WorksheetsRegional II
Total questions: 82
Worksheet time: 41mins
Select all the of the absolute contraindications for a Spinal or epidural
Patient Refusal
Severe Aortic Stenosis
Severe uncorrected Hypovolemia
Untreated Chronic Hypertension
What is the generalized acceptable platelet count to perform a spinal
90,000
100,000
35,000
50,000
Which statement regarding spinal disadvantages is false
Sympathetic blockade occurs 100% of the time
Intense motor blockade
Placing a spinal takes a long time
Surgeons complain that spinals take to long
The spinal cord ends at what level in children
L1
L2
L3
L4
Artery of Adamkiewics (Radicularis Magna) supplies what portion of the spinal cord
Posterior 2/3 of the spinal cord
Anterior 2/3 of the spinal cord
Posterior 1/3 of the spinal cord
Anterior 1/3 of the spinal cord
What is the principle site of action in spinal anesthesia
CSF fluid bathing the nerve
Dorsal nerve roots that have somatic and conduction properties
anterior nerve roots which prevents motor and autonomic function
Lamina X, central canal working from the inside out
What happens when there is an injury to the artery of Adamkiewics
Nothing; Circumferential arterial supplies the spine
Paraplegia; ischemia to the posterior 1/3 lower blood supply to the spine causes motor loss
Paraplegia; ischemia to the anterior lower 2/3 blood supply to the spine causes motor loss
Sensory loss; Patient usually have lower extremities sensation deficit
Mr. Jones just received spinal anesthesia by a SRNA for a TRUP procedure what level is the motor blockade if sensory loss is at T8? Sympathetic blockade is at what level?
Motor T6; Sympathetic T6
Motor T10; Sympathetic T8
Motor T9; Sympathetic T4
Motor T10; Sympathetic T6
If the patient loss sensation 2 cm superior to the umbilicus what level is the sensory spinal based on the dermatome man
T10
T9
T8
T11
What dermatome level are the hips located at?
L1
L2
L3
T12
What medication would you give first for a drop in blood pressure if the patient cannot feel their nipples
Epinephrine
Ephedrine
Vasopressin
Neosynephrine
A laboring patient that just received an epidural is feeling nauseous and dizzy, what would you do?
Give a fluid bolus
Give a pure alpha-1 agonist
Give a Beta-1 and alpha 1 agonist
Give an anti-emetic, and wait
How would you assess a L4-L5 motor block? How about a T6-T12 motor block?
Dorsiflexion; Lift shoulders off the bed
Plantar flexion; Lift shoulders off the bed
Raising on the knee; Lift shoulders off the bed
Dorsiflexion; raise knees
Select all the intervention utilized to prevent a Cardiovascular effect in a spinal
Atropine
Fluid bolus 10-20 ml/kg
Epinephrine 15-20 mcg bolus
Left uterine displacement if patient is pregnant
Trendelenburg after the spinal
Frank is 83 year old patient having a robotic prostatectomy, he has smoked from 63 years and has severe COPD; the surgeon is fast and requests a spinal prior to surgery, as the CRNA what do you do?
Perform the spinal at requested
Give half the dose anticipated
Discuss with the surgeon the risk of severe COPD and spinals and avoid the spinal
Discuss with the surgeon the risk of steep Trendelenburg and spinals and give it anyway
Which of the following statements about spinal anesthesia is false
Loss of control of the bladder function leads to urinary retention and distention of the bladder
Sympathetic outflow originates from T5-L1
Vagal tone dominance cause small contracted gut with active peristalsis
Hepatic blood flow increases with decrease MAP
Maria is taking Warfarin for her atrial fibrillation she is having a laparoscopic hysterectomy and requested a spinal to reduce the pain, she stopped her warfarin 3 days ago what do you do?
Check an INR only and if it less than 1.5 perform the spinal
Perform the spinal
Abort the procedure and ask the patient to come tomorrow and not take her warfarin
Give vitamin K and perform the spinal
What is the minimum number of days off of Plavix required to perform a spinal? What about Ticlopidine?
7days;14 days
7 days; 8 days
1 week; 20 days
5 days; 12 days
Dr. T is an orthopedic surgeon that gives intraoperative heparin how much time is need before administration of heparin if the patient has a spinal on board
60 minutes
120 minutes
45 minutes
30 minutes
A patient has an epidural catheter in place that has been in place for 16 hours and needs to be pulled by 24 hours per hospital policy. The patient received Lovenox just now what do you?
