Spinal and Epidural Anesthesia
Thomas Halaszynski
1. A spinal neuraxial anesthetic was given 20 minutes earlier to a 28-year-old G3P2 parturient scheduled for repeat cesarean section. Alcohol swab exam revealed that she has lost temperature sensation up to T2 level. At what level do you anticipate the block will reach to provide adequate pain control?
A. T2
B. T3
C. T4
D. T5
2. You have just administered a bolus of 2% lidocaine (25 mL) through an epidural catheter that has been working well for labor analgesia in preparation for emergency cesarean section for fetal distress in an otherwise-healthy 35-year-old woman. Shortly after administration of lidocaine, the patient complains of nausea, and you notice that her heart rate has decreased from 99 to 38 bpm. The most likely cause is
A. Anaphylactic reaction to lidocaine
B. Pneumothorax
C. Epidural level is higher than T4
D. Amniotic fluid embolus
3. Contraindication(s) for neuraxial blockade include(s)
A. Severe aortic stenosis
B. Severe bleeding tendency
C. Existing severe hypotension
D. All of the above
4. During epidural placement using a midline approach, the epidural needle penetrates all the following anatomical layers, except
A. Ligamentum flavum
B. Subarachnoid membrane
C. Supraspinous ligament
D. Intraspinous ligament
5. Major benefits of a neuraxial block in a Whipple procedure include all the following, except
A. Decreases the incidence of atelectasis
B. Leads to earlier return of GI function
C. Decreases the risk of urinary retention
D. Reduces the risk of pulmonary embolism or deep-vein thrombosis
6. The correct statement for human neuraxial anatomy is
A. Adult spinal cord ends at L2
B. Spinal cord in children ends at L3
C. The dural sac and subarachnoid space in adults end at S1
D. The dural sac and subarachnoid space in children end at S2
7. Blood supply to the human spinal cord includes all of the following, except
A. Blood supply to the spinal cord is from a single anterior spinal artery and two posterior spinal arteries
B. The anterior spinal artery supplies the anterior two-thirds of the spinal cord, and the posterior spinal arteries supply the posterior one-third
C. Anterior spinal artery originates from the vertebral artery
D. Posterior spinal artery originates from the posterior cerebral artery
8. The principal site of action of local anesthetics placed into the epidural space is the
A. Spinal cord
B. Nerve roots
C. Epidural space
D. Subarachnoid space
9. Lidocaine and epinephrine are commonly used together when testing epidural anesthesia because
A. Lidocaine injection (3 mL of 1.5%) intravascularly will induce local anesthetic toxicity such as perioral numbness
B. Intrathecal injection of epinephrine will result in a high spinal
C. Intrathecal injection of lidocaine can cause a low-level spinal anesthesia with some degree of motor block
D. Intravascular injection of epinephrine (typically 15 μg/3 mL) can cause hypertension more than tachycardia
10. As an adjuvant in epidural anesthesia, epinephrine can
A. Prolong duration of blockade
B. Improve the quality of blockade
C. Decrease the peak plasma levels of local anesthetic concentration
D. All of above
11. Factors that can affect the level of an epidural anesthetic include
A. Patient weight, amount of local anesthetic injected, patient position
B. Patient height, amount of local anesthetic injected, patient position
C. Patient age, amount of local anesthetic injected, patient position
D. B and C
12. Addition of sodium bicarbonate to epidural local anesthetics may accelerate the onset of blockade with all of the local anesthetics, except
A. Lidocaine
B. Chloroprocaine
C. Mepivacaine
D. Bupivacaine
13. Factors influencing the level of spinal anesthesia achieved include all of the following, except
A. Baricity of anesthetic solution
B. Patient age
C. Volume of anesthetic solution injected
D. Patient gender
14. All of the following factors may influence the spinal level achieved during spinal anesthesia, except
A. Drug dose
B. Needle direction
C. Patient position at the time and immediately following injection
D. Patient weight
15. Complications from neuraxial blockade may include all of the following, except
A. Radiculopathy
B. Anterior spinal artery syndrome
C. Arachnoiditis
D. Constipation
