V 3 H

Front 1

Give two other names for spinal anesthesia:

Back 1

subarachnoid anesthesia.

intrathecal anesthesia.

Front 2

Between which two meningeal layers is the local anesthetic administered with spinal anesthesia?

Back 2

pia.

arachnoid.

Front 3

a line between the left and right iliac crest crosses the spinal of which lumbar vertebrae?

Back 3

the fourth.

Front 4

What is the highest curve of the spinal column in the supine position?

where is this found?

Back 4

the apex of the lumbar curve.

it is found at L3 L4.

Front 5

Where is the largest interlaminar interspace of the vertebral column found?

Back 5

L5 to S1.

Front 6

Using the L5 to S1 interspace is a variation of what approach?

Back 6

the paramedian approach.

Front 7

Name six structures traversed by the needle for midline spinal anesthesia:

Back 7

skin and subcutaneous tissue.

supraspinous ligament.

interspinous ligament.

ligamentum falvum.

dura.

arachnoid.

Front 8

What is the last structure the needle passes before entering the epidural space?

Back 8

ligamentum flavum.

Front 9

As the needle is being inserted for subarachnoid block, you feel a pop. What has happened?

Back 9

you have penetrated the dura.

Front 10

With which needle is penetration of the dura most easily detected?

Back 10

pencil point needles.

Front 11

The patient will have the sympathectomy one local anesthetic reaches which level after spinal or epidural anesthesia?

Back 11

T1 OR HIGHER.

Front 12

Where do local anesthetics work after they are given into the intrathecal space?

Back 12

they work on the spinal nerve root, the spinal nerve rootlets, and the spinal cord.

Front 13

What is the result of blocking each type of the nerve fiber types (b, c, a delta, a gamma, a beta, a alpha)?

Back 13

b = venous dilation and hypotension.

c and a delta = loss of pain and temperature sensation.

a gamma = loss of muscle tone.

a beta = loss of motor function and proprioception (position sense).

Front 14

What nerve fibers are responsible for proprioception?

Back 14

a alpha and a beta.

Front 15

Describe the clinical progression of differential block by local anesthetics, first to last blocked:

Back 15

autonomic fibers.

sensory fibers.

then motor fibers.

Front 16

What six factors contribute to differential nerve block by local anesthetics?

Back 16

the anatomic and geometric arrangement of the individual fibers in a nerve bundle.

the diameter of the individual nerve fibers.

the inherent impulse activity (firing rate, frequency) of the individual nerve.

the variability in longitudinal spread of agent along the nerve fibers.

the effects on ion channels other than the sodium channel.

the choice of local anesthetic.

Front 17

Which fibers fire more often, sensory or motor?

Back 17

sensory.

this may explain why sensory fibers are blocked before motor fibers.

Front 18

What is the order of nerve fiber blockade during a spinal?

Back 18

b fibers.

c and a Delta fibers.

a gamma fibers.

a beta fibers.

a alpha fibers.

Front 19

What do we need to remember about the order of nerve fiber blockade during a spinal?

Back 19

b fibers are blocked first and a alpha fibers are blocked last.

Front 20

What nerves are least likely to be blocked during spinal anesthesia?

Back 20

a alpha.

they are the most difficult to block.

Front 21

Describe in order of most difficult to block, the sequence of nerve fibers with a spinal:

Back 21

a alpha fibers are most difficult.

a beta fibers are next most difficult.

a gamma fibers are next most difficult.

b fibers are the easiest to block.

Front 22

What sensations are lost first after injection of a spinal anesthetic?

which fibers carry these signals?

Back 22

pain and temperature.

c and a Delta fibers carry the signals.

Front 23

The sympathetic response to spinal anesthesia occurs because of local anesthetics act on what neurons?

Back 23

sympathetic pre ganglionic efferents.

Front 24

Why does blood pressure fall with spinal anesthesia?

Back 24

sympathetic nervous system blockade produces venous dilation and venous pooling, with subsequent decrease in preload, cardiac output, and arterial blood pressure.

systemic vascular resistance is only slightly decreased.

Front 25

With a high spinal block, what is decreased, preload or after load?

what else can happen?

Back 25

preload is decreased. Systemic vascular resistance is only slightly decreased.

bradycardia can also occur, which contributes to hypotension.

Front 26

What reflex best explains bradycardia during spinal anesthesia?

explain:

Back 26

Bainbridge reflex. There is blockade of sympathetic efferents from t1 to t4 (cardio accelerator fibers) with subsequent unopposed parasympathetic stimulation.

but most often, the bradycardia associated with spinal anesthesia is from decrease venous return. The reduced venous pressure is sensed by low pressure venous baroreceptors, resulting in reflex bradycardia.

Front 27

What are the two most common physiologic changes associated with spinal anesthesia?

Back 27

hypotension and bradycardia.

Front 28

What effect does spinal anesthesia have on the intestines?

why?

Back 28

blockade above t5 inhibits sympathetic innervation to the gastrointestinal tract which results in contracted intestines, relaxed sphincter tone and increased peristalsis.

in this situation, the parasympathetic nervous system is unopposed.

Front 29

Spinal anesthesia is administered and the patient reports tangling in the little finger on the right and left and. What is the level of the block?

Back 29

c8.

Front 30

The patient complaints of numbness of the fingers and thumb with a subarachnoid block. What is the level of the anesthetic?

Back 30

c6, c7, c8.

Front 31

What level of spinal block would be appropriate for a patient with kidney pain?

Back 31

t10 to l1.

the kidneys received sensory innervation from spinal levels t10 to l1 to l2.

Front 32

A patient received the subarachnoid block for a turp. What dermatome level needs to be reached?

Back 32

t10 sensory level.

Front 33

Spinal anesthesia to what dermatome level would be required for testicular surgery?

Back 33

t10 sensory level.

Front 34

Spinal anesthesia to what dermatome level would be required for lower abdominal surgery?

Back 34

t6.

Front 35

Spinal anesthesia to what dermatome level would be required for upper abdominal surgery?

Back 35

t4.

Front 36

Blockade to which spinal segments will take away urinary bladder tone and inhibit the reflex to urinate?

Back 36

lower lumbar and sacral spinal segments s2 s4.

Front 37

Compared with the level of sensory block associated with spinal anesthesia, motor blockade and sympathetic blockade occur where?

Back 37

motor blockade occurs 2 to 3 segments lower than sensory blockade.

sympathetic blockade occurs 2 to 6 segments higher than sensory blockade.

Front 38

You are doing a case where a traffic it will be used on the lower extremity. What is the minimum sensory level required for cutaneous anesthesia?

Back 38

t8.

Front 39

Explain why a patient with a sensory block to T5 has a heart rate of 50 after producing a subarachnoid block?

Back 39

because sympathetic block can be 2 to 6 dermatome's higher than sensory block. Since cardio accelerators arising from t 1 to t 4 can be blocked when sensory block is at the T5 level, decreased heart rate can occur.

Front 40

As fluid is aspirated after placement of the needle for spinal anesthesia, blood tinged cerebral spinal fluid appears first and is followed by clear cerebral spinal fluid. What should you do?

Back 40

proceed with the spinal anesthetic.

the blood probably was from tissue damage during needle insertion.

Front 41

As fluid is withdrawn during placement of the needle for spinal anesthesia, blood tinged cerebral spinal fluid appears in the hub of the needle initially. If blood tinged cerebral spinal fluid continues to flow, what should you do?

Back 41

remove the needle and reinsert it at a different interspace.

Front 42

After withdrawing blood tinged cerebral spinal fluid during placement of the needle for a spinal anesthetic, the needle is withdrawn and reinserted at a different interspace. Blood tinged fluid is seen again. What should you do?

