Flashcards in 3B: Morbidly Obese Patients Deck (57):
Morbid obesity is associated with ___x increase in mortality.
2 - 12x
Larger babies born to obese mothers may be more at risk for _____(2), often as a consequence of shoulder dystocia.
birth trauma and asphyxia
This often restricts the ROM of the neck leading to difficulty during mask ventilation, laryngoscopy and intubation.
Fat pads on the back of the shoulder
Cardiac output increase in:
1. Normal pregnancy
1. 35 - 45%
2. Double (70 - 90%)
___ and ___ expand in proportion to increased mass of fat tissue that must be perfused.
Blood volume and cardiac output
When does aortocaval compression severely reduce cardiac output and placental perfusion?
second half of pregnancy
1. ___ increases in proportion to the increase in cardiac output and total blood volume.
2. It can occur and may be position dependent.
1. Pulmonary blood volume
2. Pulmonary hypertension
In the supine position, there is ___% increase in oxygen consumption and ___% increase in PCWP.
11% ....... 30%
Primary therapy for patients with increased pulmonary blood volume, pulmonary hypertension (fluid overload)
1. Excess body weight requires increased energy expenditure proportionate to the increase in ___ (2)
2. Increased energy expenditure increases ____ (2)
3. Oxygen and CO2 production double as ___ doubles.
1. body mass and surface area
2. oxygen consumption and CO2 production.
3. weight doubles
1. If patient is not for CS and is having trouble breathing, you can manage this by
2. If patient is for C/S?
1. lowering epidural to T10 level (contractions)
2. T4 level
___ may represent a more efficient breathing pattern than large TV.
frequent shallow respirations (these patients conserve energy by decreasing TV)
Vent setting in Obese pregnant patients.
Pressure control to prevent barotrauma
This is an indication of acid reflux.
1. This may be used to assess the adequacy of maternal oxygenation.
2. Used to assess maternal ventilation.
1. pulse ox
Anesthesia for vaginal delivery:
1. T/F: Oxygen throughout labor to prevent hypoxemia and pulse ox
2. T/F: Insertion of epidural catheter early in labor due to increased incidence of CS.
3. T/F: You may give IV (or spinal) opioid before inserting a difficult epidural.
Epidural catheter should be inserted to a distance of ___
Margin of safety in the obese parturient is very much reduced. ___ (4) can develop with great rapidity.
hypertension, hypotension, acidosis, hypoxemia
Studies have reported a 20% incidence of failed epidural analgesia in morbidly obese patients. This due to (2)
1. increased depth of the epidural space
2. Failure to identify the epidural space.
This is the preferred position when inserting epidural.
sitting. (less distance from skin to epidural space)
During CS, you may be asked to participate in cephalic retraction of the panicles. Be aware that this can lead to (2)
hypotension and fetal compromise
This means that the trachea cannot be intubated under direct vision despite optimal head and neck positioning, multiple attempts by different laryngoscopists, etc.
This is used as an intubation conduit.
Management for patients who cannot be intubated but can be ventilated by Mask with Fetal distress present (3)
1. Awaken the patient
2. Cricothyrotomy or tracheostomy
3. Continue mask ventilation with cricoid
Management for patients who cannot be intubated or ventilated by Mask
2. Jet ventilation
3. Emergent cricothyrotomy or tracheostomy
Management for non-emergent, difficult airway (2)
1. Intubate awake
2. Regional anesthesia
2 things to assess in managing a pregnant patient who has airway difficulty.
1. Can the mom be ventilated?
2. Is the baby in distress?
If the airway management is anticipated to be difficult, a safe option is to
secure the airway with ETT while the patient is awake.
Drug used for transtracheal block.
5 cc of Lidocaine 2%
1. This is the most common first-trimester procedure.
2. This is the most frequent procedure during the remainder of the pregnancy.
Regional anesthesia should be decreased 25 - 30% during any stage of pregnancy lest an excessively high level of anesthesia occur.
