Regional Anesthesia Complications

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Regional Anesthesia Complications
2014-02-13 16:05:43
Principles II Exam Two

Principles 2 Exam 2
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  1. What are absolute contraindications for regional anesthesia??
    • 1. patient refusal
    • 2. infections at the site of injection
    • 3. coagulopathy
    • 4. severe hypovolemia
    • 5. increased ICP
    • 6. severe aortic or mitral stenosis
    • 7. fibrinolytic/thrombolytic therapy
  2. Why would you not want to do a spinal on a patient with mitral stenosis or aortic stenosis??
    They patients can not tolerate decreases in preload that are caused by spinals (specifically the side effect of hypotension).
  3. What are some relative contraindications for spinal anesthesia??
    • 1. systemic sepsis (risk of infection from the blood)
    • 2. uncooperative patient
    • 3. patients with neuro defecits prior to spinal
    • 4. severe spinal deformity (puts you at risk for making things worse)
    • 5. prior surgery at spinal site of injection
    • 6. if you need to manipulate the airway..might as well do general anesthesia
  4. What must you obtain prior to spinal on all patients who are on Coumadin?
    PT and INR

    and they must be in the normal range to proceed

    get these labs even if they only took a few doses

  5. If you know a patient is on Coumadin before a schedule procedure when is the ideal time to hold the medication??
    you would d/c it at least a week before the procedure and at a min. of 5 days prior to surgery
  6. At what INR is spinal an absolute contraindication??

    if <1.5 proceed with caution and do a spinal rather than epidural at this number
  7. Do ASA or Nsaids increase the risk of spinals like Coumadin??  Would you draw any labs before the procedure??
    by themselves they do not appear to increase the risk of spinal or epidural hematomas with regional anesthesia

    go ahead and draw a PTT if they have been taking these meds >2 weeks before procedure
  8. What should you do with a patients medication regimen if they are having a planned spinal procedure on chronic NSAID therapy??
    d/c at least 3 days prior to surgery

    5-7 days is best
  9. What is your concern with patients on Plavix or other related medications with a schedule spinal procedure??
    these drugs are absolute contraindications for regional anesthesia
  10. These drugs need to be d/c for at least how many days/hours prior to a procedure...

    • at least 7 days prior to procedure
    • at least 14 days prior to procedure
    • at least 48 hours prior to procedure

    Patients on these medications must also have a PTT drawn prior to any regional anesthetic being performed even if the medications were discontinued as ordered preop.
  11. Is minidose SQ heparin a contraindication to neuraxial blockade?? What about Heparin infusion??

    on infusion --- Heparin must be d/c for at least 4 hours prior to block and a normal PTT must be documented prior to block being performed.
  12. Remember.. always have a DOCUMENTED LAB to back you up!
  13. What would you do if your patient that received an epidural for surgery was also heparinized during the surgery but it's time for the catheter to come out??
    the catheter must stay for 4 hours after heparin is d/c and a normal PTT is obtained.
  14. If bleeding occurs during the block procedure, how long must you wait before the patient can be heparinized???
    1 hour
  15. why is bleeding with a neuraxial procedure such a big deal??
    bc you have no way to stop the bleeding
  16. How long should you delay the administration of Lovenox if bleeding is experienced during a block??
    delay at least 24 hours post procedure
  17. If an epidural cath is in place, it should be removed at least ____ prior to the administration of the first dose of Lovenox.
    2 hours
  18. If Lovenox is given while a epidural catheter is in place, it cannot be removed for ___ following the last dose, and the next dose cannot be given for at least ____ after the removal of the epidural cath.
    10 hours

    2 hours
  19. Fibrinolytic therapy should be d/c'ed for at least ____ prior to performing a block.  What should you obtain for completing this block??
    3 days

