 5-10 min and a prolonged duration 90-120 min

question

Lidocaine and procaine for spinal anesthesia

answer

Both have a relatively rapid onset 3- 5 min and short duration of action 60- 90 min

question

(T/F) Repeat lidocaine doses following an initial "failed" block should be avoided.

answer

TRUE

question

"saddle block"

answer

can be achieved by keeping the patient sitting for 3- 5 min following injection, so that only the lower lumbar nerves and sacral nerves are blocked.

question

Lidocaine

answer

used for spinal anesthesia worldwide, but some experts no longer use this agent because of the phenomenon of transient neurological symptoms and cauda equina syndrome (CES)

question

septa or connective tissue bands

answer

explain the phenomenon of a one-sided epidural block

question

segmental block

answer

is characterized by a well-defined band of anesthesia at certain nerve roots; leaving nerve roots above and below unblocked.

question

epidural anesthesia

answer

using relatively dilute concentrations of a local anesthetic combined with an opioid; provides analgesia without motor block; most often performed in the lumbar region

question

cervical block

answer

are usually performed with the patient sitting, with the neck flexed, using the midline approach. Clinically, they are used primarily for the management of pain.

question

Tuohy needle

answer

most commonly used; the blunt, curved tip theoretically helps to push away the dura after passing through the ligamentum flavum instead of penetrating it.

question

standard epidural needle

answer

is typically 17- 18 gauge, 3 or 3.5 inches long , and has a blunt bevel with a gentle curve of 15- 30 ° at the tip.

question

Crawford needle

answer

Straight needles without a curved tip may have a greater incidence of dural puncture, but facilitate passage of an epidural catheter.

question

Weiss winged needle

answer

modifications include winged tips and introducer devices set into the hub designed for guiding catheter placement.

question

When using a curved tipped needle, the bevel opening is directed either cephalad or caudad, and the catheter is advanced ________ into the epidural space.

answer

2- 6 cm

question

hanging drop technique

answer

requires that the hub of the needle be filled with solution so that a drop hangs from its outside opening. The needle is then slowly advanced deeper. As long as the tip of the needle remains within the ligamentous structures, the drop remains until negative pressure pulls in the drop when the epidural space is entered

question

test dose

answer

designed to detect both subarachnoid and intravascular injection; combines local anesthetic and epinephrine, typically 3 mL of 1.5% lidocaine with 1: 200,000 epinephrine (0.005 mg/ mL). The 45 mg of lidocaine, if injected intrathecally, will produce spinal anesthesia that should be rapidly apparent with an increase ~20 % in HR from baseline (if injected intravascularly)

question

Test dose FALSE positive

answer

usually from a uterine contraction causing pain or an increase in heart rate coincident to test dosing

question

Test dose FALSE negative

answer

bradycardia and exaggerated hypertension in response to epinephrine in patients taking β-blockers

question

(T/F) Incremental dosing is a very effective method of avoiding serious complications.

answer

TRUE

question

Techniques to prevent accidental intrathecal injections

answer

1. initial test dose 2. aspirating prior to each injection 3. always uses incremental dosing

question

Rescue lipid emulsion (20% Intralipid 1.5 mL/ kg)

answer

should be available whenever epidural blocks are performed, in the event of local anesthetic toxicity.

question

In adults, _______ of local anesthetic per segment to be blocked is a generally accepted guideline for epidural blocks

answer

1- 2 mL

question

The dose required to achieve the same level of anesthesia ________ with age.

answer

decreases

question

A patient's ________ affects the extent of cephalad spread.

answer

height

question

(T/F) Opioids tend to have a greater effect on the duration of epidural anesthesia.

answer

FALSE

question

epinephrine

answer

concentrations of 5 mcg/ mL prolongs the duration and improves the quality of block, delays vascular absorption and reduces peak systemic blood levels of all epidurally administered local anesthetics.

question

chloroprocaine, lidocaine, and mepivacaine

answer

commonly used short and intermediate acting epidural agents for surgical anesthesia

question

bupivacaine, levobupivacaine, and ropivacaine

answer

Longer acting agents epidural agents for surgical anesthesia

question

chloroprocaine

answer

an ester with rapid onset, short duration, and extremely low toxicity, may interfere with the analgesic effects of epidural opioids. Previous formulations with preservatives, specifically bisulfite and ethylenediaminetetraacetic acid (EDTA), produced cauda equine syndrome when accidentally injected in a large volume intrathecally; low potency and metabolized very rapidly

question

sodium bicarbonate (1 mEq/ 10 mL of local anesthetic)

answer

immediately before injection may accelerate the onset of the neural blockade. This approach is most useful for lidocaine, mepivacaine, and chloroprocaine.

