AP 3 Final LAST ONE!!!!!!!!! Flashcards
1
Q
What does “gravida” mean?
A
Number of times a patient has been pregnant
2
Q
What does “parity” mean?
A
Number of babies born
3
Q
What do the 4 numbers listed under “parity” on a patient’s chart mean?
A
- Full term births
- Preterm births
- Losses (spontaneous or otherwise)
- Living children
4
Q
What is a baby considered “full term” when calculating gestational age?
A
Full term starts at 38 weeks gestation
5
Q
A woman’s blood volume increases by __% during pregnancy
A
40
6
Q
A woman’s heart rate increases by __% during pregnancy
A
15-20
7
Q
A woman’s stroke volume increases by __% during pregnancy
A
25%
8
Q
A woman’s cardiac output increases by __% during pregnancy
A
50%
9
Q
How is a woman’s arterial pressure affected by pregnancy? Why?
A
Decreases by up to 15% due to decrease in peripheral vascular resistance
10
Q
How much does a woman’s cardiac output increase immediately after delivery?
A
As much as 80% (12-14L/min)
11
Q
What EKG changes can be seen in the pregnant woman? Why?
A
Left axis deviation due to the displacement of diaphragm by uterus
12
Q
What is aortocaval compression (aka supine hypotensive syndrome)?
A
When a pregnant women is supine, the uterus causes…
-Aortoiliac compression in 15-20% of women
-Compression of the inferior vena cava in ALL women.
This causes decreased venous return to the heart, leading to hypotension.
13
Q
What is the solution for aortocaval compression?
A
Left uterine displacement - elevate the right hip to roll the uterus off the vena cava
14
Q
How does minute ventilation change in a pregnant woman?
A
Increases due to increased RR and TV
15
Q
How does the position of the diaphragm in a pregnant woman affect lung volumes?
A
The diaphragm is pushed more cephalad, which causes a decrease in FRC
16
Q
How does a decrease in the FRC of pregnant women affect induction of general anesthesia?
A
They have less oxygen in their lungs and it gets used more rapidly, thus they desaturate much more quickly
17
Q
How does the airway change during pregnancy?
A
Capillary engorgement of the mucosa causes swelling and difficult DL views
18
Q
What airway management techniques should be avoided in pregnant women?
A
Nasal instrumentation due to swollen and friable tissue
19
Q
What pregnancy condition can cause the airway to worsen quickly over a couple hours?
A
Pre-eclampsia
20
Q
Most common cause of anesthesia-related mortality in pregnant patients
A
Loss of airway
21
Q
Major GI changes in pregnant women (3)
A
- Delayed stomach emptying (due to uterus displacing stomach)
- GERD (due to GE junction loosening)
- Stomach contents are more acidic (placenta secretes gastrin)
22
Q
Due to the GI changes of pregnant women, all of these patients are treated as…
A
Full stomach
23
Q
GI changes of pregnant women cause them to be at significant risk of…
A
Aspiration
24
Q
What should you consider when picking ETT sizes for pregnant women
A
Pick slightly smaller size due to airway swelling
25
Due to their GI changes, what medication should pregnant women take before surgery
Sodium citrate (bicitra) - makes stomach contents less acidic
26
What hematologic condition is common during pregnancy?
Anemia
27
Why are pregnant women prone to anemia?
Plasma volume increases by 40% and red cell mass increases by 20%, so there is a slightly reduced red cell concentration in the blood
28
Normal Hgb levels for pregnant patients
11-12g/dL
29
Normal Hct for pregnant patients
35%
30
How does platelet count change in a pregnant woman
Decreases
31
How does clotting change during pregnancy? Why?
Pregnancy is a "hyper-coagulable state". There is an increase in coagulation factors and also anti-clotting activity, so there is increased clot formation and clot breakdown.
32
Since pregnancy is a "hypercoagulable state" - pregnant woman are more at risk for...
DVT
33
Oxygen consumption increases by __% in pregnant women
20%
34
How does PaCO2 change in pregnant women
Decreases
35
How does pH change in pregnant women
Unchanged
36
How do placental hormones affect the mother's glucose levels
Can lead to hyperglycemia, can cause gestational diabetes
37
How does plasma cholinesterase levels change in pregnant women
Decreases - but not enough to affect succinylcholine clearance
38
How do plasma protein concentrations change in pregnant women
Decrease via dilution
39
How long after conception does there begin to be a decrease in MAC levels for the pregnant patient?
8-12 weeks after gestation
40
How does the spread of neuraxial medications change during pregnancy?
Increases
41
Number one cause of pregnancy-related mortality worldwide
Hemorrhage
42
Number one cause of pregnancy-related mortality in the US
Cardiovascular disease
43
Anesthesia related maternal mortality is the __th leading cause of maternal mortality
10th
44
Causes of anesthesia-related maternal mortality
Failure to secure the airway is the top cause...others include
- pulmonary aspiration
- high spinal
- LAST due to IV injection of local
45
Safest and most effective medical intervention for labor pain
Lumbar epidural
46
Can opioids be given for labor pain?
Yes - they can be a risk for the baby and mother and not as effective as epidurals, but possibly the best option if epidural isnt possible
47
When is a patient in "labor"
When they are having uterine contractions that result in a cervical change
48
What is stage 1 of labor
Dilation of cervix to 10cm
49
Stage 1 of labor is broken down into what 3 phases
1. Latent labor
2. Active labor (accelerated cervical change that beings at 4-6cm)
3. Transition into stage 2 of labor
50
Where does the pain from stage 1 of labor originate?
Visceral pain from uterus and cervix, innervated by T10-L1
51
Stage 2 of labor
Fetus passing through cervix and into vaginal canal
52
Where does the pain from stage 2 of labor originate?
Somatic pain from compression of perineal tissue, innervated by S2-S4
53
Stage 3 of labor
Delivery of the placenta
54
Sudden, severe pain during stage 3 of labor should cause concern for...
Uterine inversion
55
What is the Puerperal period of labor (stage 4)?
From after delivery of the placenta until return to non-pregnant physiology (usually 2-6 weeks after delivery)
56
Contraindications to neuraxial block
1) Patient refusal
2) Thrombocytopenia
3) Coagulopathy/recent use of anticoagulants
4) Infection at site of needle placement
5) Untreated intravascular bacteremia/viremia
6) Foreign bodies/hardware in back
7) Certain pathologies of spinal cord (spina bifida)
57
There is a contraindication to a neuraxial block during what phase of labor
Complete dilation of the cervix during the 2nd stage of labor
58
Most painful stage of labor
2
59
When is an epidural for delivery normally placed?
After active labor has begun - can be placed any time after a patient is committed to labor
60
What can help prevent hypotension from epidural placement
Fluid bolus before or during placement
61
Patient history needed before placing an epidural for delivery
- Age
- Gravida
- Parity
- Gestation
- Medical problems
- Cervical exam
62
Physical exam needed before epidural placement for delivery
- Vital signs (including temp)
- Height
- Weight
- Airway
63
Labs needed before epidural placement for delivery
- Platelet #
- Hgb/hct
- White count
64
What monitors are necessary to have on patient during epidural placement
- Pulse ox
| - BP every 5 minutes
65
What gauge are epidural needles used for delivery
17 or 18 gauge
66
Why is extra care and precision needed when assessing loss of resistance during epidural placement for a delivery
The ligaments are softer in pregnant women so loss of resistance can be more subtle
67
A test dose for an epidural tells us what?
