General, Spinal, blocks, oh my 411 please

[tsm007]

I work on an orthopedic floor and am still feeling inadequate understanding the different anesthesia used and the implications for me as a nurse taking care of a pt the first 24 hours after surgery. We use generals, spinals, and intrethecals on our floor and then they've been using an adductor?? block. Don't understand exactly what that means. Honest I don't think all the other nurses really do either. I know generals they are put under and have some type of airway. Intrathecals I know that they're vitals are closely monitored for 24 hours and narcotic administration is discouraged. What I don't understand is how to know when blocks should wear off? Implications for pain management regarding the different anesthesia and implications on assessment findings I should/or should not expect from one anesthesia versus another. At the moment I kind of assess everyone the same, watch vitals closely, neurovascular checks, and address pain as it is reported. I'd like to be able to skim the post op anesthesia report if I don't get details in report and have a better clue what the info in thier reports means to me in caring for the patient. Mostly pain management implications. Also we have been using Exparel recently and the other nurses will say they used an abductor/adductor (sorry I'd have to get a chart open) block. From what I can tell from reading that has nothing to do with anything except the location of the block? I think what they should be sharing is the medication in the block because I would think one medication would be different than another. I also don't really understand why one is better than an other, why they choose one over another other than maybe pt history, but not got a firm understanding on this. Just feeling very inadequate in this area and keep trying to read on this, but just not finding great resources to answer the questions I have. Any links, info, books, podcasts, etc or just your personal two cents would be greatly appreciated.

[tsm007]

Intrathecal and Spinal are two different terms to say the same thing. Intrathecal means they are injecting the local (or whatever) into the arachnoid space which lies right on top of the pia mater. If you went deeper than that you'd be in the spinal cord, causing damage. When people say "spinal" that's the space they are injecting the meds.

Maybe you're trying to define the difference between spinal and epidural? The dura lies on top of the arachnoid space where we mentioned injecting "spinal" anesthesia. If you go one layer further out from the dura you enter this larger space called the epidural space. It's sandwiched posteriorly by the ligamentum flavum (named after that rapper Flava Flav I think) and this space is where and an epidural catheter is threaded and dosed. I've been told those are allowed to stay in for 24-48 hours for prolonged pain relief. Don't ask me about baracity and all that because I'll tell you just head on to CRNA school.

Just did a case yesterday where we had a total knee arthroscopy and femoral nerve block was done. The surgeon didn't want any further block done beyond that because he likes getting his patients up moving post op quickly. General anesthesia was used for the procedure. Ropivacaine was the local of choice. Do I remember the PKA, no, probably not.

Okay, I *think* I may have found the problem. I think the nurses I work with may just not be using precise terminology and that's why I am confused. Maybe???

I found this article

Spinal anesthesia should be performed using only local anesthetics, as intrathecal opioids increase the risk of urinary retention, pruritus, and respiratory depression19 unless low doses (less than 200 µg) are used, and may not have superior analgesic efficacy compared with LIA in TKA

I think what they may be referring to is intrathecal OPIOIDS vs local anesthetic being used in the spinal. I think. I'm going to do some chart digging in the next few weeks but I think this is why I am seeing some people having "spinals" in report, but not on "intrathecal" precautions.

[BigPappaCRNA]

Intrathecal generally means the use of Duramorph injected, with or without local anesthetics. If they receive Duramorph (aka preservative free morphine) placed intrathecally, than they are on respiratory precautions, generally for 24 hours because the Duramorph can last that long. The initial analgesia from the Duramorph takes place at the level of the spinal cord, and on the narcotic receptors in the substantia gelatinosa in the posterior horn. Slowly, over hours, the Duramorph in the CSF works its way cephalad, and begins to enter the CSF in the brain, and bathes the periaqueductal gray in the walls of the ventricles, and this is where its later, delayed effect takes place. If a spinal is used for the procedure, but there is no long acting narcotic administered, only local, than you would not need to worry at all about the the long term, delayed effects.

[Julius Seizure]

Going to keep reading. I am big on understanding why things happen and most of the nurses I work with don't seem to care about the why of things. Understanding pharmacology, mechanism of action, and pathophysiology just puts the pieces together better for me. Thanks for the info and appreciate the comments.

Good for you for wanting to understand why we do the interventions that we do. I want a nurse like you when I am a patient.

[tsm007]

Intrathecal generally means the use of Duramorph injected, with or without local anesthetics. If they receive Duramorph (aka preservative free morphine) placed intrathecally, than they are on respiratory precautions, generally for 24 hours because the Duramorph can last that long. The initial analgesia from the Duramorph takes place at the level of the spinal cord, and on the narcotic receptors in the substantia gelatinosa in the posterior horn. Slowly, over hours, the Duramorph in the CSF works its way cephalad, and begins to enter the CSF in the brain, and bathes the periaqueductal gray in the walls of the ventricles, and this is where its later, delayed effect takes place. If a spinal is used for the procedure, but there is no long acting narcotic administered, only local, than you would not need to worry at all about the the long term, delayed effects.

This! I want to thank all of you who responded. I have a much, much better understanding now.