Back 42

terminate the attempt and further evaluate the patient.

Front 43

How is the baracity of a local anesthetic determined?

Back 43

it is the specific gravity.

specific gravity is the density of local anesthetic solution divided by the density of cerebral spinal fluid at 37°C.

Front 44

What is the specific gravity of cerebral spinal fluid?

Back 44

1.003 to 1.008.

Front 45

What is the cut off for specific gravity of a hypobaric solution?

Back 45

less than 1.003.

Front 46

What is the cutoff for specific gravity of hyperbaric solutions?

Back 46

greater than 1.008.

Front 47

How is hypobaric solution prepared?

Back 47

local anesthetic is mixed with sterile water.

Front 48

How is isobaric solution prepared?

Back 48

local anesthetic is mixed with cerebral spinal fluid, or a commercially prepared solution to make it isobaric.

Front 49

How is hyperbaric solution prepared?

Back 49

local anesthetic is mixed with an equal volume of 10% dextrose.

Front 50

Why is dextrose added to spinal drugs?

Back 50

to make the solution hyperbaric. It increases the specific gravity of the solution.

Front 51

The anesthetic level reached for subarachnoid block is determined by what four factors?

Back 51

baracity of solution.

concentration (increasing concentration will increase the spread.)

contour of the spinal canal.

position of the patient in the first few minutes after placement of the drug into the subarachnoid space.

Front 52

What factor most influences the level of block achieved with hyperbaric spinal solution?

Back 52

position. Since hyperbaric solution is heavier, the solution settles to the dependent aspects of the subarachnoid space.

this is determined by position.

Front 53

State the maximum dose of agent for spinal anesthesia with lidocaine:

Back 53

60 mg.

Front 54

State the maximum dose of bupivicaine for spinal anesthesia:

Back 54

9 to 15 mg.

Front 55

State the maximum dose of ropivicaine for spinal anesthesia:

Back 55

15 to 22.5 mg.

Front 56

State the maximum dose of tetracaine for spinal anesthesia:

Back 56

10 mg hypo baric.

12 mg hyperbaric.

15 mg iso baric.

Front 57

Why do relatively small amount of local anesthetic produced profound blockade when administered intrathecally?

Back 57

because spinal nerve roots are bathed in cerebral spinal fluid, making them readily accessible to injected local anesthetics.

Front 58

Of the local anesthetics administered intrathecally, which produces the most profound motor block?

Back 58

tetracaine.

Front 59

What type of drug is injected with local anesthetics to prolong their action?

why?

Back 59

drugs that have alpha 1 adrenergic agonists properties (like phenylephrine or epinephrine.)

they produce vasoconstriction, which slows the washout of local anesthetic from the injection site.

Front 60

What vasopressor would be safest to use in the solution on patients with coronary artery disease during epidural anesthesia?

why?

Back 60

phenylephrine.

phenylephrine electrically stimulate the heart. In contrast, if epinephrine is given, beta 1 stimulation might occur.

Front 61

At what level is the spinal anesthetic usually injected?

Back 61

between L3 and L4, or between L4 and L5 interspaces.

Front 62

Why is local anesthetic injected between L3 and L4 or L4 and L5 with spinal anesthesia?

Back 62

at this level, the spinal cord is not in danger of trauma from the needle. The anesthetic is injected below the conus medullaris.

Front 63

Where does the conus medullaris and in normal adults?

Back 63

at the L1 L2 interspace.

Front 64

What is the duration of action of lidocaine used for spinal anesthesia with and without epinephrine?

Back 64

45 to 60 minutes without epinephrine.

60 to 90 minutes with epinephrine.

Front 65

Assessment of subarachnoid block should begin how long after the local anesthetic is injected?

Back 65

five minutes, then you test the block.

Front 66

The adequacy of the blockade after administering local anesthetic into the subarachnoid space assess how?

Back 66

inability to raise the lake is a good indicator of motor block in the lumbar dermatomes.

for sensory block, a dull needle (pinprick) is used at the operative site. The pinprick is advanced cephalad up the back until a sharp sensation is elicited. The sensation should be equivalent to the sensation elicited by a pinprick at a high, un anesthetized dermatome, such as C 4.

the dermatome immediately caudad to the dermatome in which sharp sensation is elicited is the dermatome representing the highest level of analgesia.

Front 67

How long does it take for subarachnoid block to reach its highest (most cephalad) level?

what is the significance of this?

Back 67

20 minutes after spinal injection, although it may move cephalad for 30 minutes.

knowing when the analgesia reaches its highest level is significant because if the level of analgesia is above T5, the probability of hypotension and bradycardia increase.

Front 68

when performing an epidural, what should alert the anesthetist to the fact that a subarachnoid injection has occurred?

Back 68

profound motor block and sensory block in the hands.

dyspnea caused by absence of proprioceptive input from afferent nerves of the abdominal and intercostal muscles.

respiratory arrest if the block spreads to the cervical segments (c3, c4 and c5 blocked with a diaphragm becoming paralyzed.)

at high concentration of local anesthetic reaches the cranium, total neural paralysis leads to loss of consciousness, respiratory arrest, and hypotension.

Front 69

During an epidural the patient's blood pressure drops precipitously to 80/35 and the heart rate falls to 50. Saturation falls to 85%. What has probably happened?

Back 69

sub dural injection of the anesthetic agent.

these are the same signs as a high spinal. You get sympathetic block with unopposed parasympathetic effects.

Front 70

What is a vague sign of subdural injection?

Back 70

patchy and markedly asymmetric extensive spread of analgesia.

Front 71

Name seven absolute contraindications to spinal anesthesia:

Back 71

refusal.

infection at the site of injection.

hi intracranial pressure.

coagulation disorders.

brain tumor.

spinal cord disease.

severe hypotension.

Front 72

Why is spinal anesthesia contraindicated in patients with increased intracranial pressure?

Back 72

it can predispose the patient to brain stem herniation.

Front 73

What are the two main differences between spinal and epidural anesthesia?

Back 73

onset of sympathetic block is slower with epidural, so there is less likelihood of hypotension.

sympathetic block is at the same level as sensory block with epidural anesthesia, where it is 2 to 6 segments higher with spinal anesthesia.

motor block is for segments lower than sensory block for epidural anesthesia, where it is 2 segments lower with spinal anesthesia.

Front 74

How does the half life of local anesthetic administered in a spinal compare with the half life when administered in an epidural?

Back 74

it is longer in a spinal.

this is because the site of injection which the local anesthetic washes out fastest will be the site which gives the drug the shortest half life. So, it is longer when given in a spinal.

Front 75

What is the hydrostatic pressure of the epidural space ?

Back 75

negative.

a drop of fluid placed on the end of a needle that is in the epidural space will get sucked in.

Front 76

Describe the negative pressure test of needle placement during epidural insertion:

Back 76

hanging drop technique.

a drop is placed on the hub of the epidural needle once it is located in the interspinous ligament.

when the needle is advanced, the drop should get sucked in by the negative pressure as the needle passes through the ligamentum flavum.

Front 77

Describe the loss of resistance method of needle placement with epidural insertion:

Back 77

apply continuous pressure to the plunger of the air filled or saline filled syringe as a needle is advanced through the interspinous ligament and ligamentum flavum. The moment the needle enters the epidural space, sudden release of the plunger occurs in the contents of the syringe will be rapidly discharged.

Front 78

After placing an epidural needle in the epidural space, blood tinged fluid is seen first, and then clear fluid is obtained.

what action should be taken?

Back 78

start over and insert the needle at the same interspace, but at a slightly different angle.

if it happens again, choose a different interspace.

