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Epidural Anesthesia

QuestionAnswer
Differences between epidural and spinal anesthesia Spinal requires smaller dose of meds leading to decreased systemic toxicity. Spinals are usually one time dosing where as epidurals are often redosed. Epidural is technically more difficult and does not produce as strong of a motor block.
Superior aspect of iliac crest corresponds with what spinal landmark L4 spinous process
Inferior border of scapula corresponds with what spinal landmark? Spinous process of T7
There is a vertebral prominence at what cervical vertebrae? C7
Root of scapular spine corresponds to what spinal landmark? T3
Supraspinous ligament Attaches the apices of the spinous processes from sacrum to C7
Ligamentum Nuchae "supraspinous ligament" from C7 to occiput
Supraspinous ligament Connects the spinous process, lying between the processes
Ligamentum flavum Connects adjacent laminae above and below
Longitudinal ligaments Bind the vertebral bodies together and are located both posterior and anterior
Depth from skin to epidural space 4-6cm
Epidural level needed for an abd C section T4-5
Epidural level needed for a vag delivery T10
Epidural level needed for TURP T10
Epidural level needed for hip surgery T10
Epidural level needed for thigh or low limb amputation L1
Epidural level needed for foot surgery L2-L3
Epidural level needed for perineal/hemorrhoid surgery S2-S5
Epidural level needed for gyn surgery T6-T8
Epidural level needed for Pelvic surgery T6-T8
Epidural level needed for ureter and renal pelvis surgery T6-T8
Peripheral sympathetic block occurs at what level. How will this exhibit in your patient. T1-L2 and results in venous pooling with CO maintained by increased HR and vasoconstriction above the level of the block.
Central sympathetic blockade occurs at what level and how will this manifest in you patient T1-T4. Will see venous pooling with bradycardia r/t blockade of cardiac accellerators.
What structures will not be passed through when using a paramedian approach versus a midline approach The supraspinous ligament and the interspinous ligaments will not be transected. Instead, the paraspinous muscle will be transected before reaching the ligamentum flavum.
Epidural space depth (anterior to posterior) in the cervical region 1.5-2mm
Epidural space depth (anterior to posterior) in the lumbar region 5-6mm
Epidural space depth (anterior to posterior) in the thoracic region 3-5mm
Contents of epidural space Nerve roots, fat, areolar tissue (loose connective tissue), lymphatics, arteries, venous plexus of Batson
Where is the venous plexus most prominent in the epidural space? In the lateral portions of the epidural space (stay midline)
Supine patient apex of lumbar curve L3-L4
Supine patient trough of the throacic curve T4
Epidural Space, where does it extend to/from Foramen magnum to sacral hiatas
How many spinal nerves? 31 pairs
Why might an elderly person need a lower dose of LA Age r/t reduction in adipose tissue
Blood supply to spinal cord Single anterior spinal artery and paired posterior spinal arteries.
Radicularis Magna Artery of adamkiewicz. A feeder artery to anterior spinal artery. Enters via intervertebral foramina (usually on the left). Damage to this artery can lead to motor defecit of lumbar area cord.
Contraindications to epidural Pt refusal, increased ICP, coagulopathy, infxn at needle insertion site, stenotic valvular disease or hypertrophic obstructive cardiomyopathy
DepoDur Extended release morphing with up to 48 hours of pain relief. 10-15mg given as a single injection. Onset of 3 hours. 90% resp depression occurs in 24 hours
Thoracic epidural is best approached from a ___________ approach Paramedian
Articular versus Radicular pain Articular pain may radiate down one leg or the other but is very diffuse, where as radicular pain is more discrete and is often along one dermatome.
How far do you thread an epidural catheter 3-5cm plus the 12 cm that it takes to get to the end of the catheter.
Can you use LA with preadded epi for a block? No, this has had a preservative added to adjuet the pH and create a stable mixture. You must use a plain LA to which you add your own epi.
Addition of epi to epidural LA is more effective for LA of __________? Lower concentrations
Epidural dosing cervical, thoracic, and lumbar 0.7-1ml per segment cervical and thoracic. 1.25-1.5 ml per segment lumbar. ?? decrease dose for shorter patient?
Pregnancy by decrease epidural dose by _____% 30%
Severe atherosclerosis may decrease epidural dose by _____% 50%
Bromage scale No Block--0% full flexion of knees and feet. Partial block---33% Just able to flex knees with full flexion of feet Almost complete block 66%--Unable to flex knees, still able to flex feet. Complete block 100%--unable to flex knees or feet.
Complications of epidural anesthesia IV injection, Subarachnoid block, neuro damage, infxn, hypotension
Why would a patient with inadvertant epidural dose of LA placed in subarachnoid space have dialated pupils? LA effect on occulomotor nerve
Epidural test dose 3cc of 1.5% lidocaine with 1:200,000 epi. Wait 3 minutes, negative if no numbness of feet and no sig change in HR.
Patients in which epidural test dose may not be a good indicator Diabetic neuropathy, beta blocker, already tachy
Test dose ijected subdurally Onset is 15-30 minutes after admin r/t LA diffusing through arachnoid mater.
