Download 5. Epidural Complications

Diagnosis
Management
Miscellaneous
Anticoagulation
Drugs
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Diagnosis
100 Points
Following epidural insertion and
test dose, a patient experiences
tinnitus, circumoral numbness, a
metallic taste, disorientation,
seizures, hypotension,
dysrhythmias, and later cardiac
arrest.
Diagnosis
100 Points
What is systemic toxicity of local
anesthetics?
Diagnosis
200 Points
Following insertion of an epidural and test
dose, the patient complains of feeling very
short of breath, followed shortly by
dysphonia, upper extremity weakness,
respiratory depression, pupillary dilatation,
bradycardia, hypotension and loss of
consciousness.
Diagnosis
200 Points
What is inadvertent intrathecal
injection of local anesthetic with high
spinal?
Diagnosis
300 Points
28-year-old woman after spinal for C-section experiences a
headache that worsens with sitting or standing, improves with
lying down.
Diagnosis
300 Points
What is post-dural puncture headache?
Diagnosis
400 Points
19 yo healthy M POD 3 from
ACL rupture repair, had
received an epidural for postop anelgesia,
and tinzaparin q 24 hours
starting 6 hours post surgery.
Epidural removed POD 2 at 12
hours after tinzaparin dose.
POD 3 having progressive loss
of sensation in perianal area,
L1 to S5, muscle weakness in
lower extremities, loss of
bladder and bowel sphincter
function. What is the
diagnosis?
Diagnosis
400 Points
What is spinal epidural hematoma?
http://www.casesjournal.com/content/pdf/1757-1626-0002-0000006732.pdf
Diagnosis
500 Points
28-year-old woman who
presented with a severe
headache, numbness in
the upper extremities,
photophobia and
vomiting 3 days post
partum from a vaginal
delivery and an epidural
anaesthesia. What is
the diagnosis and way
to minimize such a
complication?
Diagnosis
500 Points
What is pneumocephalus and loss of
resistance using saline rather than air?
The mechanism involves inadvertent puncture of the dural layer during epidural
injections for treatment of radiculopathy or induction of epidural anaesthesia
with the introduction of air in the dural space. The headache of
pneumocephalus is usually immediate in onset, aggravated by any motion, and is
not relieved by lying down. As little as 2 ml of air can cause symptoms. The air
is usually reabsorbed after 2 days and the headache usually resolves within 5
days of the dural puncture. The development of pneumocephalus following
blood patches and epidural anaesthesia involving the placement of catheters has
also been reported. No randomised trials have studied the treatment of
pneumocephalus, but administration of 40–100% oxygen has been suggested.
Patients should be admitted for observation if symptoms are severe.
BMJ Case Reports Pneumocephalus after epidural injections
R B Nolan, D A Masneri, D Pesce
Management
100 Points
Cause and treatment of shivering after
neuraxial anesthesia
Management
100 Points
Shivering after neuraxial anesthesia is caused by sympathetic block induced
vasodilation with redistribution of heat from core to the periphery
Treatment is IV meperidine 25 mg Q5 min PRN
Other options include IV Clonidine 150 mcg, IV tramadol 3 mg/kg and IV
nefopam 10 mg
Management
200 Points
This procedure is the treatment of choice for
severe debilitating post-dural puncture
headaches. Describe it.
Management
200 Points
What is an epidural blood patch?
10 – 20 mL of the patient’s blood is injected into the
epidural space to form a clot over the dural defect.
Management
300 Points
If left untreated, how many days does it usually
take for a postdural puncture headache to
resolve?
Management
300 Points
What is 7-10 days?
Management
400 Points
Dosing of 20% intralipid emulsion for treatment of
systemic bupivacaine toxicity
Management
400 Points
IV bolus of 20% lipid emulsion 1.5 mL/kg of lean body mass given
over 1 minute, followed by infusion of 0.25 mL/kg until at least 10
mins following achievement of circulatory stability
If ciruculatory stability is not obtained within 5 minutes, administer a
second 1.5 mL/kg bolus, followed by infusion of 0.5 mL/kg/min
Maximum total cumulative dose of lipid is 10 mL/kg over 30 minutes
(Side note: even though propofol is formulated as a 10% lipid
emulsion, don’t use it for lipid rescue because the dose needed to treat
LA toxicity would result in massive hypotension)
Management
500 Points
What are conservative and non-invasive
treatments of post-dural puncture
headaches?