Front 79

Where do local anesthetics work after epidural administration?

Back 79

spinal nerve roots within the epidural space.

spinal nerve rootlets bathed by cerebral spinal fluid.

within the spinal cord.

Front 80

An epidural is given. What is the first sign is working?

Back 80

sensory analgesia.

Front 81

How is the sensory block assessed for epidural blockade?

Back 81

it is tested by assessing pinprick sensations in each dermatome on both sides of the body.

Front 82

What is the most sensitive indicator of initial sensory block?

Back 82

sensation of temperature.

this is done with an alcohol swab.

Front 83

What does the pinprick test assess?

Back 83

analgesia.

Front 84

Compared with the level of sensory block associated with epidural anesthesia, sympathetic and motor blockade occur where?

Back 84

sympathetic blockade occurs at the same level as sensory blockade.

motor blockade may be four dermatomes lower than sensory blockade.

Front 85

It is important to obtain which two laboratory values before administering epidural anesthesia?

Back 85

hematocrit and prothrombin time.

Front 86

In addition to hematocrit and prothrombin time, what other lab values may you want to look at before administering epidural anesthesia?

Back 86

PTT if there is any suggestion that coagulation abnormality exists.

bleeding time if the patient is taking antiplatelet drugs.

Front 87

List some antiplatelet drugs we should watch for when evaluating patients for epidural anesthesia:

Back 87

aspirin.

nsaids.

valproic acid.

Front 88

What volume of local anesthetic per dermatome is injected and what local anesthetics can be used for lumbar epidural block?

Back 88

one to 2 mL of anesthetic is injected for each spinal segment to be anesthetized (1 mL for short patient and 2 mL for tall patients.)

Front 89

What local anesthetics can be used for lumbar epidural block?

Back 89

2 chloroprocaine.

lidocaine.

mepivicaine.

bupivicaine.

etidocaine.

Front 90

List local anesthetics and concentrations that produce minimal motor blockade when administered epidural:

Back 90

lidocaine 1%.

mepivicaine 1%.

bupivicaine 0.25%.

Front 91

List local anesthetics and concentrations that produce intense (dense) motor blockade when administered epidural:

Back 91

chloroprocaine 3%.

lidocaine 2%.

mepivicaine 2 to 3%.

etidocaine 1.5%.

prolocaine 3%.

Front 92

Which of the following local anesthetics produces the greatest motor blockade when administered into the epidural space:

lidocaine 1%, bupivicaine 0.25%, chloroprocaine 3%, or mepivicaine 1%?

Back 92

chloroprocaine 3%.

Front 93

Epidural administration of what combination of local anesthetics and opioid is effective for postoperative pain control and permits the patient to ambulate?

Back 93

bupivicaine 0.0625 to 0.125% in combination with morphine 0.1 mg per ML or fentanyl 5 mcg per ML.

this provides excellent analgesia without motor blockade.

Front 94

Of the local anesthetic agents administered epidurally, which produces the most profound sensory block?

Back 94

bupivicaine produces the most profound sensory block.

Front 95

What is the duration of action of lidocaine used for epidural anesthesia with and without epinephrine?

Back 95

80 to 120 minutes without epinephrine.

120 to 80 minutes with epinephrine.

Front 96

What is the usual onset time of effect of plain lidocaine for epidural anesthesia?

Back 96

5 to 15 minutes.

Front 97

Give two reasons for administering epidural local anesthetic test dose:

Back 97

determined that the injection is neither intravenous nor intrathecal.

Front 98

How long should you wait after giving an epidural test dose?

Back 98

3 to 5 minutes.

Front 99

How long does it take for a test dose of epinephrine to reach the heart after intravascular injection during epidural placement of a local anesthetic in the nonpregnant patient?

Back 99

30 to 60 seconds.

Front 100

Is the test dose technique with epinephrine in epidural anesthesia reliable with pregnant patients? :

Back 100

it is not reliable with pregnant patients.

Front 101

How long does it take to recognize intravascular injection with epidural anesthesia?

Back 101

the response to epinephrine (increased heart rate of more than 20 beats per minute, palpitations and tremors) will occur within 30 to 60 seconds in may last only 15 seconds.

Front 102

How long does it take to recognize intrathecal injection with epidural anesthesia?

Back 102

the effects may not be apparent for 3 to 5 minutes.

you should wait 3 to 5 minutes after giving a test dose to determine if you have injected intrathecally.

Front 103

What structures do you pass when performing an epidural placement with the paramedian approach?

Back 103

skin, subcutaneous,paraspinous muscle mass, ligamentum flavum.

Front 104

Why is there less resistance with the paramedian approach to epidural or spinal anesthesia?

Back 104

because this approach is lateral to the supraspinous and interspinous ligaments.

Front 105

How far is the epidural space from the skin in the non obese adult in centimeters?

Back 105

4 to 6 cm in 80% of the population.

4 cm in 50% of the population.

Front 106

How far is the epidural space from the skin in obese adults?

Back 106

it may be greater than 8 cm.

Front 107

How far is the epidural space from the skin in skinny adults?

Back 107

it may be less than 3 cm.

Front 108

How far should an epidural catheter be safely threaded into the epidural space ?

Back 108

3 to 5 cm.

4 cm is a good answer.

Front 109

Into what space is a local anesthetic injected for caudal anesthesia?

Back 109

into the epidural space.

Front 110

What single factor most determines the height of a caudal anesthetic?

Back 110

the volume of the local anesthetic injected.

Front 111

Negative pressure during a caudal anesthetic is detectable after going through what structure?

Back 111

the sacrococcygeal ligament.

the sacrococcygeal ligament is an extension of the ligamentum flavum.

Front 112

How far should a needle be advanced into the epidural space during caudal anesthesia?

Back 112

after loss of resistance, the needle is advanced 1 to 1.5 cm.

Front 113

What gauge needle do you use for caudal anesthesia ?

Back 113

22gauge.

Front 114

After placement of the needle into the epidural space with caudal technique, should aspiration be performed to confirm placement and should test dose be given?

Back 114

yes, aspiration should be performed, and yes, test dose is given.

Front 115

How do you get a test dose to determine if the needle is in the caudal canal?

Back 115

you give 5 mL of preservative free saline quickly while the freehand is used to palpate across the dorsal sacral region.

if the needle is located subcutaneously, a bulge will be felt over the midline during injection.

if the needle is correctly positioned, however, no midline bulge should occur.

Front 116

The test dose for caudal anesthesia to prevent intravascular injection in children should contain what concentration of epinephrine?

Back 116

0.5 mcg per kilogram of body weight of epinephrine.

this is 0.1 mL per kilogram of 1:200,000 solution.

Front 117

The pediatric patient will undergo caudal anesthesia. List the two most commonly used agents and doses and volumes appropriate for caudal anesthesia:

Back 117

bupivicaine 0.125% or 0.25% and lidocaine 1% are the most commonly used agents.

the volume of local anesthetic required ranges from 0.5 mL per kilogram for sacral block to 1.25 mL per kilogram for mid thoracic block.

Front 118

What is the dosing of 0.25% bupivicaine for caudal block in a child?

Back 118

maximum dosing for bupivicaine in children is 3 mg per kilogram.

therefore, the dose would be 0.5 mL per kilogram.

Front 119

With caudal block, what type of dose reduction is done for infants less than six months old?

Back 119

reduce dose by 30%.

Front 120

What volume of local anesthetic is injected for a 70 kg adult male of average height for a caudal block?

Back 120

one to 2 mL of anesthetic per spinal segment.

at least 12 to 15 mL is required to adequately fill the sacral canal.

Front 121

The needle is inserted at what angle for lumbar epidural anesthesia?