Epidural "top off" dosing and maintenance dosing 20% of original dose 20 minutes after first dose. Will not increase level but will fill in missed segments. Maintenance dosing is 50% of original dose when the block has receded by 1-2 dermatomes
Top off time for lidocaine 2% 60min
Top off time for prilocaine 2-3% 60 min
Top off time for chloroprocaine 45 min
Top off time for mepivicaine 60min
top off time for bupivicaine 120 min
top off time for etidocaine 120 min
top of time for ropivicaine 120 min
Is an epidural or a spinal more likely to lead to a hematoma and why An epidural is more likely to cause a hematoma....larger needle size and presence of epidural veins
Patient factors a/w increased risk for spinal hematoma Female sex, increased age, ankylosing spondylitis or spinal stenosis
Anesthetic factors a/w increased risk for spinal hematoma Epidural more likely than spinal, traumatic needle insertion, indwelling epidural catheter during LMWH administration
LMWH factors a/w increased risk for spinal hematoma Immediate preop or intraop LMWH, early postop LMWH, Concaminat antiplatelet or anticoag meds, twice daily LMWH admin
Postop management for patient with neuraxial catheter on coumadin Monitor INR daily, remove catheter when INR is less than 1.5, if INR is greater than 3 than it is recommended that the catheter not be removed. Check MAR for other hemostasis meds. Neuro checks, baseline, continued until INR has reached desired level
Platelet count 150,000-450,000. Measure of number not fxn. Life span of platelet=8-12 days
Bleeding time Indirectly measures platelet number and fxn and capillary integrity. Normal is 3-8 min
PT Measures ext. pathway (VII) & common pathways (I,II,VII, X). Also measures Vit K dependent factors=II, VII, X. Gives info @ coumadin therapy, liver fxn, & ability to absorb vitK. Time for fibrin to form after addition of tissue thromboplastin to pt blood.
aPTT Time to clot after addition of activating agent, Ca, & partial thromboplastin. Measures Intrinsic (VIII, IX, XI) & common (I,II,V,X) pathways...monitors heparin therapy
INR Refernce point to compare results from different labs. Ratio of patient's pt to reference PT.
Coumadin prior to neuraxial anesthesia Must be stopped 4-5days prior, PT/INR should be WNL if pt has been on coumadin more than 24 hours or has received more than 2 doses in 24 hours. Some may elect to do with INR less than 1.5.
Coumadin reversal Vit K 1-2mg oral with return to normal PT/INR in 4-24 hrs. If urgent, give 2.5-5 mg of oral or IV vit K. If imediate, give 1-2units ffp
Bridging pt at high risk for thromboembolism who are on coumadin LMWH with last daily dose given 24 hours preop at 1/2 the usual daily dose. UFH IV with it being d/c'd four hours preop.
Post op coumadin management Low risk, resume coumadin on post op day. Increased risk, minor surgery, resume LMWH 24 hours postop. Increased risk, major surger, continue LMWH 48-72 hours postop
UFH and neuraxial anesthesia 5000 units w 2x daily dosing, no CI to neuraxial anesthesia. Safety not established in pt receiving greater than 10,000 units daily or more than twice daily dosing of UFH. If on heparin more than four days, check platelets (HIT)
Intraoperative heparin therapy (vascular pt) and neuraxial anesthesia. Delay heparin admin for 1 hour after needle puncture. Remove catheter 2-4 hours after last dose of heparin. Resume heparin 1 hr after needle removal. Assess neuro status, consider decreasing dose of LA so motor deficits will be more readily recognized.
LMWH and Neuraxial anesthesia Unable to monitor anticoag response, prolong T1/2B, irreversibility w protamine, plasma T1/2B increased in pt w renal failure. Pt on 1mg/kg bid or 1.5mg daily, delay needle by 24 hrs. Pt got lovenox 2hrs preop...NO neuraxial anesthesia.
Postop LMWH BID dosing: 1st dose no sooner than 24hrs, remove catheter 2 hrs prior to 1st dose. Daily dosing, 1st dose 6-8 hours postop, 2nd dose no soonter than 24hrs. Catheter out 10-12 hrs after last dose and next dose not given for 2 hours after cath removal.
NSAIDS and neuraxial anesthesia Alone, do not appear to add significant risk
Clopridogel and neuraxial anesthesia D/C 7 days prior (thienopyridine derivative)
Ticlopidine D/C 14 days prior (thienopyridine derivative)
GPIIb/IIa antagonists Not known for sure, not recommended. Abciximab, eptifibatide, tirofiban
Fibrinolytic therapy and neuraxial anesthesia Recommend 10 days between meds and neuraxial anesthesia. If received block at or near time of therapy, monitor neuro status.
Neuraxial anesthesia and direct thrombin inhibitiors No recommendations, lack of info (Dsirudin, lepirudin, bivalirudin, argatroban).
Fondaparinux and neuraxial anesthesia New factor Xa inhibitor. Lack of clinical experience. Consider using if single needle pass with atraumatic placement, avoid indwelling catheters.
One of the last clotting factors to recover from fibrinolytic therapy. Fibrinogen. May be a useful measure to determine if pt can undergo neuraxial anesthesia after receiving on of these meds.
Created by: mandyrosern