16. Neuraxial block complications using local anesthetics alone include all of the following, except
A. Post–dural puncture headache
B. Urinary retention
C. Postoperative cognitive dysfunction
D. High spinal anesthesia
17. Spinal anesthesia was performed on a 25-year-old healthy male for ureter stent placement. A total of 1.5 mL of 5% preservative-free lidocaine in 7.5% dextrose was injected intrathecally after being mixed with CSF. There was evidence of free CSF flow before and after injection. The surgery was performed in the lithotomy position and was uneventful, but the patient complained of severe buttock pain in the post–anesthesia care unit. A neuro exam was negative for sensory and motor deficits. The most likely diagnosis is
A. Spinal hematoma
B. Spinal abscess
C. Transient neurological symptoms
D. Radiculopathy
18. You are consulted as to when a patient would be an appropriate candidate for a neuraxial block following administration of the following anticoagulant medications (patient does not have any other coagulopathies, and does not take other medications that could influence coagulation). The most correct statement is
A. Last dose of ticlopidine (Ticlid) 7 days ago
B. Last dose of clopidogrel (Plavix) this morning
C. Last dose of abciximab (ReoPro) 24 hours ago
D. Last dose of eptifibatide (Integrilin) 12 hours ago
19. You performed an epidural anesthetic for an elective open–abdominal aneurysm repair. You are asked to advise the surgeon when it would be considered safe to administer intraoperative intravenous heparin:
A. Not at all
B. One hour after epidural placement
C. Two hours after epidural placement
D. Four hours after epidural placement
20. A higher-than-expected spinal level achieved or greater dermatomal spread of local anesthetic can be associated with all of the following clinical situations, except
A. Pregnancy
B. Ascites
C. Elderly
D. Female gender
21. Commonly used spinal anesthesia adjuvants include all the following, except
A. Morphine
B. Clonidine
C. Dexmedetomidine
D. Ephedrine
22. A 75-year-old female with ovarian cancer is scheduled for total abdominal hysterectomy/bilateral salpingo oophorectomy and tumor debulking. A thoracic epidural anesthesia was performed using a test dose of 1.5% lidocaine with 1:200,000 epinephrine injected through the epidural Tuohy needle that resulted in no evidence of adverse sequelae. An epidural catheter was then threaded through the needle followed by evidence of negative aspiration through the catheter. A total of 10 mL 0.5% bupivacaine was administered through the epidural catheter. Thirty seconds later, the patient became agitated and complained of lightheadedness, tinnitus, and feeling faint, but still able to move all of her extremities. Her BP decreased from 150/70 to 100/45 mm Hg and her HR decreased from 85 to 55 bpm. The patient maintained spontaneous breathing throughout with an oxygen saturation (SpO2) of 95%. The most likely diagnosis is
A. Local anesthetic systemic toxicity (LAST)
B. High epidural anesthesia
C. Total spinal anesthesia
D. Anaphylactic reaction
23. All of the following local anesthetic systemic toxicity (LAST) treatment measures should be performed when caring for a patient who may be experiencing toxicity, except
A. Stop epidural medication administration
B. Support the airway with 100% oxygen
C. Administer intravenous epinephrine according to ACLS protocols
D. Administer an intralipid bolus and continuous infusion
24. You have just placed a lumbar epidural for labor analgesia at L3–L4 interspace in a 34-year-old G2P1 woman of 39 weeks’ gestation. The patient is 6-feet tall and weighs 300 pounds. Two hours later, you are called for an emergency cesarean section on the woman. The minimum amount of 2% lidocaine you would need to administer through the epidural catheter in order to achieve a T4 level is
A. 5 mL
B. 10 mL
C. 20 mL
D. 30 mL
25. The correct statement regarding caudal anesthesia is
A. Caudal anesthesia is essentially sacral epidural anesthesia
B. Caudal anesthesia can only be performed in pediatric population
C. A caudal anesthesia catheter should be positioned without penetrating the sacrococcygeal ligament
D. The younger the child, the less likely you are to experience an intrathecal injection