Management
500 Points
Conservative treatment with oral analgesics and caffeine.
Alternative to epidural blood patch is a transnasal sphenopalatine ganglion
block
Miscellaneous
100 Points
The anatomic structures that are
crossed when performing a spinal
block
Miscellaneous
100 Points
What is:
1.
Skin
2.
Subcutaneous tissue
3.
Supraspinous ligament
4.
Interspinous ligament
5.
Ligamentum flavum
6.
Dura mater
7.
Arachnoid membrane
Miscellaneous
200 Points
Four risk factors for increased risk of
KMultiPulmNod.jpg
post-dural puncture headache
Miscellaneous
200 Points
What is:
1. Women
2. Obese
3. Parturients
4. Younger patients
Miscellaneous
300 Points
Give five advantages of spinal
anesthesia over general anesthesia
Miscellaneous
300 Points
What is:
1. Endotracheal intubation avoided
2. Mental status can be followed
3. Pulmonary compromise is decreased
4. Decreased incidence of venous thromboembolic complications
5. In elective hip surgery, there is 20-30% reduction in blood loss
Miscellaneous
400 Points
Imaging modality of choice to
diagnose spinal epidural hematoma
Miscellaneous
400 Points
What is MRI?
Miscellaneous
500 Points
Treatment of spinal epidural
hematoma
Miscellaneous
500 Points
What is laminectomy and
neurosurgical evacuation of
hematoma?
Anticoagulation
100 Points
Latest gestational age at which
pregnant women taking vitamin K
antagonists should be transitioned to
heparin (UFH or LMWH)
Anticoagulation
100 Points
What is GA = 36 weeks?
Miscellaneous
200 Points
Minimum number of hours before induction of
labour or C-section at which pregnant women
taking LMWH should be transitioned to IV or
subcutaneous UFH
Anticoagulation
200 Points
What is 36 hours before induction of
labour or C-section?
Anticoagulation
300 Points
Number of hours before scheduled delivery at
which IV heparin should be discontinued
Anticoagulation
300 Points
What is 4-6 hours before scheduled delivery?
Anticoagulation
400 Points
How long should postpartum
prophylactic anticoagulation with
heparin (UFH or LMWH) be delayed
after 1) vaginal delivery and
2) C-section?
Anticoagulation
400 Points
What is:
1) 12 hours post vaginal
delivery and
2) 24 hours after C-section?
Anticoagulation
500 Points
Patients receiving UFH for more than
4 days should have this test prior to
neuraxial block and catheter removal.
What’s the test and why?
Anticoagulation
500 Points
What is platelet count and heparininduced thrombocytopenia?
Drugs
100 Points
In systemic LA toxicity, CNS toxicity symptoms typically
precede CVS toxicity so a patient may experience
cerebral symptoms without hemodynamic compromise.
Which local anesthetic drug is an exception to this
pattern: i.e. where cardiac toxicity may occur in the
absence of CNS toxicity?
Drugs
100 Points
What is bupivacaine toxicity?
Drugs
200 Points
Which opioid has local anesthetic effects?
Drugs
200 Points
What is meperidine?
Drugs
300 Points
3 drugs that can treat neuraxial opioid induced
pruritis and doses
Drugs
300 Points
What is
1. Naloxone (opioid antagonist) 40 to 160 mcg IV sometimes up to 400
mcg total?
2.
Naltrexone (opioid antagonist) 6 mg orally
3.
Nalbuphine (mixed opioid agonist-antagonist) 2.5 – 5 mg IV ?
FYI: Ondansetron prohylaxis does not decrease incidence of pruritis but
reduces severity of pruritis and the need for treatment of the pruritis
Mechanism of opioid-induced pruritiis is unclear but it is NOT caused by
histamine release so treatment with antihistamine e.g. diphenhydramine is
NOT indicated, but often used for its soporific effect
Drugs
400 Points
Drug and dose to treat uterine
hypertonus
Drugs
400 Points
What is IV nitroglycerin
60 – 90 mcg x 1 or 2 doses?
Drugs
500 Points
The duration of action of intrathecal
fentanyl vs intrathecal morphine
Drugs
500 Points
What is 6 hours vs 24 hours?
Causes
Bad things
Management
Miscellaneous
Drugs
Causes
Bad things
Management
Miscellaneous
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Causes
Bad things
Management
Miscellaneous
Drugs
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Causes?
