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Explain the clinical significance of the curvatures of the spinal canal for spinal and epidural anesthesia.
Each question is a level 2 APA heading Spinal and Epidural Lecture Objectives 1. Identify anatomy of the spinal column: vertebrae, sacrum, muscles, ligaments, spinal cord, meningeal layers, epidural, arachnoid and subarachnoid space. 2. Describe the different characteristic features of the spinous process and laminae of the thoracic and lumbar vertebrae and how they affect performance of block placement. 3. Describe and identify the ligaments that connect the spinous processes and laminae between vertebrae. 4. Explain the clinical significance of the curvatures of the spinal canal for spinal and epidural anesthesia. 5. Explain where nerves lie in the spinal column. Explain how this effects onset and density of block for spinal and epidural anesthesia. 6. Define dermatome. 7. Identify nerve innervation of body structures using a dermatome map. 8. Explain the mechanisms of action for spinal and epidural anesthesia. 9. Describe the nerve fibers blocked in spinal and epidural anesthesia and the order in which this occurs. 10. Explain differential sensory block. Describe how differential block is used clinically. 11. Describe the difference between sympathetic nerve block and sensory nerve block. 12. Describe the effect of spinal and epidural anesthesia on systemic vascular resistance, cardiac output, coronary blood flow, respiratory, gastrointestinal and renal system. 13. Apply guidelines for regional anesthesia in patients receiving antithrombotic or thrombolytic therapy from the American Society of Regional Anesthesia. 14. Create an anesthesia plan for placement of an epidural anesthetic: a. Preoperative – list common components to the preoperative assessment for an epidural anesthetic. Describe education for the patient regarding epidural anesthesia. b. Contraindications – list common indications and contraindications to epidural anesthesia. c. Risks and complications– describe risks to epidural anesthesia. d. Select proper dose of local anesthetic. e. Anatomy i. Describe the anatomy of the epidural space. ii. Identify structures within the epidural space. iii. Define the site of action of local anesthetics in the epidural space. f. Placement i. Describe landmarks used to determine the approximate level for placement. ii. Describe the tissue planes traversed as the needle is advanced toward the epidural space in the midline and in the paramedian approach. iii. Describe ways to determine the Touhy needle has reached the epidural space. iv. Explain how needle placement in the epidural space is confirmed. 1. Differentiate between loss of resistance and hanging drop technique. v. Identify markings on epidural catheter. Determine proper insertion depth of the epidural catheter. vi. Describe drugs, concentration and volume used for test dose. Describe the purpose of the test dose. vii. Describe delivery of the local anesthetic into the epidural space. viii. Describe ways to secure the epidural catheter. g. Additives – list the advantages and disadvantages of adding epinephrine, opioids, alpha 2, bicarbonate to epidural anesthetics. h. Complications – describe the signs and symptoms and management of complications associated with epidural anesthesia. i. LAST ii. Hematoma iii. POST-Dural Headache iv. TNS v. Cauda equina syndrome i. Complex Patients – describe management of patients with complex coexisting diseases and surgical history (chronic back pain, previous back surgery, aortic stenosis, coagulation abnormalities, infection). 15. Create an anesthesia plan for placement of a spinal anesthetic: a. Preoperative – list common components to the preoperative assessment for spinal anesthetic. Describe education for the patient regarding spinal anesthesia. b. Contraindications – list common indications and contraindications to spinal anesthesia. c. Risks and complications– describe risks to spinal anesthesia. d. Select proper dose of local anesthetic. e. Placement of spinal anesthesia: i. Describe landmarks used to determine the approximate level for placement. ii. Describe the tissue planes traversed as the needle is advanced toward the subarachnoid space in the midline and in the paramedian approach. iii. Describe ways to determine the spinal needle has reached the subarachnoid space. iv. Explain how spinal needle placement in the subarachnoid space is confirmed. v. Describe delivery of the local anesthetic into the intrathecal space. f. Additives – list the advantages and disadvantages of adding epinephrine, opioids, alpha 2, bicarbonate to spinal anesthetics. g. Complications describe the signs and symptoms and management of complications associated with spinal anesthesia. i. LAST ii. Hematoma iii. POST-Dural Headache iv. TNS v. Cauda equina syndrome h. Recovery – describe recovery of sensation and movement after spinal anesthesia. i. Complex Patients – describe management of patients with complex coexisting diseases and surgical history (chronic back pain, previous back surgery, aortic stenosis, coagulation abnormalities, infection). 16. Create an anesthesia plan for a combined spinal/epidural anesthetic. a. Discuss management of CSE. b. Discuss complications associated with CSE. 17. Explain use of the needles available for spinal and epidural anesthesia. a. Describe how spinal needs are classified. b. Describe characteristics of spinal and epidural needles. 18. Describe the mechanism of hypotension, bradycardia, respiratory depression, nausea and vomiting, urinary retention and shivering following spinal and epidural anesthesia. 19. Describe management of hypotension, bradycardia, respiratory depression, nausea and vomiting, urinary retention and shivering following spinal and epidural anesthesia. 20. Explain the mechanism of action of local anesthetics in the epidural and subarachnoid space. 21. Describe how baricty effects spinal and epidural anesthesia. 22. Explain the difference between hypobaric, isobaric and hyperbaric solutions. 23. Describe benefits and risks of local anesthetics used for spinal and epidural anesthesia. 24. Determine drug doses for spinal anesthetic used for various surgical procedures. 25. Determine drug doses for epidural anesthetic used for various surgical procedures.

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