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Advanced Principles A (Spring 2024) > Anesthesia For Operative Delivery (Exam III) > Flashcards

Anesthesia For Operative Delivery (Exam III) Flashcards

1
Q

What is Macrosomia?

A

Fetus/Newborn w/ excessive birth weight

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2
Q

What is TOLAC?

A

Trial of Labor after Cesarean

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3
Q

What is VBAC?

A

Vaginal Birth after Cesarean

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4
Q

What is PPH?

A

Post-partum Hemorrhage

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5
Q

What is SAB?

A

Spontaneous Abortion

Or subarachnoid block.

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6
Q

What are indicators for operative vaginal delivery?

A
  • Bad FHR variability
  • Maternal exhaustion
  • Arrested Descent
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7
Q

If a denser sensory block is necessary for operative vaginal delivery, what medications can be used?

A

Epidural:
- Lidocaine 2% 5-10mls
- 2-Chloroprocaine 2-3% 5-10mls

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8
Q

What is the most common majory surgery in the USA?

A

C-section

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9
Q

Maternal mortality is _____ times greater with a c-section vs vaginal delivery.

A

10x greater

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10
Q

What are anesthesia complications that can contribute to mortality in converting to a C-section from a vaginal birth?

A
  • Pulmonary aspiration
  • Edematous/friable airways
  • Inadequate ventilation requiring GETA
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11
Q

What factors are contributing to an increased national rate of c-sections?

A
  • ↑ maternal age
  • Obesity
  • Fetal macrosomia
  • ↓ TOLAC attempts
  • Fear of instrumented vaginal deliveries.
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12
Q

What are the maternal indications for c-section?

A
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13
Q

What are the fetal indications for c-section?

A
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14
Q

What type of c-section incision is used for emergencies?

A

Midline incisions

Umbilicial to pubic symphysis.

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15
Q

What are the three different types of c-section incisions?

A
  • Low Transverse (best if possible)
  • Vertical
  • Classical (highest risk)
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16
Q

With what type of c-section incision is TOLAC contraindicated?

A

Classical incision

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17
Q

With what type of c-section incision is TOLAC possible?

A

Low-Transverse Incision

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18
Q

Why does GETA potentiate blood loss?

A

Due to GETA vasodilation.

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19
Q

What is the most common c-section complication?

A

Hemorrhage

Usually due to uterine atony → oozy uterus.

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20
Q

What complications (other than hemorrhage) can happen in c-sections?

A
  • Infection
  • Uterine/cervical lacerations
  • Bladder damage
  • Fetal damage
  • Hysterectomy
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21
Q

What is the terminology for abnormal placental invasion of surrounding tissues?

A

Accreta → Increta → Percreta

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22
Q

_______ ______ is when the placenta develops in such a way that it blocks the baby’s ability to exit out of the cervix & vagina.

A

Placenta Previa

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23
Q

What risk occurs with external cephalic version?

A

↑ risk of uterine rupture

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24
Q

What is the preferred anesthetic technique for a c-section?

A

Neuraxial Anesthesia

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25
Q

Previous c-sections indicates an increased risk of ______.

A

bleeding

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26
Q

What sensations are normal even with a spinal anesthetic?

A

pushing, pulling, tugging, & pressure

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27
Q

Which two drugs need to be stocked and ready to go in the OB operating room?

A

Propofol & Succinylcholine

Be ready to RSI.

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28
Q

What three medications are given to prevent (or diminish consequences) aspiration in parturients?

A
  • Famotidine 20mg IV
  • Metoclopramide 10mg IV
  • Na⁺ Citrate (Bicitra) 30mLs PO
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29
Q

What type of drug is famotidine?

A

H2 receptor antagonist that decreases gastric acid production.

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30
Q

What is the onset & peak of famotidine?

A

Onset: 30 min
Peak: 60 - 90 min

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31
Q

How does metoclopramide work?

A
  • ↓ stomach volume via increased motility.
  • increased LES tone
  • ↓ N/V

Dopamine D2 antagonist

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32
Q

When should metoclopramide be administered?

A

15-30 min prior to anesthesia start

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33
Q

What type of drug is Bicitra?

A

Non-particulate antacid that decreases gastric acidity to > 6pH

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34
Q

When should Bicitra be administered?

A

20-30 min before going to the OR.

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35
Q

What antibiotic given to parturients should be administered slowly due to risk of N/V?

A

Azithromyicin

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36
Q

What things/factors put a parturient at risk for higher blood loss?

A
  • GETA
  • Abnormal placenta
  • Unscheduled C-section after attempted vaginal
  • Multiparous
  • Multiple past c-sections
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37
Q

What monitoring equipment is necessary before spinal placement?

A

At minimum:
- FHT
- Mom’s BP
- Pulse oximetry

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38
Q

Why is versed “discouraged” but not contraindicated?

A
  • Crosses placenta & sedates baby
  • Amnestic effects on bonding
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39
Q

Is oxygen necessary for an elective c-section?

A

Not necessarily (but is typically done).

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40
Q

What is an ideal spinal dose of morphine?