If the epidural is in the intrathecal or intravascular space
68
Classic test dose for epidurals
3mls of Lidocaine 1.5% and 1:200,000 epi
69
Signs that an epidural catheter is intrathecal
- Warmth in bottom
- Numbness
- Difficulty moving legs
70
Signs that an epidural catheter is intravascular
- Ringing in ears
- Numbness around mouth
- Metallic taste
- Increased HR within 30 seconds (usually to ~130bpm)
71
When dosing an epidural, what amount of local is incrementally injected?
3 or 5mL boluses
72
What local anesthetic is usually used for an epidural for delivery
Long acting agent such as bupivicaine or ropivicaine
73
Tools used to assess which dermatomes are blocked to pain after an epidural placement
- Pinprick
- Alcohol swabs
- Ice
74
What is a CSE?
Combined spinal epidural - once the epidural space is found, a spinal needle is inserted through the epidural catheter and medications are injected (usually fentanyl or low dose local)
75
Benefits of CSE
- Near-immediate pain relief
| - Confirmation of epidural space
76
Risks of CSE
- Spinal headache
| - Paresthesias
77
What is a subdural catheter?
When the epidural catheter ends up between the dura and the arachnoid
78
Risks of epidural placement
- Inadvertent dural puncture
- Hypotension (can affect fetus)
- Failed block
- IV/intrathecal injection
- Nerve injury
- Prolongation of stage 2 of labor
- Epidural hematoma
- Infection
79
What is an inadvertent dural puncture?
Also called a "wet tap" - when the epidural needle punctures the dura and CSF comes through
80
A wet tap dramatically increases the risk of...
Postdural puncture headache due to continual leakage of CSF
81
Definitive treatment for inadvertent dural puncture
Blood patch - epidural injection of blood
82
What treatments for inadvertent dural puncture should be tried first?
- Lying flat
- Caffeine
- Pain pills
83
Complications of blood patch
- Shooting pains in legs
- Infection
- New wet tap
84
What is done by the practitioner in the event of a wet tap?
Either...
1) The needle is removed and epidural placed at an adjacent level
2) Catheter is inserted into the intrathecal space
85
Indications for C-section
- Arrest of dilation
- Nonreassuring fetal heart rate
- Cephalopelvic disproportion
- Prior c-section
- Malpresentation
- Prior surgery involved uterine corpus
- Arrest of descent
- Uterine cord prolapse
- Placental abruption
86
Normal fetal heart rate
110-160bpm
87
Early decelerations in fetal heart rate during a contraction is often associated with...
Head compression as fetus moves toward delivery
88
Variable decelerations in fetal heart rate during a contraction can be associated with...
Uterine cord prolapse
89
Late decelerations in fetal heart rate during a contraction are suggestive of...
Fetal asphyxia during contractions
90
Anesthetic options available for c-section
Epidural, spinal, or general
91
What are neuraxial considerations for c-section?
- Need T4 block to block peritoneal stimulation
| - Need denser block than for labor
92
Mortality rates in c-sections are __ times greater with general than neuraxial anesthesia
17
93
Fetal transfer of general anesthesia induction drugs are all but inevitable if the delivery is delayed more than __ minutes after induction
2
94
What induction drugs are not transferred to fetus
Paralytics
95
What is a single spot spinal
A small gauge needle is inserted into subarachnoid space and meds are injected
96
Benefits of single shot spinal
Quick with no risk of large gauge dural punction
97
Risks of single shot spinal
- High block
| - Hypotension
98
Single shot spinals are contraindicated in pregnant patients with what disease
Multiple sclerosis
99
What local anesthetics are used in epidurals for a C-section
More concentrated locals...
- Bupivicaine 0.5%
- Lidocaine 2%
- Chloroprocaine 3%
100
Effects of morphine in a spinal or epidural
Gives 24 hour improved pain control but delayed risk of respiratory depression
101
Monitors needed for c-section
- ASA
| - Fetal heart tones must be assessed and monitored after anesthesia is induced
102
First sign of hypotension in patient undergoing c-section under regional anesthesia
Nausea/vomiting
103
Reflexing the table so the uterus is at the bottom of the patient reduces the risk of...
Venous air embolism
104
What medication is given immediately after the baby is born in a c-section
Pitocin - reduces uterine atony and hemorrhage
105
Pain med considerations for the mother once the baby is delivered in a c-section
Epidural opiods are given. Can safely give more sedatives, narcs, etc since there is no longer a fear of fetal transfer
106
Anesthetic options for emergency c-section
- If epidural is functioning and in place, dose it up
| - If not, choose general or lateral spinal
107
Preparations necessary if a general anesthetic is chosen for an emergency c-section
Patient must be prepped and draped prior to induction of general anesthesia so that if induction goes badly, the fetus can be saved
108
Induction plan for emergency c-section
RSI with propofol and succinylcholine
109
How must volatile anesthetics be managed after the baby is delivered in a c-section?
Use MINIMAL volatile because volatile agents relax the uterus and contribute to uterine atony
110
In general, the patient feels more sensation during a c-section with what neuraxial method?
Epidural
111
When should you consider re-dosing catheter during c-section
1-1.5 hr after surgery start
112
If a single shot spinal wears off during c-section, what can be given for powerful pain management that will still preserve ventilation
Ketamine
113
Premature labor is labor that occurs between...
20 and 37 weeks gestation
114
Contributing factors to premature labor
- Extremes of age
- Inappropriate prenatal care
- Increased physical activity
- Unusual body habitus
- Previous preterm delivery
- Multiple pregnancies
- Infection
115
Fetal complications of premature labor
- Hypoxemia/asphyxia from umbilical cord compression
- Inadequate surfactant levels
- Intracranial hemorrhage due to poorly calcified cranium
116
When are surfactant levels adequate in fetuses
After 35 weeks
117
What is premature rupture of membranes (PROM)?
Leakage of amniotic fluid that occurs before the onset of labor
118
Predisposing factors for PROM
- Short cervix
- History of preterm labor
- Infection
- Multiple gestations
- Polyhydramnios
- Smoking
119
If PROM occurs, delivery is indicated if the the fetus is over __ weeks gestation
34
120
What is done if PROM occurs and the fetus is less than 34 weeks
Give prophylactic antibiotics and tocolytics to prevent labor for 5-7 days
121
Maternal complications from chorioamniotitis
- Dysfunctional labor
- Intraabdominal infection
- Septicemia
- Postpartum hemorrhage
122
Fetal complications from chorioamniotitis
- Premature labor
- Acidosis
- Hypoxia
- Septicemia
123
Clinical signs of chorioamniotitis
- Fever over 38C
- Maternal and fetal tachycardia
- Uterine tenderness
- Foul smelling/purulent amniotic fluid
124
Predisposing factors to uterine cord prolapse
- Excessive cord length
- Malpresentation
- Low birth weight
- Grand parity (over 5 births)
- Multiple gestations
- Artificial rupture of membranes
125
Diagnosis of uterine cord prolapse
- Sudden fetal bradycardia
| - Profound decelerations
126
Treatment of uterine cord prolapse
- Immediate steep trendelburg or knees to chest
| - Pushing of fetal part back into pelvis
127
Anesthetic method for uterine cord prolapse
General anesthesia for the c-section
128
Classic triad of signs of an amniotic fluid embolism
1. Acute hypoxemia
2. Hemodynamic collapse - severe hypotension
3. Coagulopathy without obvious cause
129
Other s/s of amniotic fluid embolism
- Pulmonary edema
- Cyanosis
- CV arrest
- DIC
- Fetal distress
- Seizures
130
3 main pathophysiological manifestations of amniotic fluid embolism
1. Acute pulmonary embolism
2. DIC
3. Uterine atony
131
Treatment for amniotic fluid embolism
- Aggressive CPR and supportive care
| - Immediate c section
132
WHICH OF THE FOLLOWING SIGNS & SYMPTOMS IS NOT ASSOCIATED WITH AMNIOTIC FLUID EMBOLISM?
