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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
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).
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
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
ALWAYS MAKE SURE YOU HAVE DOCUMENTED LABS THAT YOU HAVE SEEN WITH YOUR OWN EYES.. DONT JUST GO BY WHAT SOMEONE TOLD YOU
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
At what INR is spinal an absolute contraindication??
if <1.5 proceed with caution and do a spinal rather than epidural at this number
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
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
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
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.
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.
Remember.. always have a DOCUMENTED LAB to back you up!
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.
If bleeding occurs during the block procedure, how long must you wait before the patient can be heparinized???
why is bleeding with a neuraxial procedure such a big deal??
bc you have no way to stop the bleeding
How long should you delay the administration of Lovenox if bleeding is experienced during a block??
delay at least 24 hours post procedure
If an epidural cath is in place, it should be removed at least ____ prior to the administration of the first dose of Lovenox.
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.
Fibrinolytic therapy should be d/c'ed for at least ____ prior to performing a block. What should you obtain for completing this block??
COMPLETE clotting studies need to be completed and documented as NORMAL prior to initiating your block (PT,PTT, INR,PFT,Plt Ct.)
If you discover your block in inadequate, what must you always be prepared for?
the conversion to a general anesthesia procedure
Urinary retention results from blockade of ____.
S2 - S4
leads to a decrease in bladder tone and inhibition of normal voiding reflex
Urinary catheterizes should be provided to all patients undergoing procedures > ___.
What anesthesia related drug can contribute to urinary retention?
Prolonged urinary retention may be a sign of serious __________.
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
What are s/s of a high neural block??
- numbness and tingling of the upper extremities
- nausea (precedes hypotension due to hypoperfusion of the chemoreceptor trigger zone)
- apnea (Resp. insufficiency)
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
What drug would you chose to give if you patient is hypotensive and bradycardic?
Phenylephrine can result in ____.
so give this to hypotensive patients who are tachy or normal HR
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
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
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
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
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
Which can cause more serious complications..a high spinal or a subdural injection???
can mimic a total spinal
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??
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
What patients are at an increased risk of postdural puncture headaches??
from book and previous lecture
women, preggo, young ppl
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
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
How do you treat a patient with PDPH?
- epidural blood patch
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
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)
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
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.
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!
What is the dominant organism found the in the mouth??
What are s/s of meningitis??
- neck stiffness
- presents much like PDPH except not changes with position
- high fever
- altered mentation
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
What are risk factors for an epidural abscess??
- back trauma
- IV drug use
- neurological surgical procedures
- indwelling epidural catheters
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
ANY PATIENT WITH BACK PAIN AND FEVER SHOULD RECEIVE FURTHER EVALUATION!!
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
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
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
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
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
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
What is Cauda Equina Syndrome??
a permanent complication
associated with sphincter dysfunction, sensory and motor deficits and paresis
lower motor dysfunction
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