question

(T/F) Sodium bicarbonate is typically not added to bupivacaine, which precipitates above a pH of 6.8.

answer

TRUE

question

Visceral afferent fibers travel with the _______

answer

vagus nerve

question

Adverse or exaggerated physiological responses to neuraxial anesthesia

answer

1. urinary retention 2. high block 3. total spinal anesthesia 4. cardiac arrest 5. anterior spinal artery syndrome 6. Horner's syndrome

question

Complications related to needle/catheter placement

answer

1. backache 2. dural puncture/leak (PDPH, diplolia, tinnitus) 3. Neural injury (nerve/spinal cord damage, CES) 4. Bleeding (intraspinal/epidural hematoma) 5. Misplacement (no effect/partial block -subdural block, septal, inadvertent spinal/intravascular injection) 6. Catheter shearing/retention 7. Inflammation (arachnoiditis) 8. Infection (meningitis or epidural abscess)

question

Drug toxicity

answer

1. systemic local anesthetic toxicity 2. transient neurological symptoms 3. CES

question

The majority of regional anesthesia claims involved either ___________ anesthesia (42%) or _________ (34%) and tended to occur mostly in obstetric patients.

answer

lumbar epidural; spinal anesthesia

question

High neural blockade

answer

Administration of an excessive dose, failure to reduce standard doses in selected patients (eg, the elderly, pregnant, obese, or very short), or unusual sensitivity or spread of local anesthetic

question

S/Sx high neural blockade

answer

dyspnea, numbness or weakness in upper extremities, nausea, hypotension

question

Spinal anesthesia ascending into the cervical levels causes

answer

severe hypotension, bradycardia, and respiratory insufficiency

question

High spinal

answer

Unconsciousness, apnea, and hypotension resulting from high levels of spinal anesthesia

question

Total spinal

answer

when the block extends to cranial nerves

question

(T/F) Apnea is more often the result of severe sustained hypotension and medullary hypoperfusion than a response to phrenic nerve paralysis from anesthesia of C3- C5 roots.

answer

TRUE

question

Treatment of an excessively high neuraxial block involves

answer

maintaining an adequate airway and ventilation and supporting the circulation.

question

Large prospective studies continue to report a relatively high incidence perhaps as high as _________ of cardiac arrest in patients having received a spinal anesthetic

answer

1:1500

question

Major risk factors leading to cardiac arrest with neuraxial anesthesia include

answer

1. high baseline vagal tone 2. decreased preload

question

Many clinicians will not allow the heart rate to fall below _____ beats per minute during spinal anesthetic blockade.

answer

50

question

Local anesthetic block of ________ root fibers decreases urinary bladder tone and inhibits the voiding reflex.

answer

S2- S4

question

As with other regional anesthesia techniques, neuraxial blocks are associated with a small, but measureable, failure rate that is usually ____________ proportional to the clinician's experience.

answer

inversely

question

Intravascular injection of neuraxial anesthetics can cause

answer

CNS effects (seizures and unconsciousness; tinnitus and lingual sensations) CV effects (hypotension, bradycardia, arryhythmias, and depressed contractility)

question

lidocaine and mepivacaine

answer

intermediate in potency and toxicity

question

levobupivacaine, ropivacaine, bupivacaine, and tetracaine

answer

most potent and toxic

question

Total spinal anesthesia onset is usually rapid, because the amount of anesthetic required for epidural and caudal anesthesia is ______ times that required for spinal anesthesia.

answer

5- 10

question

A __________ injection of epidural doses of local anesthetic produces a clinical presentation similar to that of high spinal anesthesia, with the exception that the onset may be delayed for 15- 30 min and the block may be "patchy".

answer

subdural

question

Postoperative back soreness or ache

answer

1. mild and self-limited 2. last for a number of weeks 3. If treatment is sought, acetaminophen, NSAIDs, and warm or cold compresses should suffice 4. may be a clinical sign for an epidural abscess or hematoma

question

post dural puncture headache (PDPH)

answer

is bilateral, frontal or retroorbital, or occipital and extends into the neck; onset of headache is usually 12- 72 hr following the procedure; however, it may be seen almost immediately; leakage of CSF from a dural defect and intracranial hypotension. Loss of CSF at a rate faster than it can be produced causes traction on structures supporting the brain, particularly the meninges, dura, and tentorium. Increased traction on blood vessels and cranial nerves may also contribute to the pain.