```
A. CARDIOPULMONARY ARREST
B. HYPERTENSION
C. BLEEDING (DIC)
D. PULMONARY EDEMA OR ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
E. SEIZURES
```
B. Hypertension
133
AN EPIDURAL IS PLACED INTO 32 YR OLD PARTURIENT RECEIVING MAGNESIUM THERAPY FOR PREECLAMPSIA. FIVE MINUTES AFTER ADMINSTRATION OF THE TEST DOSE, THE BOLUS INFUSION IS INTERRUPTED BECAUSE OF A CONTRACTION. AFTER THE CTX SUBSIDES, A SLOW EPIDURAL INJECTION OF THE LOADING DOSE OF BUPIVACAINE & FENTANYL IS RESUMED. AT THE SAME TIME, THE PATIENT COMPLAINS OF SHORTNESS OF BREATH. SHE IS PANIC-STRICKEN & WRESTLES VIOLENTLY WITH THE NURSES WHO ARE TRYING TO REASSURE HER. SHE REPEATS THAT SHE CANNOT BREATHE, BECOMES CYANOTIC, & LOSES CONSCIOUSNESS. DURING RESUSCITATION, BLOOD IS OOZING FROM THE IV SITES & PINK FROTH IS NOTED IN THE ENDOTRACHEAL TUBE.
THE MOST LIKELY DIAGNOSIS IS:
```
A. AMNIOTIC FLUID EMBOLISM
B. HIGH SPINAL
C. INTRAVASCULAR BUPIVACAINE INJECTION
D. MAGNESIUM OVERDOSE
E. ECLAMPSIA
```
A. Amniotic fluid embolism
134
What is placenta previa
When the placenta covers the internal cervical opening
135
Risk factors for placenta previa
- Scarring of uterine wall by previous pregnancies, surgeries, abortions, etc.
- Multiple pregnancy (twins, triplets, etc)
- Many previous pregnancies
- Abnormally developed uterus
136
Symptoms of placenta previa
- Painless vaginal bleeding
| - Episodic bleeding
137
Until proven otherwise, all pregnant patients with vaginal bleeding are assumed to have...
Placenta previa
138
Anesthetic management for placenta previa of an unstable patient
General anesthesia
- 2 large bore IVs
- Vigorous volume replacement
- Crossmatch 2 units
- Central line good for rapid transfusion and monitoring
139
A 30 YR OLD PRIMIPAROUS PATIENT WITH PLACENTA PREVIA & ACTIVE VAGINAL BLEEDING ARRIVES IN THE OPERATING ROOM WITH A SYSTOLIC BP OF 85 MM HG. A CESAREAN SECTION IS PLANNED. THE PATIENT IS LIGHTHEADED & SCARED.
WHICH OF THE FOLLOWING ANESTHETIC INDUCTION PLANS WOULD BE MOST APPROPRIATE FOR THIS PATIENT?
A) SPINAL ANESTHETIC WITH 12 TO 15 MG OF BUPIVACAINE
B) EPIDURAL ANESTHETIC WITH 20-25 ML 3% 2-CHLOROPROCAINE
C) GA INDUCTION W/ 3-4 MG/KG THIOPENTHAL, INTUBATING WITH 1-1.5 MG/KG SUCCINYLCHOLINE
D) GA INDUCTION W/ 0.5 MG/KG KETAMINE, INTUBATION W/ 1-1.5 MG/KG SUCCINYLCHOLINE
E) REPLACE LOST BLOOD VOLUME FIRST, THEN USE ANY ANESTHETIC THE PATIENT WISHES
D) GA INDUCTION W/ 0.5 MG/KG KETAMINE, INTUBATION W/ 1-1.5 MG/KG SUCCINYLCHOLINE
140
Causes of antepartum hemorrhages
1) Placenta previa
| 2) Placental abruption
141
What is placental abruption
Separation of normal placenta after 20 weeks of gestation causing fetal distress
142
Most common cause of intrapartum fetal death
Placental abruption
143
Risk factors for placental abruption
- HTN
- Trauma
- Short umbilical cord
- Multiparity
- Prolonged PROM
- Tobacco use
- ETOH abuse
- Cocaine use
144
Symptoms of placental abruption
- Painful vaginal bleeding
- HTN
- DIC
- Uterine tenderness
- Increased uterine activity
145
Diagnosis of placental abruption
- U/s to exclude placenta previa
| - Amniotic fluid is port wine colored
146
With mild to moderate placental abruption, fibrinogen levels are reduced to...
150-250 mg/dL (normal 200-500)
147
With severe placental abruption, fibrinogen levels are reduced to...
Below 150
148
Anesthetic management of placental abruption
- Fetal heart rate monitoring
- Large gauge IVs
- Aggressive volume resuscitation
- Check HCT and coagulation
- Type and cross units
149
If a pregnant patient is unstable and needs blood but you don't know her blood type, what type should you give?
O negative
150
Cause of peripartum hemorrhage
Uterine rupture
151
S/s of uterine rupture
- Constant pain
- Hypotension
- Fetal distress
- Ineffective contractions
152
Most reliable sign of uterine rupture
Fetal distress
153
Treatment for uterine rupture
Volume resuscitation and immediate laparotomy under general anesthesia
154
Even with epidural anesthesia, uterine rupture often presents as...
Abrupt onset of continuous abdominal pain with hypotension
155
What is a retained placenta
When fragments of placenta are still attach to uterus after delivery and cause the open blood vessels on the uterus to continue to bleed
156
Causes of postpartum hemorrhages
1) Placenta accreta
| 2) Uterine atony
157
What is placenta accreta
Abnormally adherent placenta
158
The majority of cases of placenta accreta are of what type?
Placenta accreta vera - adherence to myometrium without invasion through uterine muscle
159
Risk factors for placenta accreta
- History of placenta previa
| - Previous c section
160
WHICH OF THE FOLLOWING PATIENTS IS MOST LIKELY TO NEED AN EMERGENCY HYSTERECTOMY FOR UNCONTROLLED BLEEDING AT THE TIME OF DELIVERY?