    COMPLETE clotting studies need to be completed and documented as NORMAL prior to initiating your block (PT,PTT, INR,PFT,Plt Ct.)
  20. If you discover your block in inadequate, what must you always be prepared for?
    the conversion to a general anesthesia procedure
  21. Urinary retention results from blockade of ____.
    S2 - S4

    leads to a decrease in bladder tone and inhibition of normal voiding reflex
  22. Urinary catheterizes should be provided to all patients undergoing procedures > ___.
    2 hours
  23. What anesthesia related drug can contribute to urinary retention?
    neuraxial opioids
  24. Prolonged urinary retention may be a sign of serious __________.
    neurological injury
  25. What is a high neural blockade?
    occurs with either spinal or epidural anesthesia

    exaggerated dermatomal spread of neural blockade

    can be due to increase dose, failure to decrease dose in selected patients or unusual sensitivity to spread of LA
  26. What are s/s of a high neural block??
    • dyspnea
    • numbness and tingling of the upper extremities
    • nausea (precedes hypotension due to hypoperfusion of the chemoreceptor trigger zone)
    • hypotension
    • bradycardia
    • unconsciousness
    • apnea (Resp. insufficiency)
  27. How do you treat a high neural block??
    • 1. change patients position with the use of hyperbaric technique
    • 2. maintain adequate airway and ventilation
    • 3. stop the administration of LA with epidural
    • 4. Give O2
    • 5. Open IV fluids
    • 6. Treat hypotension with ephedrine or phenylephrine
    • 7. trendelenburg position
    • 8. treat bradycardia
  28. What drug would you chose to give if you patient is hypotensive and bradycardic?
  29. Phenylephrine can result in ____.
    reflex bradycardia

    so give this to hypotensive patients who are tachy or normal HR
  30. What are signs that indicate the local anesthetic was administered into the vascular system??
    • if you have high levels in the CNS--
    • seizures and unconsciousness

    • if you have high levels in the cardiovascular system--
    • hypotension, arrhythmias and eventual cardiovascular collapse
  31. Intravascular injections rarely occur with spinals but can occur with epidurals and caudals...why??
    because the doses given with a spinal procedure are so much smaller than with an epidural/caudal
  32. What will occur right after you inject your local with a block that means you have a good block...
    the HR will drop a few beats..

    if the HR increases be concerned about injection into the vessels
  33. How can you prevent the severe side effects of LA ??
    ALWAYS inject meds in increments of 3-5cc and wait to see if any side effects occur

    side effects include ringing in the ears, metallic taste in mouth, circumoral numbness, lightheadedness, sudden weakness or numbness in legs
  34. What is the subdural space??
    the potential space between the dura and the arachnoid

    this is different than the subarachnoid space

    often formed during trauma and you may be unaware such as s car wreck, needle injury, spine surgery
  35. Which can cause more serious complications..a high spinal or a subdural injection???
    subdural injection

    can mimic a total spinal
  36. If a backache after a spinal persists or gets worse, this may be a sign more serious complications...what are examples of these and what should you do??
    abscess, hematoma

    consult NEURO
  37. What is a postdural puncture headache casued from??
    • causes by disrupting the integrity of the dura
    • headache is caused by the leaking of CSF through the dura causing intracranial hypotension

    it can occur with spinal anesthesia or a "wet" tap with an epidural where the epidural cath migrates and the tip of the needle indents into the dura enough to cause a leak of CSF

    it can occur even with uncomplicated procedures even if the needle just barely scrapes the dura

    the BIGGER the needle the bigger the risk
  38. What patients are at an increased risk of postdural puncture headaches??
    from book and previous lecture

    women, preggo, young ppl
  39. How would you immediately recognize a wet tap when performing a procedure???
    the pouring of CSF from the epidural needle or if CSF is aspirated from the epidural cath
  40. Why does sitting upright make the patients headache worse with a PDPH?
    the upright position leads to traction on the dura, tentorium, and blood vessels causing more pain
  41. How do you treat a patient with PDPH?
    • hydration
    • caffeine
    • analgesics
    • epidural blood patch
  42. what is a epidural blood patch?
    it involves the injection of 15-20 ml of a paitents own blood at the level of the dural puncture or one space below the puncture site