Back 121

at a right angle (90° angle).

Front 122

The needle is inserted at what angle for thoracic epidural anesthesia?

Back 122

upward at an angle that is 40° to the ligamentum flavum.

Front 123

Which five nerves form the brachial plexus with most individuals?

Back 123

C5, C6, C7, C8, and T1.

sometimes there are contributions from C 4 and T 2.

Front 124

What two nerves are derived from the posterior cord of the brachial plexus?

Back 124

the axillary and radial nerves.

Front 125

What two nerves are derived from the lateral cord of the brachial plexus?

Back 125

musculocutaneous and median nerves.

Front 126

What two nerves a derived from the medial cord of the brachial plexus?

Back 126

median and ulnar nerves.

Front 127

The median nerve supplies sensory innervation to what areas of the hand?

Back 127

thumb, index finger, middle finger, and lateral finger.

Front 128

How is the function of the median nerve assessed?

Back 128

by checking for normal sensation on the Palm surface of the index finger.

Front 129

The ulnar nerve passes distally through the axilla, medial to the distal artery and the brachial artery, until the middle of the arm. Before passing to the forearm, the ulnar nerve pierces the medial intermuscular septum and descends into the groove between what two structures?

Back 129

medial epicondyle of the humorous and the olecranon process of the ulna.

Front 130

The median nerve innervate what muscles of the forearm?

Back 130

pronator teres, flexor carpi radialis, palmarin longus, and flexor digitorum superficialis.

Front 131

Describe the landmarks and relative needle location in order to perform the median nerve block at the wrist:

Back 131

822gauge needle is directed just medial to the ulnar artery pulse.

if the ulnar pulse is not palpable, then go just medial to the flexor carpi radialis.

3 to 5 mL of anesthetic is injected to block the median nerve.

Front 132

The ulnar nerve supplies sensory innervation to what areas of the hand?

Back 132

to the little finger and the medial ring finger.

Front 133

How is the function of the ulnar nerve assessed?

Back 133

by checking for normal sensation on the Palm surface of the fifth finger.

Front 134

Describe the sensory innervation of the radial nerve in the upper extremity:

Back 134

it provides sensory innervation to the dorsum (back) of the hand, covering the width of the first two and one half digits (thumb, first finger, lateral half of middle finger.)

the unique sensory area served by the radial nerve is the web space between the thumb and first finger.

Front 135

Damage to what nerve cause inability to adduct the thumb?

Back 135

the median nerve.

Front 136

Damage to what nerve causes inability to abduct the thumb?

Back 136

radial nerve.

Front 137

What four functional changes occur after the radial nerve is blocked by local anesthesia?

Back 137

inability to supinate (rotate) the extended forearm.

inability to extend (lift) the wrist.

inability to abduct the thumb.

inability to extend the metacarpophalangeal joints.

Front 138

Checking which movement assesses the motor function of the radial nerve after it is blocked by local anesthesia or injured?

Back 138

ability to abduct the thumb.

Front 139

In addition to extending the wrist and abducting the thumb, what other motor function does the radial nerve provide?

Back 139

it extends the arm at the elbow (straightens the elbow) and it supinates the forearm.

Front 140

What muscles are innervated by the ulnar nerve?

Back 140

in the forearm: flexor carpi ulnaris muscle and the medial half of the flexor digitorum profundus.

in the hand: palmarus brevis muscle, the three short muscles of the hypothenar eminence (abductor digiti minimi, flexor digiti minimi, opponens digiti minimi.), the adductor pollicic, the third and fourth lumbricals and all the interossei.

Front 141

What muscle of the thumb is innervated only by the ulnar nerve?

Back 141

the adductor pollicis.

Front 142

Name four approaches to the brachial plexus:

Back 142

supra clavicular.

infraclavicular.

axillary.

interscalene.

Front 143

Describe the anatomic relationships of the median, ulnar, and radial nerves to the axillary artery. What is the Mneumonic:

Back 143

median nerve life anterior (superior) to the axillary artery.

the ulnar nerve is medial and slightly posterior (inferior) to the artery.

the radial nerve is posterior and slightly lateral to the artery.

Mneumonic:RUMM PISS.

Front 144

In preparing to do an axillary block, why would you do subcutaneous infiltration?

Back 144

to block the intercostobrachial nerve (branch T2) in order to provide anesthesia for the trachea.

to block the medial brachial cutaneous nerve, which leaves the sheath just below the clavicle.

Front 145

Which nerve is damaged by an intravenous needle in the antecubital space?

Back 145

median nerve.

Front 146

What nerve leaves the fascial sheath early in the axilla and lies within the coracobrachialis muscle?

Back 146

the musculocutaneous nerve.

Front 147

Which nerve is most commonly blocked with a trans arterial approach to an axillary block?

Back 147

the radial nerve.

Front 148

What nerve is least likely to be blocked with the axillary approach to the brachial plexus?

why?

Back 148

the musculocutaneous nerve.

that is because within the axilla, this nerve has already left the sheath and lies within the coracobrachialis muscle.

Front 149

What nerve will be blocked when the coracobrachialis muscle is infiltrated with an axillary approach?

Back 149

the musculocutaneous nerve.

Front 150

What nerves innervate the medial aspect of the upper arm?

Back 150

the medial cutaneous nerve of the arm.

the intercostobrachial nerve.

they innervate the upper arm down to the elbow.

Front 151

What nerve innervate the medial aspect of the forearm (from slightly above the elbow down to the wrist?)

Back 151

the medial cutaneous nerve.

Front 152

Which nerve from the brachial plexus provides sensory innervation to the lateral aspect of the forearm?

Back 152

the musculocutaneous nerve.

Front 153

What is the name of the specific terminal sensory branch of the musculocutaneous nerve to the lateral forearm?

Back 153

the lateral cutaneous nerve of the forearm.

Front 154

fullness of feeling the medial aspect of the upper arm after axillary block of brachial plexus is due to what?

Back 154

blockade of the medial cutaneous nerve of the arm.

Front 155

What approach to the brachial plexus is associated with the greatest risk of pneumothorax?

Back 155

supraclavicular approach.

Front 156

What approach to the brachial plexus is associated with the least risk of pneumothorax?

Back 156

axillary approach.

Front 157

Is pneumothorax a potential complication of infraclavicular block?

Back 157

yes.

Front 158

What syndrome is associated with stellate ganglion blockade?

Back 158

horner's syndrome. It occurs when the stellate ganglia is blocked.

Front 159

What are the six signs of stellate ganglion block (horners syndrome.?)

Back 159

on the ipsilateral side of the head/face as the side on which the stellate ganglion is blocked, you will see:

ptosis (droopy eyelid).

meiosis.

facial and arm flushing (from vasodilation).

increased skin temperature.

anhydrosis (lack of sweating on the face).

nasal congestion.

Front 160

What approach to the brachial plexus is the least likely to cause horners syndrome?

why?

Back 160

axillary approach.

this is because horners syndrome is caused by blockade of the stellate ganglia which is located on the lateral border of the vertebral body of C7.

Front 161

What nerve is often missed when using the interscalene approach to the brachial plexus?

what can be done to help in this situation?

Back 161

the lower inferior trunk (c8 to t1) of the brachial plexus may be inadequately anesthetized.

since the ulnar nerve arises from the lower inferior trunk, ulnar nerve block may be required for adequate surgical anesthesia in that distribution.

Front 162

What are the indications for interscalene brachial plexus block?

Back 162

any procedure in the upper extremity, including the shoulder.

it is most often done for procedures on the arm and forearm and when the armed cannot be positioned for the axillary approach.