A) PATIENT WITH PLACENTA ABRUPTION
B) PATIENT UNDERGOING A VAGINAL BIRTH AFTER CESAREAN SECTION
C) PATIENT WITH QUADRUPLETS
D) PATIENT WITH A PLACENTA PREVIA (NOT BLEEDING) FOR AN ELECTIVE REPEAT CESAREAN SECTION
E) PATIENT WITH AN ABDOMINAL PREGNANCY
D. PATIENT WITH A PLACENTA PREVIA (NOT BLEEDING) FOR AN ELECTIVE REPEAT CESAREAN SECTION (PREVIA & PREVIOUS SCAR OF THE UTERUS HIGH CHANCE OF PLACENTA ACCRETA)
161
Treatment for uterine atony
- Oxytocin
- Methergine
- Prostaglandin F2-alpha (Hemabate)
162
MOA of oxytocin in uterus
Stimulates frequency and force of contraction
163
MOA of oxytocin in mammary glands
Stimulates contraction of cells to force milk into large sinuses
164
MOA of oxytocin in cardiovascular system
Causes vasodilation, decreased BP, flushing, reflex tachy, increase in limb blood flow
165
Postpartum dose of oxytocin
20 units in 1000mL LR
166
Infusion rate of oxytocin
20-40mU/minute
167
Onset of IV oxytocin
1 min
168
Duration of IV oxytocin
30 min
169
Side effects of oxytocin
- Hypotension
| - N/V
170
MOA of methergine
Acts directly on smooth muscle of uterus via alpha receptors to increase tone, rate, amplitude of uterine contractions
171
Dosing for methergine
- 0.2 mg IM
| - 0.02 mg IV every 5 min
172
Onset of IV methergine
Immediate
173
Duration of IV methergine
45 min
174
Use methergine cautiously in patients with...
- Pre-eclampsia
- HTN
- Asthma
- Cardiac disease
175
MOA of prostaglandin F2alpha (hemabate)
Stimulates smooth muscle and uterine contractions
176
Dosage and route of PF2a
250mcg IM
177
Max dose of PF2a
2mg
178
Onset of PF2a
Less than 5 min
179
Duration of PF2a
Over an hour
180
Contraindications for PF2a
Asthmatics
181
15-METHYL PGF2alpha IS ADMINISTERED DIRECTLY INTO THE MYOMETRIUM TO TREAT UTERINE ATONY IN A 28-YR-OLD MOTHER. POSSIBLE EFFECTS FROM TREATMENT WITH THIS DRUG INCLUDE:
```
A. NAUSEA & VOMITTING
B. BRONCHOSPASM
C. FEVER
D. HYPOXEMIA
E. ALL OF THE ABOVE
```
E. All of the above
182
DRUGS USEFUL IN THE TREATMENT OF UTERINE ATONY IN AN ASTHMATIC WITH SEVERE PREECLAMPSIA INCLUDE:
```
A. OXYTOCIN, 15-METHYL PROSTAGLANDIN F2a (PGF2a), AND ERGONOVINE
B. OXYTOCIN AND 15-METHYL PGF2a
C. OXYTOCIN AND ERGONOVINE
D. 15-METHYL PGF2a ONLY
E. OXYTOCIN ONLY
```
E. Oxytocin only
183
EBL for uterine inversion
Up to 700ml/min
184
Drug management for uterine inversion
Give NTG and sevo to relax uterus so OB can manually get it back into shape
185
Which partum hemorrhage causes severe fetal distress?
Placenta abruption
186
Which partum hemorrhages have potentially massive intra-op blood loss?
- Placenta previa
| - Placenta accreta
187
WHAT CONDITION MOST FREQUENTLY REQUIRES BLOOD TRANSFUSIONS DURING DURING OR AFTER A CESAREAN DELIVERY?
```
A. MULTIPLE GESTATIONS
B. PREECLAMPSIA
C. INTRAUTERINE FETAL DEMISE
D. PLACENTA ABRUPTION
E. PLACENTA PREVIA
```
E. Placenta previa
188
How is chronic HTN distinguished from pregnancy induced HTN
Chronic HTN is diagnosed by systolics over 140 or diastolics over 90s before 20 weeks gestation
189
Pre-pregnancy HTN meds must be changed to a safe antihypertensive such as
Labetolol
190
THE LEADING DIRECT CAUSE OF PREGNANCY RELATED DEATHS IN THE U.S. IS:
```
A. GENERAL ANESTHESIA (FAILED INTUBATION OR ASPIRATION)
B. HEMORRHAGE
C. THROMBOEMBOLISM
D. HYPERTENSIVE DISORDERS OF PREGNANCY
E. INFECTION
```
D. HYPERTENSIVE DISORDERS OF PREGNANCY
191
Triad of symptoms of pre-eclampsia
1. Hypertension
2. Proteinuria (over 300mg per day)
3. Edema after 20 weeks and resolving 48 hours after delivery
192
Risk factors for pre-eclampsia
1) Primigravida
2) Primipaternity (first baby with this father)
3) Previous history
4) Obesity
5) Multiple gestations
6) Chronic HTN
193
Signs of severe preeclampsia
1. Systolics over 160 diastolics over 110
| 2. Proteinuria over 5 grams per day
194
Symptoms of severe preeclampsia
- Headache (due to cerebral edema)
- Blurred vision
- Oliguria
- Pulmonary edema
- Myocardial dysfunction
- RUQ pain
- Hepatic rupture
- Low platelets
- HELLP syndrome
195
WHICH OF THE FOLLOWING IS NOT A SIGN OF “SEVERE PREECLAMPSIA”?
```
A. PROTEINURIA GREATER THAN 5G/24 HRS
B. VISUAL DISTURBANCES
C. URINE OUTPUT LESS THAN 500 ML/24 HRS
D. WHITE BLOOD COUNT GREATER THAN 15,000
E. ALL ARE SIGNS OF “SEVERE PREECLAMPSIA”
```
D. WHITE BLOOD COUNT GREATER THAN 15,000
196
What is HELLP syndrome
PIH associated with
1) Hemolysis (anemia and lactate dehydrogenase over 600)
2) Elevated Liver enzymes (AST and ALT over 40)
3) Low Platelet count (less than 100k)
197
What anesthetic method is contraindicated in HELLP syndrome
Regional due to low platelets
198
What is eclampsia
When seizures occur with preeclampsia
199
Treatment of preeclampsia
1) Bedrest
2) Sedation
3) Antihypertensives
4) Magnesium sulfate
200
Dose of labetolol for preeclampsia
5-10mg IV
201
Dose of hydralazing for preeclampsia
5mg IV
202
Dose of methyldopa for preeclampsia
250-500mg PO
203
MOA of magnesium sulfate to treat preeclampsia
- Treats hyperreflexia and prevents seizure by reducing CNS irritability
- Directly vasodilates smooth muscle of arterioles and uterus
204
Administration of magnesium sulfate can affect the action of what other drugs
- Potentiates NMBs
| - Potentiates sedative effects of opioids
205
Dose of magnesium sulfate to treat preeclampsia
4g loading dose IV, then 1-3g/hour
206
Therapeutic plasma levels of magnesium sulfate
4-6mEq/L (normal is 1.5-2)
207
Serum magnesium levels over 5-10mEq/L can cause
Prolonged PQ interval, wide QRS
208
Serum magnesium levels over 10mEq can cause
- Skeletal muscle weakness
- Loss of deep tendon reflexes
- Resp depression
209
Serum magnesium levels over 15mEq can cause
- SA/AV block
| - Resp paralysis
210
Serum magnesium level that can cause cardiac arrest
25mEq
211
WHICH OF THE FOLLOWING STATEMENTS REGARDING MGSO4 THERAPY FOR PREECLAMPSIA IS TRUE?