Induction and emergence from anesthesia is more rapid because of ____(3)
1. increased ventilation
2. Decreased FRC
3. Decreased anesthetic requirements.
1. Elective surgery should not be performed, especially in the first trimester during the period of ____.
2. This is the optimal time to perform surgery because risk of preterm labor is lowest.
2. 2nd tri
___ may be more common also due to increased steroid levels of pregnancy may suppress the normal inflammatory response and prevent the "walling off" of the appendix by the momentum.
One of the major concerns regarding the use of N20 for surgery during pregnancy relates to the adverse effects of N20 on the DNA synthesis. This is caused by the ____. This can continue for up to 72 Hrs after exposure.
Vit B12 inactivation
Surgery in OB:
1. When possible, local or regional should be performed. However, this type of block should be avoided due to risk of fetal bradycardia.
2. Continuous fetal heart monitoring should be employed after the _____ weeks gestation
1. Paracervical block
2. 16th week
1. To prevent accidental puncture (during lap), most surgeons suggest using the ____ rather than the verse needle to obtain access to the abdominal cavity.
2. Adequate muscle relaxation should be provided and insufflation limited so that intra-abdominal pressure is kept low and does not exceed ___.
1. Open Hanson Technique
2. 15 mmHg
These (3) significantly increase the risk of DVT and thromboembolism during laparoscopy.
1. Increased fibrinogen
2. Increased CF 7 and 12
3. Decreased venous return
1. How is MH inherited?
2. T/F: Small quantities of anectine cross the placenta
1. Autosomal dominant
1. This drug increases halothane-induced muscle contractors in vitro.
2. This drug can cause an increase in temperature, so avoid to keep from having diagnostic dilemma.
3. If uterine relaxation is needed, give ____. This is easily reversible with oxytocin if needed.
Apgar scoring (5) (Max score 10)
When do you check the Apgar score?
at birth and after 5 minutes.
1. The sum of volumes of the brain is constant.
2. What are these volumes (3)
1. Monroe-Kellie Doctrine
2. CSF, blood, brain
1. The consequence of a decrease in CSF volume is compensatory increase in ____.
2. This is responsible for the headache
3. Vasoconstrictors used to manage PDPH (3)
1. blood volume
3. Caffeine, theophylline, sumtriptan
These factors are inversely proportional to the incidence of PDPH (2)
Age and operator skill
1. Optimum spinal needle sizes.
2. for purposes of CSF aspiration and CSF pressure measurement, what spinal needle gauge are thought to be the smallest practical needles?
3. T/F: When an unintentional dural puncture is made with a G16 or 18 epidural needle, up to 75 - 80% of the subjects will report symptoms related to PDPH.
1. 25, 26, 27
Difference between PDPH vs. SDH
SDH: pain is constant. PDPH can be relieved by supine position
The production rate of CSF in adults is_____which results in complete turnover of the CSF 3 – 4 x per day.
The purpose of ____ is to ensure that the rate of CSF production exceeds loss through the dura puncture site, thus restoring the CSF pressure to normal.
Prophylactic measure to prevent PDPH. This is done prior to removal of epidural catheter.
Saline injection 40 - 50 ml
This is the gold standard therapy for PDPH.
Blood patch (10 - 20 ml of blood)
What do you need to check before you do blood patch?
afebrile, WBC and platelet WNL
1. Increasing CSF pressure may result in _____
2. EBP can result in ____x increase in lumbar CSF pressures.
1. reflex cerebral vasoconstriction
Suggested that failure is more likely if EBP is performed within 24 H of dura puncture
What do you need to monitor when performing blood patch? (3)
1. Bradycardia (due to cushing's reflex: bradycardia due to increased ICP)
1. This improves the likelihood of EBP success.
2. Patients should avoid these post EBP
3. What to Rx
1. BEdrest 2H
2. Valsalva and heavy lifting (baby)
3. Stool softener and or cough suppressant