Front 163

Which segment of the brachial plexus is targeted in the interscalene approach to a brachial plexus block? (Hint: branches, roots, cords, trunks, divisions.)

what is the mnemonic?

Back 163

it targets the trunks of the brachial plexus. After the roots emerge from cervical and thoracic vertebrae (c5 to t1) the trunks are sandwiched between the anterior and middle scalene muscles. Two sheathes of fibrous tissue and close the trunks between the scalene muscles, forming the space into which local anesthetic can be injected to produce brachial plexus block.

mnemonic: Robert Taylor drinks cold beer (roots, trunks, division, cords, branches.)

Front 164

Your patient requires hand surgery. Which upper extremity block would not be appropriate?

Back 164

interscalene block.

it is suitable for shoulder and arm surgery, but not hand surgery.

Front 165

What type of block could you do for hand surgery?

Back 165

supraclavicular blocki.

ifraclavicular block.

axillary block.

beir block.

Front 166

What are indications for the supraclavicular brachial plexus block?

Back 166

procedures on the distal upper extremity.

it also offers arm block with high success rate for hand surgery with patients who cannot circumduct the humorous for the axillary approach.

Front 167

What is the major advantage of the supracpavicular approach to the brachial plexus?

Back 167

because the brachial plexus is blocked where it is most compactly arranged (at the level of the three trunks) there is minimal possibility of missing peripheral or proximal nerve branches from failure of local anesthetic to spread.

Front 168

What are indications for the axillary brachial plexus block?

Back 168

any surgical procedure from the mid humerus to the hand.

Front 169

What peripheral nerve blocks are appropriate for shoulder surgery?

Back 169

interscalene brachial plexus block.

supraclavicular brachial plexus block.

Front 170

For shoulder surgery, what could be done in adjunct to interscalene block?

Back 170

superficial cervical block may be performed as an adjunct to interscalene block.

Front 171

What volume of local anesthetic is injected, and what local anesthetics can be used for a 70 kg adult male of average height for interscalene block?

Back 171

10 to 40 mL.

lidocaine and bupivicaine are used, which usually provides anesthesia for the entire brachial plexus and the cervical plexus as well.

Front 172

What volume of local anesthetic is injected in what local anesthetic can be used for a 70 kg adult male of average height for supraclavicular block?

Back 172

20 to 30 mL.

lidocaine is used.

Front 173

What volume of local anesthetic is injected in what local anesthetics can be used for a 70 kg adult male of average height for axillary blocks?

Back 173

40 to 50 mL.

mepivicaine and lidocaine are used.

Front 174

What is thoracic outlet syndrome?

Back 174

compression of the brachial plexus and subclavian artery at the thoracic outlet between the first rib and the clavicle, or between the anterior and medial scalene muscles.

Front 175

When do people get thoracic outlet syndrome?

Back 175

patients get this when working with the arms overhead for extended period.

Front 176

Why are we so concerned in screening patients with thoracic outlet syndrome?

Back 176

all patients scheduled for surgery in the prone position should be assessed for symptoms of thoracic outlet syndrome. If they have it, the arms to be placed alongside the trunk during the surgery, rather than surrender position.

Front 177

What are the possible surgical interventions for thoracic outlet syndrome?

Back 177

resection of the first rib, resection of the cervical rib, partial resection of the scalene muscle, or removal of anomalous fibrous bands.

Front 178

when resection of the first rib, resection of the cervical rib, partial resection of the scalene muscle, or removal of anomalous fibrous bands is performed for thoracic outlet syndrome, what are the six possible complications that can occur?

Back 178

pneumothorax.

brachial neuralgia.

pleural fusion.

temporal phrenic nerve palsy .

injury to the subclavian artery.

injury to the long thoracic nerve and T1 roots.

Front 179

What peripheral nerve block will provide adequate analgesia for surgical procedures on the anterior thigh and knee?

Back 179

femoral block.

it provides analgesia for both deep and superficial surgical procedures on anterior thigh and knee.

Front 180

What single nerve block is best for anterior cruciate ligament (ACL) repair?

Back 180

femoral nerve block.

Front 181

In addition to the femoral nerve, what three other nerves may be blocked for surgery on or above the knee?

Back 181

sciatic nerve.

lateral femoral cutaneous nerve.

obturator nerve.

these nerves may be blocked to provide complete coverage above and at the knee.

Front 182

Describe the three in one block and its utility:

Back 182

it is another name for lumbar plexus block.

it blocks the femoral, obturator, and lateral femoral cutaneous nerves.

used alone, the three in one block is the applicable for minor knee surgery, and in combination the spinal anesthesia is appropriate for major knee surgery.

Front 183

Give three potential disadvantages of the three in one block:

Back 183

large volumes of local anesthetic solutions are required to achieve adequate spread along the fascial plane of the plexus.

the block often misses the obturator nerve.

quadricep weakness may limit ambulation after the procedure.

Front 184

What is the terminal branch of the femoral nerve?

Back 184

the saphenous nerve.

Front 185

The nerves of the foot are branches of what two major nerves?

Back 185

femoral and sciatic nerves.

Front 186

What nerve is a terminal branch of the femoral nerve?

Back 186

the saphenous nerve.

Front 187

How does the sciatic nerve branch down the leg?

Back 187

it branches into the tubular (which further branches into the posterior tibial and sural nerves) and the common peroneal nerve (which further branches into the deep and superficial peroneal nerves.

Front 188

What five sensory nerves require blockade for an ankle block?

Back 188

the saphenous nerve (which is a terminal branch of the femoral nerve).

the deep peroneal nerve (which is a branch of the common peroneal nerve.)

the superficial peroneal nerve (a branch of the common peroneal nerve.)

the posterior tibial nerve (which is a direct continuation of the tubular.)

the sural nerve (which is a branch of the tibial nerve.)

Front 189

Of the five sensory nerves to the ankle and foot, which three lie most superficial?

what pneumonic should you remember?

Back 189

the superficial peroneal nerve.

the saphenous nerve.

the sural nerves.

all superficial sensory nerves to the foot start with "S."

Front 190

with one exception, all sensory nerves to the foot arise from the sciatic system.

name the sensory nerve to the foot that does not arise from the sciatic system:

Back 190

the saphenous nerve. It is a terminal branch of the femoral nerve and the only innovation of the foot that is not part of the sciatic system.

Front 191

What are the five nerves of ankle in the foot?

Back 191

the saphenous nerve.

the deep peroneal nerve.

the superficial peroneal nerve.

the posterior tibial nerve.

the sural nerve.

Front 192

What is the function of the saphenous nerve?

Back 192

it supplies the superficial sensation to the anterior medial foot.

Front 193

What is the function of the deep peroneal nerve?

Back 193

it permits toe extension and also sensation to the medial half of the dorsum of the foot.

Front 194

What is the function of the superficial peroneal nerve?

Back 194

it permits sensation superficially to the dorsum of the foot and all five toes.

Front 195

What is the function of the tibial nerve?

Back 195

it permits sensation to the heel, the medial soul, and lateral sole of the foot.

Front 196

What is the function of the sural nerve?

Back 196

it provides sensation to the lateral foot.

Front 197

the sural nerve is a branch of which nerve?

Back 197

it is a branch of the tibial nerve, which, in turn, is a branch of the sciatic nerve.

Front 198

What nerves causes flexion of the foot?

Back 198

the medial plantar nerve and lateral plantar nerve.

Front 199

Of what nerve are the medial plantar and lateral plantar branches of?

Back 199

the tibial nerve.

Front 200

What nerve causes extension of the foot?

Back 200

the peroneal nerve.

Front 201

Which three of the five sensory nerves of the foot are usually blocked by superficial (subcutaneous) infiltration?