200 Points
Gravid uterus compressing on the inferior vena cava and
aorta causing maternal hypotension and tachycardia,
decrease in uterine and placental blood flow and resulting
in fetal distress. What is this syndrome called?
Causes?
200 Points
What is aorto caval compression
syndrome?
Causes?
400 Points
Pain during first stage of labour is due to
uterine contractions and cervical dilation, is
visceral and is transmitted via sympathetic
fibres entering the spinal cord at these
levels.
Causes?
400 Points
What is T10 – L1?
Causes?
600 Points
During stage 2 of labour, pain is transmitted from the
pelvic floor, lower vagina and perineum, entering the
spinal cord at these levels
Causes?
600 Points
What is S2 to S4?
Causes?
800 Points
A 24 year old G2 P1 parturient is anesthetized for emergency C/S. On
emergence from GA, endotracheal tube is removed and the patient
becomes cyanotic. O2 is administered by PP bag mask ventilation.
High airway pressures are necessary to ventilate the paitent, and
wheezing is noted over both lung fields. The patient’s blood pressure
falls from 120/80 to 60/30 mHg and the heart rate increases from 105
to 180 beats per minute. The most likely cause is:
A. Venous air embolism
B. Amniotic fluid embolism
C. Mucous plug in trachea
D. Pneumothorax
E. Aspiration
Causes?
800 Points
What is E?
A 24 year old G2 P1 parturient is anesthetized for emergency C/S. On
emergence from GA, endotracheal tube is removed and the patient
becomes cyanotic. O2 is administered by PP bag mask ventilation.
High airway pressures are necessary to ventilate the patient, and
wheezing is noted over both lung fields. The patient’s blood pressure
falls from 120/80 to 60/30 mHg and the heart rate increases from 105
to 180 beats per minute. The most likely cause is:
A. Venous air embolism
B. Amniotic fluid embolism
C. Mucous plug in trachea
D. Pneumothorax
E. Aspiration (Wheezing over both lung fields and temporally fits
best)
Causes?
1000 Points
An epidural is placed in a 32 yo parturient receiving magnesium therapy for
preeclampsia. Five minutes after admin of the test dose, the bolus infusion is
interrupted because of a contraction. After the contraction subsides, a slow
epidural injection of the loading dose of bupivacaine and fentanyl is resumed.
At the same time, the patient complains of shortness of breath. She is panic
stricken and wrestles violently with the nurses who try to reassure her. She
repeats that she cannot breathe, becomes cyanotic and loses consciousness.
During resuscitation, blood is oozing from the IV sites and pink froth is noted
in the ETT. The most likely diagnosis is:
A. Amniotic fluid embolism
B. High Spinal
C. Intravascular bupivacaine injection
D. Magnesium overdose
E. Eeclampsia
Causes?
1000 Points
What is A?
An epidural is placed in a 32 yo parturient receiving magnesium therapy for
preeclampsia. Five minutes after admin of the test dose, the bolus infusion is
interrupted because of a contraction. After the contraction subsides, a slow epidural
injection of the loading dose of bupivacaine and fentanyl is resumed. At the same
time, the patient complains of shortness of breath. She is panic stricken and wrestles
violently with the nurses who try to reassure her. She repeats that she cannot breathe,
becomes cyanotic and loses consciousness. During resuscitation, blood is oozing from
the IV sites and pink froth is noted in the ETT. The most likely diagnosis is:
A. Amniotic fluid embolism
B. High Spinal (would be too weak to wrestle)
C. Intravascular bupivacaine injection (would have CNS symptoms and CV collapse)
D. Magnesium overdose (would usually be weak)
E. Eeclampsia (usually would not complain of SOB unless aspiration or pulmonary
edema)
Bad things
200 Points
HELLP syndrome stands for
Bad things
200 Points
Hemolytic Anemia, Elevated Liver
Enzymes, Low platelets
Bad things
400 Points
Four adverse effects of neuraxial opioids
Bad things
400 Points
Four adverse effects of neuraxial opioids
What is:
1. Pruritis
2. Nausea and vomiting
3. Respiratory depression
4. Urinary retention
Bad things
600 Points
Potential problems that may occur in patients receiving
magnesium sulfate such that they have the following serum
levels
1. 10 mEQ/L
2. 15 mEq/L
3. 25 mEq/L
(Remember therapeutic range = 4-8 mEq/L)
Bad things
600 Points
As plasma concentrations increase, patients develop
ECG changes with widening of the QRS complex and
prolonged QT interval
1. 10 mEQ/L  Deep tendon reflexes are absent
2. 15 mEq/L  Sinoatrial block and respiratory
paralysis
3. 25 mEq/L  Cardiac arrest
(Remember therapeutic range = 4-8 mEq/L)
Bad things
800 Points
While moving a parturient from the birthing room to the
OR for emergency C/section for prolapsed umbilical cord,
the parturient develops cough, wheezing stridor and
becomes cyanotic. The trachea is intubated and food is
noted in the pharynx. Approriate treatment in this patient
should consist of:
A. IV lidocaine to suppress the cough
B. Glucocorticoids
C. 100% oxygen and PEEP
D. Saline lavage
E. Sodium bicarbonate lavage
Bad things
800 Points
What is C?