A

100 - 150mcg

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41
Q

What is an ideal spinal dose of Fentanyl?

A

5 - 10mcg

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42
Q

What is an ideal dose of epidural morphine?

A

3mg

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43
Q

What are some disadvantages to C-section?

A
  • N/V
  • Diaphragm stimulated
  • HoTN
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44
Q

What causes referred shoulder/chest pain during a c-section?

A

Uterus being pulled out

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45
Q

How is the diaphragm stimulated during a c-section?

A

Irrigation can stimulate the diaphragm & cause N/V, cold, pain sensations.

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46
Q

What reflex can be activated during a c-section?

A

Bezold Jarisch Reflex

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47
Q

What are the triad of symptoms associated with the Bezold-Jarisch Reflex?

A
  • Vasodilation
  • Hypotension
  • Bradycardia
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48
Q

What causes the Bezold-Jarisch reflex?

A

Mechanoreceptors sensing a hyperdynamic LV w/ low preload.

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49
Q

Which drug can be administered to prevent the bezold-jarisch reflex associated with a spinal block?

A

Ondansetron 4mg

Antagonizes 5HT-3 receptors & prevents activation of BJR.

50
Q

What position should a patient be in after a spinal block?

A

Slight (10°) head up

Bed can also be tilted left for slight LUD.

51
Q

Which colloid has an increased risk for anaphylaxis?

A

Hetastarch

52
Q

What is the IM dose of ephedrine for hypotension?

A

25mg

53
Q

What acid-base imbalance of the umbilical artery can be caused by ephedrine?

A

Metabolic Acidosis

54
Q

Which of the following readily crosses the placenta:
Ephedrine
Phenylephrine

A

Ephedrine

55
Q

Hyperbaric Lidocaine (5%) is not commonly seen due to risk of ____.

A

TNS
Transient Neurologic Syndrome (leg & back pain 24-48 hrs after spinal).

56
Q

We want our spinal anesthetic to reach what sensory level?

A

T4

57
Q

What is the most common local anesthetic used for spinals?

A

0.75% bupivacaine

58
Q

Do spinally administered opioids increase or decrease PONV occurrence?

A

Both.

Can decrease occurrence due to decreased sensations that trigger PONV.

59
Q

What is the dose of Fentanyl for SAB?

A

10 - 25mcg

60
Q

Is early or late respiratory depression seen with fentanyl?

A

early

61
Q

What is the dose of morphine for SAB?

A

100 - 150mcg

62
Q

What is the onset and duration for morphine administered spinally?

A

Onset: 30 - 60 min
Duration: 12 - 24 hrs

63
Q

Will respiratory depression be seen earlier or later with morphine administered via SAB?

A

Later (6-18 hrs after!)

64
Q

How is the pruritus associated with SAB morphine treated?

A

Nalbuphine or Butorphanol
Naloxone or Naltrexone

65
Q

What is the dose of an “epi wash”?

A

0.1 - 0.2mg epinephrine administered in a SAB.

66
Q

What is the purpose of an “epi wash”?

A

Can prolong block by 15% or more

67
Q

What dose of Precedex is utilized in spinals?

A

5-10 mcg

68
Q

What is the purpose of spinally administered Precedex?

A
  • Prolongs sensory & motor blockade
  • Post-op pain control
  • Minimizes shivering
69
Q

What are the adverse effects associated with spinally administered dexmedetomidine?

A

Bradycardia & Hypotension

70
Q

Epidural medication doses are approximately _____ times that of spinal doses.

A

5 - 10 x

71
Q

Are spinals or epidurals better for C-sections?

A

Spinals (more reliable and dense)

72
Q

What VAA can be added to a patient with an epidural who is undergoing an unplanned C-section?

A

N₂O

73
Q

IV anesthetics such as ______ or ______ are commonly used as adjuncts to epidurals for patients undergoing unplanned c-section.

A

ketamine ; precedex

74
Q

2% Lidocaine is just as fast as chloroprocaine when what additive is added to it?

A

Na⁺ Bicarbonate

75
Q

What dose of 1% Lidocaine is utilized for spinal blocks for c-sections?

A

Trick Question. Concentrations less than 2% Lidocaine are inadequate for c-section anesthetics.

76
Q

What metabolized chloroprocaine?

A

Pseudocholinesterases

77
Q

What drug can decrease the efficacy of epidural morphine? Why?

A

2-Chloroprocaine

Antagonizes μ and κ opioid receptors

78
Q

Which dose of bupivacaine IS NOT utilized in epidurals?

A

0.75%

↑ Only for spinals

79
Q

What dosage of bupivacaine is used for epidurals?

A

0.5%

80
Q

What dosage of ropivacaine is common for epidurals?

A

0.5%

81
Q

Compare the cardiac toxicity profiles of ropivacaine & bupivacaine?

A

Ropivacaine is less cardiotoxic than bupivacaine

82
Q

Between fentanyl and morphine, which opioid administered spinally provides for a more dense block?

A

Fentanyl

83
Q

What ratio of dexmedetomidine to LA is typically used in epidurals?

A

4-5 mcg/mL of precedex for each 1mL of LA.