Back 201

superficial peroneal nerve.

sural nerve.

saphenous nerve.

Front 202

Which nerves of the foot are usually not blocked by superficial (subcutaneous) infiltration?

why?

Back 202

the posterior tibial nerve and the deep peroneal nerve.

this is because they lie in relatively deep planes within the tissues of the foot and are not blocked by subcutaneous infiltration.

Front 203

Which nerve of the ankle is least likely to be blocked by superficial and filtration?

Back 203

the posterior tibial nerve.

Front 204

What approach would you use to block the posterior tibial nerve?

Back 204

3 cm needle is advanced through the skin wheal raised along the medial aspect of the Achilles tendon at the level of the superior border of the medial mallous to the posterior aspect of the tibia, posterior to the tibial artery.

Front 205

Blockade of what nerves will provide complete anesthesia of the leg?

Back 205

femoral nerve block combined with sciatic nerve block as well as lateral femoral cutaneous and obturator nerve blocks.

Front 206

Surgical anesthesia of the lower leg and foot can be achieved by block of what nerve?

Back 206

sciatic nerve.

Front 207

Describe the anatomic approach to block the sural nerve at the ankle:

Back 207

it is blocks laterally between the lateral malleolus and the Achilles tendon with a deep subcutaneous fan infiltration of 3 to 5 mL of local anesthetic.

Front 208

Describe the anatomic approach to block the superficial and saphenous nerves at the ankle:

Back 208

the superficial peroneal and saphenous nerves are blocked with subcutaneous infiltration on the dorsal foot from the medial malleolus to the extensor digitorum longus tendon with 3 to 5 mL of local anesthetic.

Front 209

Describe the anatomic approach to block the deep peroneal nerve:

Back 209

insert the needle at the intermaleolar line between the extensor digitorum longus and extensor hallicus longus tendons to the periosteum or elicitation of parasthesia and inject 5 mL of local anesthetic.

Front 210

Describe the anatomic approach to block the posterior tibial nerve:

Back 210

it is blocked posterior to the medial malleolus.

the posterior tibial artery is palpated and the needle is directed adjacent to the pulse until paresthesia or bone contact is encountered.

inject 5 mL of local anesthetic.

Front 211

Can an ankle block of all five nerves be achieved with a ring block of the ankle?

Back 211

several nerves can be blocked with a ring block, but more reliable ankle block can be achieved by blocking each of the five nerves individually.

Front 212

What volume of local anesthetic is injected in what local anesthetics can be used for a 70 kg adult male of average height for ankle block?

Back 212

25 mL.

lidocaine and bupivicaine are used.

Front 213

What five factors are considered for choosing a particular local anesthetic?

Back 213

duration of the surgery.

the regional technique selected.

the needs of the particular type of surgery (sensory block for obstetric, motor block for orthopedics.

the skill of the anesthetist.

the potential for systemic toxicity.

Front 214

Rank the following local anesthetic injection sites from fastest absorption to slowest absorption:

brachial plexus, caudal, lumbar epidural, intercostal, paracervical, subcutaneous:

Back 214

the rate of absorption depends on blood flow to the tissue at the injection site.

accordingly,

intercostal> caudal> paracervical> lumbar epidural> brachial plexus> sciatic> subcutaneous.

Front 215

You perform an intramuscular injection of local anesthetic (trigger point injection.)

will the systemic rate of absorption be fast or slow?

Back 215

the rate will be relatively slow. This is because blood flow to resting muscle is low.

it is faster with intercostal because this muscle is active.

Front 216

The fastest absorption of local anesthetics and the fastest increase in plasma concentration of local anesthetics will occur after injection from which of the following sites:

epidural, intramuscular, paracervical, subarachnoid, subcutaneous?

Back 216

paracervical.

Front 217

What gauge needle is probably satisfactory for performance of the majority of nerve blocks?

Back 217

23gauge.

Front 218

Name three situations in which epinephrine should not be used in a local block:

Back 218

digital (toes or fingers) injection.

penile injection.

intraocular injection.

"epinephrine is not used for peripheral nerve block because of possibility of end artery vasoconstriction and subsequent tissue ischemia."

Front 219

What nerve may be blocked by injection of agent at the base of the tonsillar pillars?

Back 219

cranial nerve nine,

Front 220

How do you block the glossopharyngeal nerve?

Back 220

by injecting 5cc of local anesthetic into the base of each tonsillar pillar.

a 22g 9cm needle is used.

careful aspiration is needed since the carotid is so close to the glossopharyngeal nerve.

Front 221

How is proper position of the needle confirmed for transtracheal block?

Back 221

by aspiration of air prior to injection of anesthetic.

Front 222

Transtracheal block is accomplished with what local anesthetic through what membrane and what gauge needle?

Back 222

plain lidocaine 4% 4 mL through the cricothyroid membrane using a 22 gauge needle attached to a small syringe.

lidocaine is sprayed into the trachea at end expiration, or during inspiration.

Front 223

What nerve is blocked when local anesthetic is applied through transtracheal puncture?

Back 223

recurrent laryngeal nerve.

Front 224

What areas does transtracheal block provide anesthesia to?

Back 224

below the cords.

up and down the trachea.

these areas are supplied by the recurrent laryngeal nerve.

Front 225

Why is the needle quickly withdrawn after injection for trans tracheal block?

Back 225

because the patient will begin to cough.

coughing spreads the anesthetic over the surface of the trachea and the inferior surface of the vocal cords.

Front 226

Plasma concentration of local anesthetic after trans tracheal block most closely resembles plasma concentration achieved after injection at which of the following sites:

intramuscular, intravenous, subcutaneous, or sublingual?

explain:

Back 226

sublingual.

in both situations, drug is absorbed across mucous membranes. In fact, it is almost as fast as intravenous administration.

Front 227

What is the maximum length of time the target should be inflated after beir block is given?

why?

Back 227

two hours.

any damage to vessels, nerves, and skeletal muscle is usually reversible for tourniquet inflation of one to two hours.

turning inflation should not exceed two hours.

Front 228

What is the minimal amount of time required before the tourniquet should be deflated after administration of a beir block? :

Back 228

30 minutes.

Front 229

What volume of local anesthetic is injected into the arm for beir block?

Back 229

25 to 50 mL.

Front 230

What volume of local anesthetic is injected into the leg for a beir block?

Back 230

100 to 200 mL.

Front 231

What local anesthetics are used for intravenous regional local anesthetic of the upper arm (beir block?)

Back 231

lidocaine 0.5% or prilocaine 0.5%.

40 to 50 mL.

Front 232

Can you use mepivicaine for beir block?

Back 232

yes.

Front 233

Which drug can you not use for a beir block?

Back 233

bupivicaine.

Front 234

What dose of lidocaine (based on weight) is appropriate for regional intravenous anesthesia (beir block) of the upper extremity?

Back 234

lidocaine 0.5% 3 mg per kilogram.

Front 235

Calculate the volume of lidocaine 0.5% that should be given for a beir block in a 70 kg patient:

Back 235

42 mL.

Front 236

Which two local anesthetic should be avoided when doing a beir block?

why?

Back 236

chloroprocaine, because it is associated with thrombophlebitis.

bupivicaine, because of cardiotoxicity.

Front 237

During an intravenous block, the tourniquet becomes incompetent and the patient develops seizures, what is the first thing that should be done?

Back 237

maintain the airway and assist ventilation with oxygen.

local anesthetic induced seizures are usually for short duration.

Front 238

Why may seizure occur with a bier block?

Back 238

leakage of local anesthetic into the general circulation before tourniquet release can occur.

seizure can also occur if tourniquet is released to quickly. This is why we perform intermittent release and reinflation of the tourniquet with bier block.