    blood patch works by mass effect and stops the leakage of CSF or alternatively by coagulating and "plugging" the hole

    normally works immediately

    90% respond to single blood patches

    the patient may experience pressure but not pain

    if not enough volume...patch will not work
  43. What are important instructions for the patients after a epidural blood patch??
    the patient must remain supine for 1-2 hours to allow the patch to work

    the patient should avoid lifting heavy items or straining for 48 hours (this prevents the dislodgement of the patch)
  44. A spinal or epidural hematoma normally occurs immediately after removal of a epidural catheter.  What are the s/s??
    • sharp leg or back pain
    • progression of numbness and motor weakness
    • sphincter dysfuction
  45. A spinal/epidural hematoma is an emergency.  Rapid diagnosis is crucial with a CT/MRI.  Call a neurosurgeon ASAP!!! Surgical decompression is essential within ____ from onset of symptoms.
    8-12 hours
  46. What is the most common cause of bacterial meningitis??
    contamination of the puncture site by aerosolized mouth particles

    this is why MASKS are soooo important!
  47. What is the dominant organism found the in the mouth??
    viridans streptococcus
  48. What are s/s of meningitis??
    • neck stiffness
    • presents much like PDPH except not changes with position
    • high fever
    • altered mentation
  49. What is arachnoiditis??
    an infection of the arachnoid that is very rare (clumping of nerve roots causes chronic pain)

    more common when supplies were reused

    can also occur with intratheccal steroids being injected for chronic pain

    very hard to treat

    chronic inflammation leads to scar tissue
  50. What are risk factors for an epidural abscess??
    • back trauma
    • IV drug use
    • neurological surgical procedures
    • indwelling epidural catheters
  51. There are four stages of development with an epidural abscess...what are they??
    • 1. back and vertebral pain intensified by percussion
    • 2. progresses to nerve root and radicular pain (pain along a dermatone)
    • 3. motor, sensory and/or sphincter dysfunction
    • 4. paralysis and or paraplegia
  53. If you suspect an epidural abscess what should you do immediately??
    • 1. removed epidural cath
    • 2. send tip for cultures
    • 3. examine epidural site for s/s of infection
    • 4. send blood cultures
    • 5. culture any drainage
  54. What are some parts of the treatment of an epidural abscess??
    • 1. consult the neurologist
    • 2. abx coverage *normally staph
    • 3. MRI/CT
    • 4. possible decompression lamiectomy
  55. What are ways to prevent an epidural abscess??
    • 1. always use sterile technique
    • 2. if you suspect contamination STOP AND START OVER
    • 3. may need to removal cath if disconnected
    • 4. maintain a closed system
    • 5. use bacterial filter that comes with kit
    • 6. minimize cath manipulations
    • 7. removal cath when required or at least change the cath, filer and solution every 4 days
  56. How can epidural catheter shearing occur??
    by attempting to withdraw the epidural catheter through the epidural needle

    also take needle off first or the cath will shear

    remove the needle and cath as one unit if you need to remove the cath

    never jerk the cath..remove it steadily

    if difficulty is encountered with removal..have the patient changes positions to maximize the intervertebral space
  57. What should you do if the tip of the cath breaks off deep in the epidural space?? What about in the superficial space??
    leave it and observe for complications

    it needs to be surgically removed
  58. Cauda Equina Syndrome is associated with....
    spinal cath and 5% lidocaine

    appears in the peripheral nerve pattern and may be due to misdistribution of the hyperbaric lidocaine
  59. What is Cauda Equina Syndrome??
    a permanent complication

    associated with sphincter dysfunction, sensory and motor deficits and paresis

    lower motor dysfunction
  60. What are risk factors for cardiac arrest that occurs due to a neuraxil blockade???
    • baseline HR<60
    • ASA class I --- bc we overlook these ppl
    • Use of BB
    • sensory level >T6
    • Prolonged P-R interval