A. THE THERAPEUTIC RANGE FOR SERUM MAGNESIUM IS 10-15 MEQ/L
B. HIGH SERUM MAGNESIUM LEVELS CAN BE ESTIMATED BY CHANGES IN DEEP TENDON PATELLAR REFLEXES IN A PATIENT WITH AN EPIDURAL ANESTHETIC LOADED FOR A CESAREAN SECTION
C. EXCESSIVE SERUM MAGNESIUM LEVELS CAUSE WIDENING OF THE QRS COMPLEX
D. THE ANTIDOTE FOR MAGNESIUM TOXICITY IS NEOSTIGMINE
E. AS SOON AS DELIVERY OCCURS, THE CHANCE FOR ECLAMPSIA NO LONGER EXISTS & THE MAGNESIUM SHOULD BE REVERSED SO THAT POSTPARTUM BLEEDING IS LESS LIKELY TO OCCUR
C. EXCESSIVE SERUM MAGNESIUM LEVELS CAUSE WIDENING OF THE QRS COMPLEX
212
Antidote for magnesium toxicity
Calcium
213
Doses of nitroprusside that increase risk of cyanide toxicity to fetus
Over 10mcg/kg/min
214
What antihypertensives should not be used during pregnancy?
1. Esmolol (adverse fetal effects)
| 2. CCBs (tocolytic action, potentiates Mg induced circulatory depression)
215
Anesthetic management of HTN in pre-eclamptic patients
- A-line
- Labetalol
- Hydralazine
- NTG
- SNP
216
Symptoms of magnesium toxicity
- Oversedation
- Loss of reflexes
- Dropping sats
217
Hypovolemia should be corrected with no more than ____ml crystalloid in preeclamptic patients
500ml
218
We should tolerate only a __% drop in BP in preeclamptic patients
10
219
Considerations for general anesthesia for a preeclamptic patient
- Edematous, difficult airways
- Limit IV fluid
- Reduce dose of NDNMBs if patient is on magnesium
- A-line if severe
220
WHICH OF THE FOLLOWING ANTIHYPERTENSIVE DRUGS USED TO TREAT SEVERE PREGNANCY-INDUCED HYPERTENSION IS NOT CAPABLE OF CAUSING INCREASED POSTPARTUM HEMORRHAGE?
```
A. NITROPRUSSIDE
B. NIFEDIPINE
C. NITROGLYCERIN
D. LABETOLOL
E. DIAZOXIDE
```
D. LABETOLOL
221
Is pregnancy tolerated better by regurgitant or stenotic valves
Regurgitant valves
222
Which lesions can tolerate epidurals - regurgitant or stenotic valves?
Regurgitant valves
223
Most common clinically significant valvular disease in pregnant women
Rheumatic fever mitral stenosis
224
Independent predictors of adverse cardiac events in pregnancy
1) Small mitral valve area
2) NYHA functional class 3 or higher
3) Ejection fraction less than 40%
4) Prior cardiac events
225
Things to avoid when managing pt with mitral stenosis
- Tachycardia
- A-fib
- Increased blood volume
226
Things to avoid when managing pt with aortic stenosis
- Decreased SVR
- Brady/tachycardia
- Hypovolemia
227
Common left to right shunts
1) VSD
2) ASD
3) PDA
228
Things to avoid in patients with left to right shunts
- XS fluids
- Trendelenberg
- Increased SVR
- Increased blood volume
229
A 28 YO GRAVIDA 1, PARA 0 PARTURIENT WITH EISENMENGER’S SYNDROME (PULM HTN WITH INTRACARDIAC RT-TO-LT OR BIDIRECTIONAL SHUNT) IS TO UNDERGO PLACEMENT OF LUMBAR EPIDURAL FOR ANALGESIA DURING LABOR. IT MAY BE WISE TO AVOID A LOCAL ANESTHETIC WITH EPINEPHRINE IN THIS PATIENT BECAUSE IT:
```
A. LOWERS PULMONARY VASCULAR RESISITENCE
B. LOWERS SYSTEMIC VASCULAR RESISTENCE
C. INCREASES HEART RATE
D ACTS AS A TOCOLYTIC AGENT
E. CAUSES EXCESSIVE INCREASES IN SYSTOLIC BP
```
B. LOWERS SYSTEMIC VASCULAR RESISTENCE
230
Risk factors for gestational diabetes
- AMA
- Obesity
- Family history of DM
- History of stillbirth, neonate death, or fetal malformation
231
Effects of gestational diabetes on the mother
- PIH
- Polyhydramnios
- Increased incidence of C section
232
Chronic effects on the fetus from gestational diabetes
- Macrosomia
| - Structural malformations
233
Acute effects on the fetus from gestational diabetes
- Intrauterine/neonatal death
- Neonatal respiratory distress syndrome
- Neonatal hypoglycemia
234
Most common fetal structural malformation associated with gestational diabetes
Cardiac
235
Anesthetic management for patient with gestational diabetes
- More frequent BP monitoring
- More vigorous IV hydration (non dextrose-containing)
- Reglan 10mg IV pre-op
- Strict glycemic control, glucose under 100
236
Pregnant women have a tendency toward which acid/base disorder
Respiratory alkalosis
237
A 32 yo PARTURIENT WITH A H/O SPINAL FUSION, SEVERE ASTHMA, & PREGNANCY-INDUCED HYPERTENSION IS BROUGHT TO THE O.R. WHEEZING & NEEDS AN EMERGENCY C/S UNDER GENERAL ANESTHESIA FOR A PROLAPSED UMBILICAL CORD.
WHICH OF THE FOLLOWING INDUCTION AGENTS WOULD BE MOST APPROPRIATE FOR THIS INDUCTION?
```
A. Sevo
B. Versed
C. Ketamine
D. Thiopental
E. Propofol
```
E. Propofol - good for RSI, rapid
238
CAUSES FETAL BRADYCARDIA INCLUDE ALL OF THE FOLLOWING EXCEPT:
```
A. HYPOXEMIA
B. ACIDOSIS
C. NEOSTIGMINE & GLYCOPYRROLATE
REVERSAL OF NEUROMUSCULAR BLOCKADE
D. MATERNAL SMOKING
E. UMBILICAL CORD COMPRESSION
```
D. MATERNAL SMOKING
239
Why can reversal of NMB with glyco & neostigmine cause fetal bradycardia
Glyco doesn't cross placenta
240
Do muscle relaxants cross placenta?
No
241
Do inhalation agents cross placenta?
Yes - keep below 1 MAC
242
Do induction agents (propofol, ketamine, benzos) cross placenta?
Yes
243
Do opioids cross placenta?