Ex. 20mL of LA + 80 - 100mcg Precedex

84
Q

How does Na⁺ bicarb helps speed up onset?

A

Shifts local anesthetic to more non-ionized state.

very useful speeding up epidural to avoid GETA.

85
Q

Your patient has an epidural in place and is being converted from a normal labor to a c-section. The epidural is unilateral, how can this be fixed?

A

Replaced the catheter if possible

86
Q

Your patient has an epidural in place and is being converted from a normal labor to a c-section. The epidural is patchy, how can this be fixed?

A
  • Supplement w/ adjuncts (ex. 50mcg Fentanyl)
87
Q

How much local anesthetic will you typically use to “top off” an epidural for a c-section?

A

10 - 15mls

88
Q

What is the Allis Test?

A

Pinch patient with clamps to assess quality of epidural anesthesia.

  • If the patient can’t feel clamps then you’re good for surgical incision.
89
Q

Why should your epidural dosing be less with a combined spinal epidural (CSE) ?

A

Hole through dura mater can result in medication going from epidural to spinal space.

90
Q

What are three reasons that one might have to convert to general anesthesia for a c-section?

A
  • Fetal Distress
  • Maternal Hemmorrhage w/ hypovolemia
  • Neuraxial Anesthetic not possible
91
Q

What are some reasons that neuraxial anesthesia may not be possible for c-section patients?

A
  • Outright refusal
  • Infection
  • Coagulopathy / thrombocytopenia
92
Q

Does GETA increase or decrease maternal mortality?

A

Increase

93
Q

How does GETA affect apgar scores?

A

↓ Apgar scores associated with GETA

94
Q

How can potential anesthesia recall occur with GETA for delivery?

A
  • ↓ MAC for delivery due to loss of uterine tone & concurrent bleeding
95
Q

What is the dose of succinylcholine?

A

1 - 1.5 mg/kg

96
Q

What induction agents are used for emergent c-sections?

A

Propofol + Succ

97
Q

What size ETT is used for c-sections?

A

6 - 7 mm ETT (remember that airway is friable & edematous)

98
Q

What other tube is placed (other than ETT) for a GETA c-section?

A

orogastric tube (suction out the stomach)

99
Q

In regards to a c-section delivery, when is pitocin/oxytocin started?

A

AFTER delivery

Needs to be announced to whole room that its being started.

100
Q

Less VAA = _______ uterine tone.

A

increased (results in less bleeding)

101
Q

What is MAC value decreased to after delivery of the baby?

A

0.5 - 0.75 MAC

102
Q

Opioids are given ____ delivery in order to decrease risk of neonate respiratory depression.

A

After.

103
Q

What paralytic is used after Succinylcholine has worn off?

A

Trick question. Use VAA to drive muscle relaxation

104
Q

Maternal hypocapnia results in what oxygenation change for the fetus?

A

↓ O₂ delivery due to leftward oxyhemoglobin dissociation curve shift.

105
Q

Maternal hypercapnia results in bradycardia or tachycardia?

A

Tachycardia

106
Q

What would cause you to do a deep extubation on a parturient patient?

A

Trick Question. Extubate patient awake. Still considered a full stomach.

107
Q

What are the three drugs used to treat uterine atony?

A
  • Pitocin
  • Methergine (methylergonovine)
  • Hemabate (Carboprost)
108
Q

What symptoms from a Pitocin drip would prompt you to slow the infusion?

A

Hypotension & flushing

109
Q

When is Pitocin started after delivery?
What dosage is used?

A
  • After umbilical cord is cut
  • 20u in NS bag (drip in slowly)
110
Q

What is the dose of Methergine (methylergonovine)?

A

0.2 mg IV/IM

111
Q

________ would cause one to be very careful using Methergine (methylergonovine).

A

Hypertension

112
Q

What is the dose of Carboprost (Hemabate)?

A

250mcg IM

113
Q

What drug is given if a patient is still bleeding after Pitocin administration?

A

Carboprost (Hemabate)

114
Q

What medical condition would make you cautious in giving Hemabate?

A

Asthma

115
Q

What factors associated with C-sections result in PONV?

A
  • Hypotension
  • Surgical Stimulation
  • Uterotonics
116
Q

How does hypotension result in PONV?

A
  • Cerebral hypoperfusion → medullary vomiting center stimulation
  • Gut ischemia → emetogenic substances released from intestines
117
Q

Why does surgical stimulation result in PONV?

A

VAGAL Stimulation

  • Uterine exteriorization
  • Intra-abdominal manipulation
  • Periotneal tract stimulation
118
Q

GETA for emergent c-section results in a very high risk for ______.

A

recall / hemorrhage

119
Q

What drug can be given to help prevent recall in emergent c-sections? When is this given?

A

2mg Midazolam as soon as the baby is out.

120
Q

Is it better to have block that is too high or too low?

A

too high

Can supplement w/ O₂

121
Q

What should anesthesia do if a block is excessively high? (loss of consciousness, loss of respiratory drive, refractory HoTN)

A

Convert to GETA

Advanced Principles A (Spring 2024) (11 decks)

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