26. You just placed a thoracic epidural in a morbidly obese female (5’1” and 350 lb). You quickly administer a total of 20 mL 0.5% bupivacaine through the epidural catheter. As you reposition the patient from the sitting to the supine position, the patient complains of shortness of breath, bilateral arm weakness, and nausea. Her HR has decreased from a baseline of 98 to 41 bpm, and her systolic blood pressure has decreased from a baseline of 140s to 70s mm Hg. The most likely cause is
A. Accidental intravascular injection of local anesthetic
B. Local anesthetic systemic toxicity
C. A high epidural block
D. Anaphylactic reaction to local anesthetic or latex
27. The most likely reason for dyspnea in a patient experiencing the effects of a high neuraxial blockade is
A. Phrenic nerve palsy when the neuraxial level reaches T3–T5
B. Patient is experiencing an anxiety attack
C. Medullary hypoperfusion
D. Congestive heart failure
28. In the situation of a high spinal anesthetic, which of the following drug is pharmacodynamically considered the least useful in controlling hypotension
A. Ephedrine
B. Atropine
C. Phenylephrine
D. Epinephrine
29. During performance of lumbar epidural anesthesia for labor analgesia, you experience free-flowing cerebrospinal fluid (CSF) from the advancing 17G Tuohy epidural needle. The epidural needle is removed and a second attempt is successfully performed with an epidural catheter placed at a different level. Which of the following you would not recommend for the patient to practice in the next 72 hours?
A. Bed rest
B. Fluid restriction
C. Increase caffeine intake
D. Continue with daily stool softener
30. You are consulted by an emergency room (ER) physician to evaluate a patient experiencing a severe and bilateral retro-orbital headache, described as constant, along with diplopia. The ER physician also indicated that the patient presented to the ER 2 days prior with fever, chills, and photophobia when a diagnostic lumbar puncture was performed with a 20G needle. The CSF study proved negative for meningitis, but now the patient has returned to the ER with complaints of a severe headache that has failed therapies of bed rest, caffeine, nonsteroidal anti-inflammatory drugs, and increased fluid intake. The next method of treatment you would suggest is
A. Repeat the CSF study as one set of negative results is not definitive
B. Recommend opioids for treatment of the headache
C. Recommend performing an epidural blood patch
D. Continue with conservative therapy as it will eventually prevail
31. Incorrect statement regarding neuraxial blockade is
A. Dermatome level of anesthesia achieved with a spinal anesthetic is often more predictable than following an epidural blockade
B. Spinal anesthesia can more rapidly and consistently produce denser motor blockade than epidural anesthesia
C. Local anesthetics administered during epidural anesthesia are typically more volume-dependent, and during spinal anesthesia are more concentration-dependent
D. Thoracic epidural anesthesia has an increased risk of urinary retention compared to lumbar epidural anesthesia when the same volume of local anesthetic is administered
32. Following performance of spinal anesthesia at the L4–L5 level with 3 mL of 5% lidocaine, you suspect a potential injury to the conus medullaris. Which of the following symptoms is least likely to be associated with cauda equina syndrome?
A. Urinary incontinence
B. Saddle anesthesia
C. Quadriceps weakness
D. Biceps femoris weakness
33. You are called to see a 76-year-old female who had a L3–L4 lumbar epidural placed 3 days prior for postoperative analgesia for a colectomy. The epidural placement was traumatic on the first attempt (at L4–L5 level) with evidence of positive blood aspiration. The patient is now complaining of new onset back pain with radiation to the right lower extremity and right knee weakness that was confirmed by physical exam. The most likely diagnosis and optimal management is
A. Breakthrough pain in a patient who is confused, treat with additional pain medications
B. Stat MRI of the back to rule out neuraxial hematoma
C. Surgical complication, consult orthopedics
D. Symptomatic spinal stenosis, consult neurology for suggestions
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