While moving a parturient from the birthing room to
the
. OR for emergency C/section for prolapsed umbilical
cord, the parturient develops cough, wheezing stridor
and becomes cyanotic. The trachea is intubated and
food is noted in the pharynx. Approriate treatment in
this patient should consist of:
A. IV lidocaine to suppress the cough
B. Glucocorticoids
C. 100% oxygen and PEEP
D. Saline lavage
E. Sodium bicarbonate lavage
Bad things
1000 Points
Four Contraindications to using
vasoconstrictor additives (e.g. epinephrine)
with local anesthetic
Bad things
1000 Points
What is:
1. Unstable angina pectoris
2. Cardiac dysrhythmia
3. Hypertension
4. Peripheral nerve blocks to fingers, toes and penis
(areas without collateral blood flow) ?
Management
200 Points
Management of Total Spinal
Management
200 Points
What is:
1. Securing the airway
2. Mechanical ventilation
3. Sedation
4. Volume Infusion
5. Vasopressor Support
6. While waiting until spinal
anesthetic subsides
Management
400 Points
This local anesthetic ____ is
associated with the risk of
methemoglobinemia and can be
treated with IV _____
Management
400 Points
What is prilocaine and methylene blue?
Prilocaine is metabolized in the liver by O – toluidine, which
is capable of oxidizing hemoglobin to methemoglobin.
This condition may be treated by IV methylene blue (1-2
mg/kg)
Management
600 Points
Dose of magnesium sulfate in treatment of
preeclampsia
Management
600 Points
What is MgSO4 IV 4-6 g bolus
over 15 minutes followed by 1-3
g/hour
Management
800 Points
A 32 yo parturient with history of spinal fusion, severe
asthma and pregnancy-induced hypertension is brough to
the OR wheezing and needs emergency C-section under
GA for prolapsed umbilical cord. Which of the following
induction agents is most appropriate for this induction?
A. Sevoflurane
B. Midazolam
C. Ketamine
D. Thiopental
E. Propofol
Management
800 Points
What is E?
A 32 yo parturient with history of spinal fusion, severe
asthma and pregnancy-induced hypertension is brough to
the OR wheezing and needs emergency C-section under
GA for prolapsed umbilical cord. Which of the following
induction agents is most appropriate for this induction?
A. Sevoflurane (Not good for RSI in emergency case)
B. Midazolam (Slow onset not good for RSI)
C. Ketamine (good for asthma but bad for PIH)
D. Thiopental (can trigger histamine release, avoid in
asthma)
E. Propofol (good for asthma and because of the PIH)
Management
1000 Points
Aortocaval compression starts to
become significant in a normal
pregnancy at how many weeks EGA?
Management
1000 Points
What is GA = 20 weeks?
Aortocaval compression is typically not a problem until
about 20 weeks gestation when the uterus is large enough
to compress the aorta and vena cava when the patient
assumes the supine position
Miscellaneous
200 Points
Neuraxial blocks should not be performed until at least:
1. ___ hours after the last dose of prophylactic LMWH (e.g. enoxaparin 40
mg)
2. ___ hours after the last dose of therapeutic LMWH (e.g. enoxaparin1
mg/kg every 12 hours)
Miscellaneous
200 Points
What is
1.
12 hours after last dose of prophylactic
LMWH
2.
24 hours after last dose of therapeutic
LMWH?
Miscellaneous
400 Points
The weeks when the fetus is most
susceptible to the effects of teratogenic
agents
Miscellaneous
400 Points
What is Week 3-8 of gestation?