question

wet tap

answer

attempted epidural usually immediately recognized as CSF pouring from the epidural needle or aspirated from an epidural catheter.

question

S/Sx of PDPH

answer

throbbing or constant HA associated with photophobia and nausea, diploplia, tinnitus; HALLMARK sign is as pain aggravated by body position (sitting or standing is worse; laying down flat makes it better), lasts weeks.

question

The incidence of PDPH is strongly related to

answer

needle size, needle type, and patient population

question

Strong risk factors for PDPH

answer

young age, female sex, and pregnancy

question

Conservative treatment PDPH involves

answer

recumbent positioning, analgesics, intravenous or oral fluid administration, and caffeine for 12-24 hours

question

epidural blood patch

answer

is an effective treatment for PDPH. It involves injecting 15- 20 mL of autologous blood into the epidural space at, or one interspace below, the level of the dural puncture; stops further leakage of CSF by either mass effect or coagulation; Approximately 90% of patients will respond, and 90% of initial nonresponders will obtain relief from a second injection.

question

neurological injury

answer

Damage to the conus medullaris may cause isolated sacral nerve dysfunction, including paralysis of the biceps femoris muscles; anesthesia in the posterior thigh, saddle area, or great toes; and loss of bowel or bladder function; most resolve spontaneously, some are permanent.

question

spinal or epidural hematoma

answer

has been estimated to be about 1: 150,000 for epidural blocks and 1: 220,000 for spinal anesthetics

question

risk factors for spinal or epidural hematoma

answer

1. abnormal coagulation secondary to disease or pharmacology 2. insertion or removal of epidural catheter

question

hematoma's mass effect

answer

pathological insult to spinal cord and nerves by compressing neural tissue and causing direct pressure injury and ischemia.

question

S/Sx of spinal or epidural hematoma

answer

include sharp back and leg pain with a motor weakness and/ or sphincter dysfunction.

question

Treatment for spinal or epidural hematoma

answer

1. immediate MRI or CT scan 2. neurosurgical consult immediately 3. surgical decompression within 8- 12 hr

question

meningitis and arachnoiditis

answer

Infection of the subarachnoid space as the result of contamination of the equipment or injected solutions, or as a result of organisms tracked in from the skin; Indwelling catheters colonized with organisms that then track deep, causing infection.

question

S/Sx of meningitis and arachnoiditis

answer

Clinically, it is marked by pain and other neurological symptoms, and, on radiographic imaging, is seen as a clumping of the nerve roots

question

4 Stages of epidural abscess

answer

1. symptoms include back or vertebral pain that is intensified by percussion over the spine; fever 2. nerve root or radicular pain develops 3. marked by motor and/ or sensory deficits or sphincter dysfunction 4. Paraplegia or paralysis

question

Most common organisms involved with EA

answer

Staphylococcus aureus and Staphylococcus epidermidis

question

Treatment for epidural abscess

answer

1. MRI or CT scanning should be performed to confirm or rule out the diagnosis 2. Early neurosurgical and infectious disease consultation 3. antibiotics 4. decompression (laminectomy) or percutaneous drainage with fluoroscopic or CT guidance

question

Prevention of EA

answer

1. minimizing catheter manipulations and maintaining a closed system 2. using a micropore (0.22-μm) bacterial filter 3. removing an epidural catheter or at least changing the catheter, filter, and solution after a defined time interval (<4 days).

question

(T/F) There is a risk of neuraxial catheters sheering and breaking off inside of tissues if they are withdrawn through the needle. If a catheter must be withdrawn while the needle remains in situ, both must be carefully withdrawn together

answer

TRUE

question

transient neurological symptoms (TNS)

answer

also referred to as transient radicular irritation, are characterized by back pain radiating to the legs without sensory or motor deficits, occurring after the resolution of spinal anesthesia and resolving spontaneously within several days; commonly associated with hyperbaric lidocaine, outpatient surgeries, males in lithotomy position

question

cauda equina syndrome (CES)

answer

characterized by bowel and bladder dysfunction together with evidence of multiple nerve root injury; lower motor neuron type injury with paresis of the legs, sensory deficits may be patchy, typically occurring in a peripheral nerve pattern.

question

Esters

answer

cocaine, procaine, benzocaine, tetracaine, 2-chloroprocaine; metabolized by plasma esterases

question

Amides

answer

lidocaine, mepivacaine, prilocaine, ropivacaine, bupivacaine, levobupivacaine, etidocaine; metabolized by liver enzymes

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