Front 239

List eight contraindications to intravenous regional anesthesia (bier block):

Back 239

patient refusal.

moderate or severe hypertension.

athletic build with strong muscles.

skeletal muscle disorder.

known hypersensitivity to esters or amides.

untreated heart block.

sickle cell disease or sickle cell trait.

tissue infection/cellulitis.

Front 240

Give two absolute contraindications for bier block:

Back 240

patient refusal.

known hypersensitivity to esters or amides.

Front 241

Which is an absolute contraindications to bier block:

sickle cell disease or allergy to procaine?

Back 241

allergy to procaine.

Front 242

Is bier block absolutely contraindicated with sickle cell anemia?

Back 242

the use of the tourniquet is controversial.

the tourniquet can be used if it is critical to the success of the operation, but normal temperature of the patient and extremity should be maintained.

bier block is relatively contraindicated with sickle cell anemia.

Front 243

What cutaneous sensory level should be reached with a central block to provide adequate analgesia for cystoscopy procedures?

Back 243

cutaneous sensory block to T 10.

Front 244

What cutaneous sensory level should be reached with central block to provide adequate analgesia for uterine surgery?

Back 244

T8 to T10.

Front 245

Which nerves are blocked in a cervical plexus block?

Back 245

C2 to C4.

C1 is a motor nerve.

deep cervical block is essentially a paravertebral block.

Front 246

What are indications for a superficial cervical plexus block?

Back 246

unilateral procedures on the anterior oral lateral neck such as carotid endarterectomy or thyroidectomy.

it is also used as an adjunct to shoulder surgery with interscalene block.

Front 247

List two indications for facial nerve (cranial nerve seven) block:

Back 247

to relieve spastic contractions of the facial muscles.

to treat herpes zoster involvement of the facial nerve.

Front 248

Topical application of lidocaine to nasal mucosa and anesthetizes what sensory nerves?

Back 248

anterior ethmoidal nerve and sphenopalatine (nasopalatine) nerves.

these are both branches of the trigeminal nerve.

Front 249

What is the most frequent complaint after celiac plexus block?

Back 249

backache or back pain.

Front 250

The patient with chronic low back pain is scheduled for a lumbar facet block. Identify the possible complications of lumbar facet injection of local anesthetic:

Back 250

infection.

allergic reaction.

transient radicular pain.

subarachnoid injection resulting in spinal block.

these are all rare.

Front 251

Where is local anesthetic injected for a penile block?

Back 251

the needle puncture sites are at 10 o'clock and two o'clock positions at the base of the penis.

Front 252

What is the most frequent cause of systemic toxicity of a local anesthetic?

Back 252

accidental intravascular injection.

Front 253

Systemic toxicity of local anesthetics is due to an excess plasma concentration of the drug. Name four determinants of systemic absorption:

Back 253

total dose administered.

blood flow to the injection site.

presence of epinephrine or phenylephrine in the solution.

physio chemical properties of the drug (greater the protein binding and greater the lipid solubility, the slower the absorption.

Front 254

List 10 symptoms of local anesthetic toxicity in order of appearance:

Back 254

circumoral numbness (numbness of the tongue.)

auditory disturbance (tinnitus.)

skeletal muscle twitching.

systemic hypotension.

myocardial depression.

seizures.

unconsciousness.

respiratory arrest.

coma.

cardiovascular depression.

Front 255

After epidural injection of local anesthetic your patient complaints of lip numbness and apprehension. Oxygen is given. What other prophylactic measures should be taken immediately?

Back 255

hyperventilate the patient. This causes constriction of cerebral blood vessels and it reduces delivery to the brain. Also, respiratory alkalosis and low potassium results in hyper polarization of nerve membranes which opposes the effects of local anesthetic.

remember, though, hypocapnia increases the seizure threshold of local anesthetics.

Front 256

What agents are best in the treatment of seizures induced by local anesthetics?

Back 256

anticonvulsants.

diazepam 0.1 mg per kilogram, thiopental 0.5 to 2 mg per kilogram, midazolam is also helpful.

Front 257

How can systemic local anesthetic toxicity best be avoided?

Back 257

meticulous attention to detail and recognizing intravascular injection with a test dose.

Front 258

List six complications of spinal anesthesia:

Back 258

spinal headache.

backache.

high spinal.

nausea.

urinary retention.

neurologic injury (rare).

Front 259

What is the most common complication of spinal anesthesia?

Back 259

backache.

11% to 13%.

Front 260

What is the second most common complication of spinal anesthesia?

Back 260

spinal headache.

0.4% to 7.8%.

Front 261

What causes spinal headache?

Back 261

decreased cerebral spinal fluid pressure resulting from leakage of cerebral spinal fluid to the opening in the dural sheath.

Front 262

The likelihood of spinal headache is increased by what five factors?

Back 262

happens more with younger patients.

happens more in women than men.

happens more with larger needles (the larger the needle, a greater the incidence.)

happens more in pregnant women than nonpregnant women.

happens more in patients with a history of multiple punctures.

Front 263

What gauge needle should be used for spinal anesthesia is the goal is to reduce the likelihood of the spinal headache?

Back 263

25 or 26gauge needle.

Front 264

What is the incidence of spinal headache when the dura is puncture with a 16gauge needle?

Back 264

18%.

Front 265

What is the occurrence rate of spinal headache following unintentional dural puncture with an 18gauge epidural needle while attempting epidural anesthesia in the pregnant patients?

Back 265

it is as great a 70 to 80%.

Front 266

What is the incidence of spinal headache in young patients if the dura and arachnoid are accidentally punctured during epidural anesthesia?

Back 266

in young patients, it occurs in 50% of cases.

Front 267

diplopia following spinal headache results from paralysis of what nerve?

Back 267

traction on the abducens nerve (CN 6.)

Front 268

After the diagnosis is confirmed, what is the initial treatment for spinal headache?

Back 268

analgesics, bed rest, hydration.

blood patch may be performed if it continues following 14 hours after treatment.

Front 269

If conventional treatment does not care spinal headache, what two other things can be done?

Back 269

intravenous caffeine (500 mg in 1 L D5 LR.)

blood patch.

Front 270

What is the maximum dose for epidural blood patch?

Back 270

20 mL.

12 to 15 mL is usually sufficient.

Front 271

After blood patch, how long should the patient rest and in what position should they rest before walking again?

Back 271

supine position for 30 to 60 minutes, up to two hours.

Front 272

What percent of blood patch is unsuccessful is given 24 hours after dural puncture?

Back 272

more than 90%.

Front 273

Define high spinal:

Back 273

undesired excessive level of sensory and motor block.

it is associated with difficulty breathing or apnea leading to hypoxemia and hypebarbia.

Front 274

Define total spinal:

Back 274

anesthesia to the cervical spinal cord and brain stem.

Front 275

What are the signs and symptoms of high or total spinal?

Back 275

complaints of dyspnea.

low blood pressure.

nausea and vomiting.

apnea.

Front 276

While performing epidural anesthesia, what signs and symptoms will lead the anesthetist to suspect that intrathecal injection has occurred?

Back 276

signs of high or total spinal. These include dyspnea, respiratory arrest, and profound hypotension.

Front 277

At what level will high spinal give you dyspnea?

Back 277

higher than T2.

Front 278

At what level will high spinal give you respiratory arrest?

Back 278

C 3, 4, and 5.

this is from paralysis of the diaphragm.

Front 279

At what level will high spinal give you profound hypotension?

Back 279

if the local anesthetic passes through the foramen magnum and blocks the cranial nerves.

this is a total spinal.