Follow hospital policy and pull the catheter at 24 hours
For patient safety wait and pull in 10 hours
For patient safety wait and pull in 12 hours
Pull it now and schedule a spinal hematoma surgery
What is the current consensus on adult neuraxial anesthesia of the asleep or awake patient?
Awake is more appropriate
Asleep is more appropriate
It does not matter
What is one critical pre-operative consent explanation needed? what type of monitors are required from neuraxial anesthesia
Back-up plan; SpO2 only
Back-up plan; All monitors in ASA standard V
Labs results; All monitors in ASA standard V
Risk and benefits; SpO2 only
Tuffier's line is what spinous process or interspace
L3; L3 L4 interspace
L4; L3 L4 interspace
L4; L4 L5 interspace
L5; L5 S1 interspace
Sitting position, lateral position with hip flexion facilitates what?
Narrowing of the Anterior spinous ligament
Widening of the interspinous ligament
Widening of the Ligamentum Flavum
Optimal view of the spinous process
Select all that apply for a midline approach spinal procedure
Palpation of the spinous process
Sterile gloves and sterile prep
Subcutaneous Local anesthetic skin wheal using a 20 gauge needle
Place needle in a slight caudal fashion
Advance through the layers until you reach the subarachnoid layer
Which is the muscle punctured in a paramedian approach
Paraspinous muscle
Psoas Major
Rhomboideous major muscle
Semispinalis
Anatomic features pertinent to the performance of nuraxial blockade include all Except:
In adults the spinal cord ends at L1-L2
The angulation of the spinous process of the thoracic vertebrae makes a paramedian approach preferable
In adults the dural sac ends at S2
The largest interspace in the vertebral column is L4-L5
How would an SRNA assess Sensory function after a spinal injection? what about sympathectomy?
Cannot test for either
Sharp needle small fast punctures; Alcohol swab
Blunt needle soft pokes; Cold alcohol swab against the test
Blunt needle soft pokes; Ice water poured down the back
Which is the sharpest spinal needle that has a higher probability of causing a post dural puncture headache (PDPH)
Quincke
Whitacre
Sprotte
Crawford
Bupivicaine has what onset time for a spinal?
3-5 minutes
15 minutes
30 minutes
10-12 minutes
Bupivicaine 0.5% plain has a specific gravity of 0.996 what does that mean?
It is isobaric
It is hyperbaric
It is hypobaric
It will be mixed with CSF making it Isobaric
Which has the longest duration of spinal Anesthesia
Tetracaine 1%
Bupivicaine 0.75%
Lidocaine 5%
Procaine 10%
Select of the following that are true about intrathecal Fentanyl
Dose is 15-25 mcg
Higher doses cause respiratory depression
Onset is 5 to 10 minutes
Duration is 5 to 6 hours
There is no itching effect with intrathecal
Fentanyl
What statement regarding intrathecal morphine is False
Most common used intrathecal opioid
onset time is 60 to 90 minutes
dose 1 to 5 mg
Provides profound analgesia for 18-27 hours
What are the most important factors to document after performing a spinal procedure. Select all that apply
No blood return upon injection
No parethesia noted prior to injection
Total volume infused with medication amount
Negative CSF swirl upon injection
Mrs. Williams is 70 year patient that fell at home and fractured her right hip. Where would you place her spinal and what baracity would you use of medication would you us
Right Lateral; Hyperbaric
Left Lateral; Hyperbaric
Sitting; Isobaric
Sitting; Hyperbaric
Mr. Baker requires a T 10 spinal for his procedure, he is 5'9" [5 feet 9 inches] how much volume would you give him?
1.45
1.015
1.03
0.58
How much volume would you give to Joanna who is 4'10" [4 feet 10 inches] for a T 4 block?
Cannot give local anesthetic
0.9
0.8
0.5
Select all that affect the level of blockade after a spinal
Age of the patient
Dosage of drug
Patient's height
CSF volume
Direction of the needle bevel
Cauda Equina Syndrome has all following symptoms Except
Sever pain in radicular pattern
Loss of sensation
Weakness in the legs
Bladder/ bowel/ sexual dysfunction
Circumoral numbness
Epidural Anesthesia has all of the following principles except
Ability to be performed over at the lumbar,thoracic, or cervical levels
Epidurals can be used for postoperative pain control or operative anesthesia
May be used as a single injection technique or with a catheter
Have a faster onset than spinals
Select all that are in the epidural space
Veins
Lymphatics
Segmental Arteries
CSF
Subdural space
Where does the epidural space start and end?