(This is when organogenesis mainly occurs)
Miscellaneous
600 Points
The components of the APGAR Score
Miscellaneous
600 Points
Miscellaneous
800 Points
Order the following list according to which
regional anesthetic is associated with greater
systemic vascular absorption of local anesthetic
(from most to least) :
• Epidural
• Intercostal nerve block
• Sciatic femoral
• Subcutaneous
• Caudal
• Brachial plexus
Miscellaneous
800 Points
What is
Intercostal nerve block (surrounded by rich vascular supply so this
type of block has the highest risk of systemic LA toxic levels)
> caudal > epidural > brachial plexus > sciatic femoral >
subcutaneous ?
Miscellaneous
1000 Points
5 absolute contraindications to spinal
anesthesia
Miscellaneous
1000 Points
What is:
1. Local infection at the puncture site
2. Bacteremia
3. Severe hypovolemia
4. Coagulopathy
5. Severe stenotic valvular lesion
6. Intracranial hypertension
Relative contraindications:
1. Progressive degenerative (demyelinating) neurologic
disease e.g. multiple sclerosis
2. Low back pain
3. Sepsis
Drugs
200 Points
This drug is associated with increased
risk of transient neurologic syndrome
when used for spinal anesthetic
Drugs
200 Points
What is lidocaine?
Drugs
400 Points
Magnesium sulfate increases a
patient’s sensitivity to this group of
drugs
Drugs
400 Points
What are muscle relaxants?
Drugs
600 Points
Magnesium sulfate may produce any of the following
effects EXCEPT:
A. Sedation
B. Respiratory paralysis
C. Inhibition of acetylcholine release at the nyoneural
junction
D. Antagonism of alpha-adrenergic agonists
E. Stimulation of NMDA receptors
Drugs
600 Points
What is E?
Magnesium sulfate may produce any of the following
effects EXCEPT:
A. Sedation
B. Respiratory paralysis
C. Inhibition of acetylcholine release at the nyoneural
junction
D. Antagonism of alpha-adrenergic agonists
E. Stimulation of NMDA receptors
MgSO4 acts as antagonist at the NMDA receptros;
however, clinically labor analgesia is minimal
Drugs
800 Points
Drugs useful in the treatment of uterine atony in an
asthmatic with severe preeclampsia include:
A. Oxytocin, ergonovine, and 15-methyl prostaglandin F2a
B. Oxytocin and 15-methyl prostaglandin F2a
C. Oxytocin and ergonovine
D. 15-methyl prostaglandin F2a only
E. Oxytocin only
Drugs
800 Points
Drugs useful in the treatment of uterine atony in an
asthmatic with severe preeclampsia include:
A. Oxytocin, ergonovine, and 15-methyl prostaglandin F2a
B. Oxytocin and 15-methyl prostaglandin F2a
C. Oxytocin and ergonovine
D. 15-methyl prostaglandin F2a only
E. Oxytocin only
15-methyl prostaglandin F2a (carboprost, Hemabate) may
cause significant bronchopasm
Ergonovine have been associated with bronchospasm (rarely)
and may not be appropriate in asthmatics. It is also
contraindicated in hypertension, preeclampsia, PVD, and IHD.
Drugs
1000 Points
What determines:
1. Local anesthetic potency
2. Duration of action of local anesthetics
3. Local anesthetic onset time
Drugs
1000 Points
1.
2.
3.
Local anesthetic potency = More lipid soluble  more
potent
Duration of action of local anesthetics = More protein
binding  longer duration of action (also less potent
vasodilator  decreased absorption and metabolism of
drug  longer clinical blockade)
Local anesthetic onset time = closer the pKa of the LA is
to tissue pH, the more rapid onset time. LA are weak
bases, so if pKa is near physiologic pH, more molecules
will be in an unionized form.
Take a deep breath…
Final Jeopardy
Bad Things
Final Jeopardy
List fifteen potential adverse effects
or complications of neuraxial
analgesia
Final Jeopardy
What is:
1. Systemic local anesthetic
toxicity
2. Spinal epidural hematoma
3. Pneumocephalus
4. Allergic reactions e.g. to
local anesthetics
5. High spinal
6. Hypotension
7. Inadequate or failed block
8. Respiratory Depression
9. Nausea and vomitting
10. Pruritis
11. Intrapartum fever
12. Fetal bradycardia
13. Post dural puncture
headache
14. Associated with longer
second stage (about 14 min
longer)
15. Urinary retention
16. Shivering
17. Infection
18. Postpartum neuropathy
Congratulations!
The Daily Double
The Daily Double
The Daily Double