Front 280

Five minutes after spinal anesthesia is administered, the patient becomes nauseous. What is the likely cause of this?

Back 280

hypotension.

hypotension causes sudden nausea and vomiting.

Front 281

What is the suggested treatment for the patient becomes hypotension during a spinal?

Back 281

300 and 500 mL bolus of balanced salt solution, or, ephedrine.

head down tilt may also be performed if the hypotension is severe.

Front 282

When can apnea with hypoxemia and hypercarbia occur after giving a spinal?

Back 282

apnea with hypoxemia and hypercarbia can occur as a result of reduced medullary blood flow from severe hypotension, or from direct C3 to C5 blockade inhibiting phrenic nerve function.

Front 283

What actions should you take when apnea and hypoxemia occur after giving a spinal?

Back 283

immediate ventilatory and cardiovascular support.

positive pressure ventilation with oxygen.

fluids and medications for blood pressure support.

place the patient in head down position to increased venous return.

Front 284

What is the cause of respiratory arrest after administration of spinal anesthesia?

Back 284

probably from ischemia of the brain stem and medullary respiratory centers secondary to profound hypotension.

Front 285

What actions should be taken to treat a high spinal?

Back 285

support of breathing and circulation.

positive pressure ventilation, fluid and drugs to support blood pressure.

head down position to facilitate venous return, as head up position (in an attempt to stop the spread of the anesthetic) will worsen hemodynamics.

Front 286

Of the following, what is the last thing you do to treat the patient who has signs and symptoms of a high spinal:

mechanical ventilation with 100% oxygen, trendellenberg position, ephedrine, give fluids?

Back 286

head down position.

because this is an emergency situation, immediate treatment includes positive pressure ventilation with 100% oxygen, fluids, and drugs for cardiovascular support.

Front 287

List four complications of epidural anesthesia, and state which one is most common:

Back 287

d backache.

dural puncture headache.

systemic toxicity from intravascular injection.

total spinal with dural puncture (which is rare.)

backache is the most common.

Front 288

What is the lowest wet tap rate reported for epidurals?

Back 288

1%.

this is with a 27gauge pencil point needle, non OB patient.

Front 289

What is the highest wet tap rate reported with epidurals?

Back 289

20 to 50%.

this is with a large needle in an OB patient.

Front 290

For which group of patients is the rate for wet tap higher, OB or non OB?

Back 290

OB.

up to 34% even with a 27gauge pencil point needle.

Front 291

How do complications for epidural differ from spinal?

Back 291

there is increased likelihood of intravascular injection and systemic toxicity with epidural compared with spinal.

Front 292

Epidural is administered and medication is injected. Afterward, block is only achieved on one side of the body. What should you do?

Back 292

block is asymmetric.

replace the catheter and insert more rostrad (headward).

the catheter is not in the epidural space. It may be located in the sub dural space, between the dura and the arachnoid.

Front 293

What causes backache associated with epidural anesthesia?

Back 293

the etiology is unclear.

most likely needle trauma, local anesthetic irritation, and ligament strain from muscle relaxation.

Front 294

What is the most common reason for backache after epidural or spinal anesthesia?

Back 294

relaxation of the paraspinous muscles allowing for stretch of the joint capsules and spinous ligaments.

Front 295

How do you know if your injecting into a nerve?

Back 295

there is intense, searing pain when local anesthetic is injected into a nerve. This is a signal to withdraw the needle immediately.

Front 296

What do you do when you have injected into a nerve?

Back 296

withdraw the needle immediately.

Front 297

List three common complications associated with interscalene approach to the brachial plexus:

Back 297

horners syndrome.

recurrent laryngeal nerve block.

phrenic nerve block leading to a feeling of heaviness on the ipsilateral chest and sensation of dyspnea.

Front 298

What is the incidence of Horner's syndrome with interscalene block?

Back 298

30 to 50%.

Front 299

What is the incidence of recurrent laryngeal nerve block with interscalene block?

Back 299

30 to 50%.

Front 300

What is the incidence of phrenic nerve block with interscalene block?

Back 300

30 to 40%.

Front 301

Interscalene block is administered for postoperative pain following thoracic incision. What two ways could pulmonary function be affected?

Back 301

pneumothorax. This is possible in any patient, but more likely with COPD patients because of superior displacement of the apex of the lung.

blockade of the phrenic nerve leads to a feeling of heaviness on the ipsilateral chest and can lead to subjective dyspnea in anxious patients.

Front 302

List six complications of interscalene block:

Back 302

total spinal anesthesia with hypotension and respiratory impairment.

intravascular injection and systemic toxicity.

phrenic nerve block which decreased ventilatory capacity.

laryngeal nerve block resulting in hoarseness.

stellate ganglion block resulting in Horner's syndrome.

pneumothorax.

Front 303

What is the most common complication of interscalene block?

Back 303

phrenic nerve block.

it ranges from 23 to 100%.

it is very common.

Front 304

Is the phrenic nerve commonly blocked with a supraclavicular block?

Back 304

yes.

incidents is 40 to 60%.

Front 305

While performing interscalene block your patient experiences a sudden cough and chest pain. What has happened?

Back 305

pneumothorax has probably occurred while exploring for nerves.

Front 306

Describe the onset and patient's description of tourniquet pain:

Back 306

approximately 45 minutes after the pneumatic tourniquet is inflated. Patient may complain of dull aching pain and patient may become restless, even though adequate analgesia exists for the operation.

tourniquet pain usually becomes more intense with time.

Front 307

Which nerve fibers mediate tourniquet pain?

Back 307

pain transmission through both a delta and c fibers and irs modulation in the dorsal horn synapses.

Front 308

Name six complications of cervical plexus block:

Back 308

intravascular injection and toxicity.

phrenic nerve blockade.

recurrent laryngeal nerve blockade leading to hoarseness.

vagal nerve blockade which can lead to dysphagia as well as hoarseness (since the recurrent laryngeal nerve is a branch of the vagus nerve.)

hematoma.

Horner's syndrome.

epidural or subarachnoid injection.

Front 309

Give two , and complications of cervical plexus block:

Back 309

systemic toxicity with hypotension.

phrenic nerve block.

Front 310

What is the least common complication of cervical plexus block?

Back 310

dysphagia from block of the vagus nerve.

Front 311

The incidence of needle induced nerve injury is greatest with which of the following regional techniques:

spinal, epidural, axillary, bier block?

Back 311

axillary block.

Front 312

What is the incidence of nerve injury with spinal and epidural?

Back 312

one in 10,000 (0.01%.)

Front 313

What is the incidence of nerve injury with axillary block?

Back 313

0.8% when the axillary artery is used as a landmark.

to 2.8% when paresthesia is actively sought.

Front 314

Is nerve injury a major adverse affect with bier block?

Back 314

no.

Front 315

what is cauda equina syndrome?

Back 315

serious injury to the cauda equina nerve roots.

it comes from exposure of the cauda equina nerve roots to high concentrations of local anesthetic.

Front 316

What is the major contributing factor to cauda equina syndrome?

Back 316

maldistribution of injected local anesthetic. This permits exposure of some nerves too high concentrations as a result of failure of mixing upon injection.

administration of continuous or repeated doses through smallbore catheters is a common cause.

Front 317

What are the three signs and symptoms of cauda equina syndrome?

Back 317

urinary and fecal incontinence.

partial paralysis of the lower extremities.

diminished sensations of the perineum.

Front 318

After inserting an epidural catheter, your patient complaints of back pain. What would you suspect?

Back 318

epidural hematoma.

back pain is the first symptom of epidural hematoma.

Front 319

The patient is being positive pressure ventilated.

what regional nerve block must to avoid in this patient?

Back 319

interplural block.