Yes
244
Which opioid should you NOT use in pregnant patients
Meperidine - seizures
245
Which beta blocker is contraindicated in pregnant patients
Esmolol - crosses placenta and causes fetal bradycardia
246
Local anesthetic that is bad for pregnant patients
Mepivacaine
247
Which local anesthetics poorly diffuse across placenta
Highly protein bound - ropivacaine, bupivacaine
248
Which anticholinergic does not cross placenta
Glyco
249
Recommended vasopressor for maternal hypotension
Phenylephrine bc ephedrine accumulates in placenta pretty rapidly
250
Which anticholinergic should be used with neostigmine to reverse NMBs
Atropine - but caution its short half life compared to neostigmine
251
Early decelerations in fetal heart rate is caused by
Fetal head compression
252
Most commonly encountered fetal heart rate patterns during labor
Variable decelerations - caused by compression of umbilical cord
253
Methods to control bleeding during intraop aneurysm rupture
Reversal of anticoagulation followed by rapid delivery of coils to seal the bleed
254
Methods to control ICP during intraop aneurysm rupture
- Hyperventilation
- Hypertonic saline or mannitol
- Propofol
255
Medical management of vasospasm after subarachnoid hemorrhage
- Nimodipine
| - Triple H therapy - HTN, hemodilution, hypervolemia
256
Key anesthetic considerations for neuroradiology procedures
- Patients need to be still
- BP tightly controlled, frequent use to vasopressors or vasodilators
- A line
257
Patient contraindications for MRI
Patients with...
- Pacemakers
- SBSs/DBSs
- Aneurysm clips
- Stents
- Prosthetic valves
- Prosthetic joints
258
What is more common intraoperatively in pediatric patients - hypo or hyperthermia?
Hypothermia
259
What predisposes pediatric patients to hypothermia during surgery
- Low body fat
- Thin skin
- Increased BSA:mass ratio, big heads lose heat more quickly
- Inability to shiver (neonates)
260
What is the typical pattern of hypothermia of pediatric patients under anesthesia?
When compared to adults...
- More intense drop due to lack of internal redistribution of heat
- More gradual heat loss to environment
- Rewarm more quickly
261
What percentage of children present with 1 or more respiratory complications in the PACU?
10%
262
Anatomical differences of the pediatric airway
- Large head, tongue, tonsils, adenoids
- Anterior and cephalad larynx
- Long, floppy, omega shaped epiglottis
263
Narrowest point of the pediatric airway
Cricoid ring
264
Vertebral level of pediatric vocal cords
C3-C4
265
Calculation for ETT diameter for children age 1 or greater
4 + age/4
266
Calculation for ETT depth for children
12 + age/2
267
Cons of microcuffed ETTs
Smaller size increases airway resistance and work of breathing
268
Cons of uncuffed ETT
- Leak of agent into environment
- Require flows greater than 2L
- Higher risk for aspiration
269
1mm of edema decreases area of the trachea by...
75%
270
When are cuffed ETTs preferable?
- High aspiration risk (bowel obstruction)
- Low lung compliance (ARDS, pneumoperitoneum, CABG)
- Precise control of ventilation and pCO2 (increased ICP, single ventricle)
271
Risk factors for postintubation croup
- Large ETT
- Change in patient position intraop
- Multiple intubation attempts
- Traumatic intubation
- Patients under 4
- Surgery over an hour
272
Treatment for post op croup
- Humidified air
- Nebulizer treatment
- Steroids
273
Pathogenesis of laryngotracheal stenosis
Ischemic injury caused by lateral wall pressure that leads to edema, necrosis, and mucosa ulceration
274
Why do pediatric patients have less efficient ventilation
They have fewer type 1 muscle fibers which causes weak intercostals and diaphragmatic muscles
275
Characteristics of alveoli in pediatric patients
Small, immature, and stiff which causes low lung compliance
276
How is chest compliance in pediatric patients
Increased due to pliable, cartilaginous ribs
277
O2 consumption in pediatric patients compared to adults
Pediatric patients have doubled O2 consumption - 6ml/kg/min
278
FRC of pediatric patients
28-30cc/kg
279
Does hypercarbia stimulate ventilation in the term newborn?
Yes because their chemoreceptors are developed
280
How soon after birth does hypoxemia induce sustained hyperventilation?
By 3 weeks after birth, before then hypoxemia will cause a transient increase in ventilation following by sustained depression
281
How does the slope of the CO2 response curve change with gestational age?
Increases
282
Older children and adults are stimulated to breath with a PaO2 under
60mmHg
283
Why is it important to ask about a child's recent URIs during the pre-op exam?
Recent URIs predisposes the child to coughing, laryngospasm, and desaturations
284
What illnesses are normally indicated by a productive cough?
Active bronchitis or pneumonia
285
What can be indicated by repeated pneumonia infections??
- GERD
| - Immune suppression
286
Signs of impending respiratory failure
- Increased work of breathing
- Tachypnea/tachycardia
- Nasal flaring
- Grunting
- Wheezing
- Stridor
- Use of accessory muscles
- Diaphoresis
287
How is the need for high O2 consumption in pediatric patients met?
Increased respiratory rate
288
How is the myocardium of pediatric patients compared to adults
- Fewer organized myocytes
- Less contractile tissue
- Less compliant ventricles
289
What are children dependent on for their cardiac output?
Heart rate because their stroke volume is fixed due to less compliant ventricles
290
When does the conversion from fetal to adult circulation occur?
First few weeks of life
291
How does the baby's circulation start to change when they take their first breaths?
Start conversion to adult circulation...PVR drops, SVR increases which begins the closure of the PDA and foramen ovale
292
When does the full closure of the PDA and foramen ovale occur in babies?
3 months-1 year
293
How is a patent foramen ovale diagnosed?
Murmur
294
Neonatal hemoglobin
15-20g/dL
295
Hemoglobin of a 3 month infant
11-12g/dL (relative anemia)
296
When does the infant begin the conversion to adult hemoglobin?
3 months
297
When does a baby's hemoglobin levels reach adult levels?
6-9 months
298
Blood volume for a preemie
90-100ml/kg
299
Blood volume for a full-term neonate
80-90ml/kg
300
Blood volume for a 12 month infant
75-80ml/kg
301
Pediatric dose of atropine
0.01-0.02mg/kg IV
302
Minimum PALS dose of atropine
0.1mg - below that you can see paradoxical bradycardia
303
Pediatric dose of IV sux
2mg/kg
304
Pediatric dose of IM sux
4mg/kg
305
Pediatric dose of PO versed
0.5mg/kg
306
Pediatric dose of IV versed
0.1mg/kg
307
Max dose of PO versed for pediatrics
15mg
308
Pediatric dose of rocuronium
0.6-1.2mg/kg
309
Pediatric dose of fentanyl
1-2mcg/kg
310
Pediatric dose of zofran
0.1mg/kg
311
Pediatric dose of ancef
25-50mg/kg
312
Infants sometimes require up to 3mg/kg of succinylcholine...why?
They have a higher volume of distribution
313
Fasting guidelines for clear liquids
2hours
314
Fasting guidelines for breast milk
4 hours
315
Fasting guidelines for milk/formula/light meal
6 hours
316
Fasting guidelines for fatty meal
8 hours
317
Metabolic rate of infants
100cal/kg/day
318
Gas combo commonly used for inhalational induction of pediatric patients
70/30 N2O/O2 with sevo all the way up
319
Why should you be more careful using fentanyl in children
More susceptible to post op apnea
320
How do MAC requirements change as you move from preemies to neonates to infants
Infants have the highest, preemies have the lowest
321
What is the rule of thumb for who to give caudal blocks to? Why?
Kids younger than 7 OE less than 30 because the fusion of the sacrum is not yet complete
322
How are caudal blocks done?
