Barry - Local Anesthetics and Regionals
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| show | (-) charges on interior of cell, (+) charges on the extracellular surface
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| What makes the cell polarized? | show 🗑
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| What propagates the nerve impulse along an axon? | show 🗑
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| show | It increases the nerves permeability for Na influx - which lowers the voltage difference until threshold potential occurs.
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| What does lowering the threshold potential do to the cell? | show 🗑
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| show | During repolarization.
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| Local MOA: | show 🗑
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| show | NO - the resting membrane potential is still negative
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| What are the 3 states of the membrane? | show 🗑
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| When do LA have the greatest affinity for Na channel activation? | show 🗑
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| show | 1)Axonal diameter (smaller more sensitive), 2)Degree of myelenation, 3)Conduction velocity (the more rapid firing nerves are more sensitive), 4)Relative location in nerve bundle (closer to the mantle [outside] of the nerve bundle more sensitive)
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| Chemistry of LA: | show 🗑
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| show | Either an ester or amide linkage.
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| show | And they carry a slightly (+) charge at physiologic pH.
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| show | By pseudocholinesterase - bi-product of some are PABA so if pts. are allergic it is to the PABA bi-product
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| show | Intrathecal injections rely on their absorption into the blood stream for metabolism - most often Tetracaine
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| show | By liver - decreases in function or blood flow will decrease metabolism.
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| What is Methemoglobinemia? | show 🗑
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| What causes Methemoglobinemia? | show 🗑
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| show | Methylene blue 1-2mg/kg of 1% soln over 5 minutes.
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| Lipid solubility correlates with... | show 🗑
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| Protein binding correlates with... | show 🗑
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| pKa correlates with... | show 🗑
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| show | the pH at which the specific drug is 50% in the ionized and 50% in the unionized state. The ratio varies with the pH of the environment.
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| show | Unionized. The closer the pKa is to physiological pH the higher the concentration of nonionized that will cross the cell membrane.
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| pKa of LA: | show 🗑
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| show | All LA are weak bases so they are more unionized in a basic environment, meaning they will work better. Infected areas are acidic so LA will not work as well due to more of the drug being in the ionized state.
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| List Ester locals: | show 🗑
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| List Amide locals: | show 🗑
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| Novocaine/procaine dose: | show 🗑
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| Nesacaine/Chloroprocaine dose: | show 🗑
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| show | Max: 3mg/kg DOA: 90m-6h
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| show | Max: 3mg/kg DOA: 30-60m
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| Lidocaine/xylocaine dose: | show 🗑
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| Mepivicaine/carbocaine dose: | show 🗑
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| show | Max: 3mg/kg DOA: 90-240m
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| show | Max: 2.5mg/kg Max with EPI: 3.2mg/kg DOA: 120-240m DOA with EPI: 180-420m
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| Etidocaine/duranest 1% dose: | show 🗑
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| Why is max dose with EPI higher? | show 🗑
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| Bier Block: | show 🗑
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| What supplies are needed for a Bier Block? | show 🗑
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| What is the purpose of using a double tourniquet for a Bier Block? | show 🗑
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| show | Always inflate upper portion prior to surgery. Use 250mmHg for upper ext. and 300-350mmHg for lower extremity - may need higher pressure for HTN
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| show | Minumum of 20 minutes - if less then have to let cuff down slowly to prevent LA toxicity. Maximum 1.5-2 hours.
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| show | Lidocaine 0.5% without EPI, 40-50cc = 200-250mg then remove IV.
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| Bier Block complications: | show 🗑
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| ***What are the s/s of LA toxicity? | show 🗑
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| show | O2 to raise the seizure threshold, ETT, hyperventilate (to decrease CO2 and decrease blood flow to brain), benzos, barbs, support CV collapse.
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| Which LA is the most carditoxic? | show 🗑
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| show | Digits, ankles, brachial plexus, lower extremities, penile.
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| show | NO - it can cause necrosis.
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| List structures you will go through with Epidurals: | show 🗑
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| What is the hanging drop method? | show 🗑
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| show | Use a touhy syringe with a few cc's air or preservative free saline. Slowly advance and tap on plunger in increments until there is a loss of resistance in epidural space.
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| How far do you insert epidural catheter? | show 🗑
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| show | 3cc's of 1.5% lidocaine with EPI 1/200K = Lido 45mg and EPI 15mcg.
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| show | To make sure you are not in the subarachnoid space or intravascular space.
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| What are ss if in IV space with test dose? | show 🗑
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| What are ss if in subarachnoid space? | show 🗑
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| show | No - always pull back 1st and then give test dose.
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| ***What is the dose per segment? | show 🗑
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| show | Between L2-L5. L4-L5 is at level of iliac crest - when advancing touhy will feel crunch of Ligamentum Flavum.
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| show | Chloroprocaine 2-3%, Lidocaine 1-2%, Mepivicaine 1-2%, Bupivicaine 0.25-0.75%, Ropivicaine 0.1-0.5%
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| What is a Caudal? | show 🗑
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| What drugs are used for Caudals? | show 🗑
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| show | 33 total - 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, 4 coccygeal.
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| show | Quinke (flat), Sprotte, whitacre (pencil point).
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| List the spinal medications: | show 🗑
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| Spinal med baracity: | show 🗑
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| show | At superior iliac crest.
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| T4: | show 🗑
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| show | Xiphoid process.
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| show | Umbilicus.
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| Absolute contraindications: | show 🗑
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| Relative contraindications: | show 🗑
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| show | Prior back sx, communication issues, complicated sx.
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| show | NS blockade resulting in vasodilation. Decreased CO and BP due to decreased venous return. Decreased HR if block higher than T4. Hypotension can cause nausea. Vasodilation can cause hypothermia.
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| show | Blockade of intercostal muscles.
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| Order "differential" of blockade: | show 🗑
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| What is the dermatome blockade? | show 🗑
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| show | Hypotension, N&V (treat hypotension), PDPH (post dura puncture headache or wet tap)
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| How do you treat PDPH? | show 🗑
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| show | Severe frontal and occipital HA, tinnitus, diplopia (light sensitivity) - worsens with sitting and standing.
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| How do you prevent PDPH? | show 🗑
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| show | Above T4 decreases HR, tingling of the fingers - C8=middle, C7=pointer, C6=thumbs
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| show | T1-4
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