Base of the cranium to the base of the sacral sulcus
C 1 to the base of the sacral sulcus
C 6 to L 5
C 1 to S 3
Epidural Needles have a curved tip to do what? What is the distance from the tip to hub?
Push the ligamentum flavum; 11 cm
Push the dura mater; 11 cm
Push the ligamentum flavum; 9 cm
Push the dura mater; 10 cm
What is the appropriate test dose for an epidural
3 ml Lidocaine 1.5% 45 mg with 15 mcg epi
2 ml Lidocaine 1.5% 30 mg with 15 mcg of epi
4 ml Lidocaine 1.5% 60 mg with 15 mcg of epi
3 ml Lidocaine 1% 30 mg with 15 mcg of epi
If local anesthetic with epi is injected intravascularly what percentage will the HR and BP systolic rise?
10%
15%
20%
25%
Select all of the side effects of an intravascular injection of local anesthetic without epi
Tinnitus
Metallic taste
Circumorally numbness
Different feeling within the patient
Increased heart rate
How far is the epidural catheter inserted
1 to 2 cm
2 to 3 cm
3 to 5 cm
5 to 7 cm
Epidural anesthesia rule of thumb is what for dosing
1 to 2 ml per inch after 5 feet
1 to 2 ml per segment of block desired
2 to 3 ml per inch after 5 feet
2 to 4 ml per segment
What is the average distance from skin to epidural space in an average person? What about an Obese person?
4-6 cm; 8 cm
2-5 cm; 9cm
5-8 cm; 12 cm
1-2 cm; 5 cm
Which surgery does not match the sensory level block desired?
S2-S5: Hemorrhoids
L2-L3: Foot Surgery
T10: TURP/ Hip Surgery
T6- T7 Cesarean Section
Frank is a patient that is 6'7" [6 feet 7 inches] how volume is required to achieve a T4 block if the catheter is inserted at L4 L5 interspinous space
29 ml
24 ml
13 ml
12 ml
Which statement regarding epidural catheters is false
Always chart that the tip of catheter intact when removed
Visually inspect catheter prior to insertion
Pull a catheter back through the insertion needle
2 dashes equals 10 cm
Potential complication occur with epidural inserted include all of the following except
Possible parethesia encountered during needle placement
Apnea and phrenic nerve paralysis
Intercostal muscle paralysis
Mild drop in B/P and HR
Select all that apply with Epidural Blood Patch
Sterility must be maintain throughout the procedure
Autologous blood is injected into the epidural space
Blood will move in the cephalad direction so inject one or two interspace below
Injected blood will increase subarachnoid and epidural pressure and form a clot sealing the dural tear
30 cc is the maximum to be pushed in the epidural space
Which anatomical structure anchors the spine
Distal dural sac
Internal filum terminale
External filum terminale
Ligamentum flavum
Select all that apply with the CSF
30 and 80 ml in the spinal cord at given time
The pH of CSF is 7.32
There is 500 ml of CSF made daily
It is reabsorbed by arachnoid granulations along the sagittal sinus
CSF pressure is 30 to 40 cm H20
What is that major issue with two level technique
Tissue Trauma
Increased discomfort- 2 sticks
Epidural catheter laceration by the spinal needle
Inability to get CSF because of compression of the dural sac by the test dose
All of the following are utilization of caudal anesthesia except
Anal surgery, hemorrhoids
Surgery of vulva or vagina
Surgery scrotum
Abdominal surgery
At what age does the S4 and S5 sacral hiatus
12 years old
15 years old
14 years old
3 years old
What ligament is punctured during a caudal block
Sacral Coccygeal ligament
Internum filum terminale
Ligamentum flavum
Dural sac
How far should a touhy needle be inserted in a caudal block
1 to 3 cm
4 to 6 cm
3 to 4 cm
2 to 4 cm
True or false you should use chlorhexidine solution instead of povidone-iodine solutions due to increase potential infection
True
False