Form of epidural that is placed as a single shot injection into the sacral hiatus after induction
323
Dose and type of local used in caudal blocks for circumcision
0.5cc/kg 0.25% marcaine
324
Dose and type of local used in caudal blocks for inguinal hernies
0.75cc/kg 0.25% marcaine
325
Surgeries that commonly have deep extubations for children
- Cath lab
| - Eye cases
326
Criteria for deep extubation
- 100% O2
- At least 1.5MAC
- Breathing spontaneously
- Suctioned
- Oral airway
- No breath holding
327
Steps to take in case of suspected laryngospasm
- Chin lift
- Jaw thrust
- Positive pressure
- Sux
328
Patients at risk for respiratory events in PACU
- Active respiratory infection
- History of reactive airway disease
- Children 0-9 y/o
- Asthma
329
At what point under anesthesia's care do most cardiac arrests occur in children?
Induction
330
Common mechanisms of cardiac arrest in children
- Bradycardia
- Airway obstruction
- Medication related
331
3 Predictors of anesthesia-related cardiac arrest
1) ASA 3-5
2) Emergency
3) Younger age
332
Why do we not put young preemie babies on a high FiO2?
They are predisposed to retinopathy until 44 weeks
333
ETT sizing for down syndrome children
Downsize tube by 0.5mm
334
At what point during gestation is extrauterine life possible?
24 weeks
335
When do lungs develop in the fetus?
Sufficient pulmonary surfactant isn't until 35 weeks gestation
336
Biggest concern for the airway of down syndrome children
Very prone to atlanto-occipital dislocation due to unstable c-spine
337
Intra-op plan for children with sickle cell
- Keep them warm
- Keep them well hydrated
- Treat pain aggressively
- Be prepared to transfuse
338
Characteristics of pediatric trachea
Small and compliant, cartilages are not well calcified. Prone to laryngomalacia
339
P50 of neonatal hemoglobin
19
340
When should elective surgery be cancelled in a patient with a URI?
- Purulent rhinitis
- Fever over 38.3C
- Elevated WBC with bands
- Infiltrate by CXR
341
Former preterm infants are at risk for what lung problems?
- Pulmonary HTN
| - Chronic lung disease
342
What medications are former preterm infants commonly on? Should they take them morning of surgery?
- Lasix to keep lungs dry (hold morning of)
| - Digoxin for right heart failure (take morning of)
343
Characteristics of bronchopulmonary dysplasia (BPD)
- Increased airway resistance
- Poor lung compliance
- VQ mismatch
- Hypoxemia
- Tachpnea
- Chronic wheezing
344
Former preterm infants should be monitored for post op apnea if they are under __ weeks post conceptual age (PCA)
52
345
Pre-op considerations if child has a murmur
- Get preop ECHO if murmur is Gr III or greater
| - Determine need for SBE prophylaxis
346
Pre-op considerations for patient with sickle cell disease
- Baseline H/H
- No electrophoresis
- Tranfuse to Hct of 30% with PRBCs
- Have blood available in OR
347
Pediatric dose for nasal versed
0.2mg/kg
348
Pediatric dose for oral ketamine
6-9mg/kg
349
Pediatric dose for transmucosal fentanyl
10-15mcg/kg
350
Pediatric dose for rectal methohexital
25mg/kg
351
What are the pre-op lab protocols for healthy children?
No routine labs (with some exception in ENT cases)
352
Pediatric dose for PO acetaminophen
20mg/kg
353
Pediatric dose for PR acetaminophen
40mg/kg
354
Pediatric dose for PO NSAIDS
5mg/kg
355
Pediatric dose for IM ketorolac
1mg/kg
356
Pediatric dose for IV ketorolac
0.5mg/kg
357
Duration of caudal block
4-6 hours
358
Minimum discharge criteria for pediatric ambulatory surgery
- Stable vital signs (within 20% baseline)
- No resp distress
- Age appropriate ambulation and LOC
- No n/v
- In tact pharyngal reflexes
359
Max dose of zofran for peds patients
4mg
360
Pediatric dose for IV droperidol for PONV
50-75mcg/kg
361
Pediatric dose for IV metoclopramide for PONV
0.15mg/kg
362
Pediatric dose for IV or PR promethazine for PONV
0.5mg/kg
363
Pediatric dose for PR prochlorperazine for PONV
0.1mg/kg
364
Potential neuroprotectants from toxicity of anesthetic agents
- Lithium
- Dexmedetomidine
- tPA, plasma, erythropoietin
365
GFR of neonate compared to adult
Neonates have 15-30% of the adult GFR
366
Renal/hepatic metabolism considerations for neonates
- Hypoglycemia and hyperglycemia can occur very easily
| - Calcium metabolism is easily disturbed and citrate binding can cause pressor resistant hypotension
367
What are omphaloceles/gastroschisis
Defects in the abdominal wall that allows portion of the intestinal viscera to remain outside of the abdominal cavity. These defects have similar management but anatomical differences
368
Characteristics of omphalocele
- Gut fails to migrate from yolk sac into abdomen
- More common than gastroschisis
- More common in males
- Defect at base of umbilicus
369
Characteristics of gastroschisis
- Occurs from occlusion of omphalomesenteric artery
- Less common than omphalocele
- Occurs equally in males and females
- Bowel inflamed and edematous due to exposure to amniotic fluid
370
Which fetal bowel abnormality still has a functional bowel
Omphalocele
371
Which fetal bowel abnormality is associated with other congenital abnormalities thus has higher mortality
Omphalocele
372
Which fetal bowel abnormality has organs that are inflamed and edematous due to exposure to amniotic fluid
Gastroschisis
373
Preop considerations for patients with Omphalocele/Gastroschisis
- Heat and fluid loss from large exposed area
- Volume depleted
- Check pulmonary status (could have RDS from prematurity)
- Check renal function
374
Patients with Omphalocele/Gastroschisis are at risk for what electrolyte imbalances
- Hypoglycemia
| - Hypocalcemia
375
Standard monitors for patients with Omphalocele/Gastroschisis
- Standard ASA
- A line
- Urinary catheter
- Intra-abdominal pressure monitoring
- +/- CVP
376
Anesthetic induction for Omphalocele/Gastroschisis
- Awake intubation if hypovolemic
| - RSI after IV atropine and O2
377
Where do you want ETT leak for patients with Omphalocele/Gastroschisis
30-40cmh2o
378
Anesthetic maintenance for patients with Omphalocele/Gastroschisis
- O2/air/volatile
- Max muscle relaxation
- Opioid 5-20mcg/kg fentanyl
379
Intraop management for patients with Omphalocele/Gastroschisis
- Labs: check calcium, glucose, ABG
- Warm OR to 80F
- Sats of 94-97% for term infants, 90-94% for preterm
- Keep hct over 30%
- UOP 1cc/kg/hr
380
Fluid maintenance for patients with Omphalocele/Gastroschisis
D10 25% NC 10-15cc/kg/hr
381
Postop management for patients with Omphalocele/Gastroschisis
- Can extubate if pt had small defect and no lung disease
- Maintain positive pressure ventilation until abdominal pressure decreases
- Use PEEP to improve FRC
382
What is the most common cause of neonatal GI obstruction
Hirschsprung's disease
383
Hirschsprung's disease
Absence of ganglion cells needed to allow relaxation of internal sphincter, presents as failure to pass meconium within first 24 hours of life
384
Anesthetic induction considerations for pediatric patients with transesophageal fistula (TEF)
- Head up position (minimize aspiration)
- NG in esophagus with continuous suction
- Warm room
- T&C units
- Good IV access
385
Induction plan for TEF
- Atropine 10-20mcg/kg IV
| - Awake vs RSI
386
Appropriate ETT position for patients with TEF
Past fistula but above carina
387
Monitors for patients with TEF
- Standard ASA
- A line
- Pre and post ductal pulse oximeters
- Axillary precordial stethoscope
388
Position for TEF procedure
Lateral decubitus
389
Postop management of TEF
- Extubation preferable to minimize stress/compression
| - Humidified O2
390
Cardiovascular mangement for infants with Necrotizing Enterocolitis (NEC)
- Urgent fluid/blood resuscitation at 150cc/kg in NICU
- Inotropes
- Infants usually acidotic, in shock, and have assc. CHF
391
Metabolic conditions of NEC
- Severe acidosis
- Hypoglycemia
- Hypocalcemia
392
Calculation for bicarb deficit in peds
Base deficit x weight x 0.3
393
How much bicarb should be given to NEC patients in preop
Half the calculated deficit - give slowly
394
EBL for NEC procedure
10-100cc/kg
395
Monitors for NEC
- Standard ASA
- A line
- Urinary catheter
- +/- CVP
396
Anesthetic plan for NEC
- Ketamine
- O2/air
- Opioids
- Muscle relaxation
- Sat 94-95%
397
Postop plan for NEC
- Maintain PPV
- Continue opioids and muscle relaxation
- Transport with extra volume, airway equipment, full monitors, drugs
398
Preop management for congenital diaphragmatic hernia (CDH)
- Stabilize or ECMO
- Correct acidosis
- Treat pulmonary HTN
- Check PT/PTT/platelets
399
Monitors for CDH
- Standard ASA
- A line
- Pre/postductal pulse oximters
- Urinary catheters
- Precordial stethoscope on side opposite defect
400
Induction plan for CDH
Awake intubation
401
Ventilation plan for CDH
- IMV 60/min
- PIP under 30cmh2o
- PaCo2 25-30
- pH over 7.5
- PaO2 under 80
* may need pressure limited ventilator
402
Fluid management for CDH procedure
- D5 1/4 NS 4-6cc/kg/hour
| - 5% albumin 5-10cc/kg
403
Postop management of CDH
- Maintain PPV and respiratory alkalosis
- Minimize suctioning
- Provide nutrition
404
Indications for pediatric ECMO
- Reversible respiratory failure
- Meconium aspiration
- CDH
- Drowning
- Infection
- Asthma
405
Entry criteria for ECMO
- Over 34 weeks gestation
- Over 2kg
- 80% predicted mortality
406
Exclusion criteria for ECMO
- Greater than grade 2 intraventricular hemorrhage
| - Other life threatening anomalies
407
What are Myelodysplasias
Abnormal fusion of neural groove leaving some portion of brain or cord exposed
408
Preop management of Myelodysplasias
- Check neurologic deficits
- Check volume status
- Plan A/W management
- Warm room
409
Induction plan for Myelodysplasias
- Awake intubation for nasal encephaloceles
| - Inhalation or IV
410
Myelodysplasia patients are extubated in what position
Lateral
411
What is a Cystic Hygroma
Large lymphatic malformations that can extend to mediastinum
412
Morbidity assc. with cystic hygromas
- Airway compromise
- Infection
- Bleeding
413
Labs needed for cystic hygroma surgery
- Hct
- Glucose
- Calcium
- T&C units
414
IV access considerations for cystic hygroma
Consider IVs in lower extremities
415
Induction plan for cystic hygroma
- Volatile + 100% O2
- Atropine before DL
- Maintain spontaneous ventilation
416
Postop plan for cystic hygroma
- Take to ICU for airway monitoring, probably wont extubate due to edema
- Monitor for RLN injury, bleeding, edema
417
Intubation plan for neonates with encephalocoele
Awake intubation for nasal encephalocele, otherwise IV or inhalational
418
How do vital signs change during the progression of neonates to children
- RR decreases
- Heart rate decreases
- BP increases
419
Indications for TIPS
- Portal vein HTN
| - ESLD
420
Which neonatal surgical emergencies require awake intubations
- Nasal encephaloceles
- Omphalocele/gastroschisis if hypovolemic
- Congenital diaphragmatic hernia
- Tracheoesophageal fistula
421
Pediatric ETT depth of insertion confirmation
- Bilateral breath sounds
| - Pressure leak test
422
Measuring pre- vs postductal circulation
- Preductal is measured on right hand and usually has higher sat %
- Postductal is measured on left hand or lower extremity and normally has lower sat %
423
Blood volume of a full term neonate
80-90ml/kg
424
Benefits of pediatric premedication
- Calms child so they accept mask induction
- Less anxiety for child and parents when separating
- Diminishes post op behavioral changes
425
What is nonshivering thermogenesis
Brown fat metabolism - norepi stimulates breakdown of brown fat and glycerol that results in heat and increases O2 production
426
Treatment for pelvic relaxation
- Bladder training and biofeedback
- Anticholinergics
- Beta agonists
- Dopamine agonists
- Antidepressants
- Kegal exercises
427
Mortality in gynecologic cancers
Ovarian
428
Blood volume during pregnancy
Increases 40% from baseline
429
Normal BP for neonate
65/40
430
Normal BP for 1 year old
95/65
431
Normal BP for 3 year old
100/70
432
Normal BP for 12 year old
110/60
433
Most common complication of 2nd trimester D&E
Gestational diabetes
434
Blood loss during L&D
- Vaginal delivery=400-500ml
| - C section=800-1000ml
435
Maternal cardiac output distribution
700ml/min to fetus
436
Determinants of uterine blood flow
Blood pressure
437
What is not a contraindication to neuraxial anesthesia for the Ob patient?
Hyperglycemia
438
MgSO4 site of action
- Calcium channel blocker -- vasodilates smooth muscles in arterioles and uterus
- NMDA antagonist -- stops seizures
439
Cause of early decelerations in fetal heart rate
Head compression
440
Cause of late decelerations in fetal heart rate
Uteroplacental insufficiency -- suggestive of asphyxia
441
Cause of variable decelerations in fetal heart rate
Umbilical cord compression
442
Causes of antepartum hemorrhage
1) Placenta previa
| 2) Placental abruption
443
Changes in cardiovascular measurements during pregnancy
- HR increases 20-25%
- SV increases 25%
- CO increases 50%
- SVR decreases
444
Signs of amniotic fluid embolism
Classic triad is acute hypoxemia, severe hypotension, coagulopathy
445
Methergine Uses
Uterine smooth muscle constrictor used to stop excessive post-delivery bleeding
446
Pregnancy - timeline of cardiac output increases
- During pregnancy it increases by 50%
| - Immediately after pregnancy it increases as much as 80%
447
P50 of maternal hemoglobin
30
448
PaCO2 normal values in 3rd trimester
30mmHg
449
Symptoms caused by cardiac tamponade
- Distant heart sounds
- JVD
- Hypotension
450
Positioning for ERCP
Prone with patient's head to their right
451
Incidence of gastroschisis
1:15,000
